What doctors wish patients knew about the deadly risk of stroke

Every 40 seconds, someone in the U.S. has a stroke, which is a medical emergency that demands swift action. Stroke is the fifth leading cause of death in the U.S. and a major cause of long-term disability for adults, but it is preventable and treatable. That is why patients and families need to know more about preventing and identifying stroke.

More than 795,000 people in the U.S. have a stroke every year. About 610,000 of these are first or new strokes. Meanwhile, nearly 25% of strokes are in people who have had a previous stroke. And about 87% are ischemic strokes in which blood flow to the brain is blocked, according to the Centers for Disease Control and Prevention (CDC).

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, two physicians took time to discuss what patients need to know about preventing and identifying stroke. They are:

• Stephen Devries, MD, a preventive cardiologist and executive director of the educational nonprofit Gaples Institute in Chicago. He is also an adjunct professor of nutrition at Harvard T.H. Chan School of Public Health.
• Brent Egan, MD, an internist and vice president of cardiovascular disease prevention at the AMA in Greenville, South Carolina.

“A stroke is an injury to the brain that results from a disruption of blood flow,” Dr. Devries explained, noting the most common type is an ischemic stroke, which “is caused by a blood clot that prevents blood from flowing to part of the brain.”

“Another type of stroke happens when an artery in the brain ruptures, often under the stress of high blood pressure,” he said. This is a hemorrhagic stroke, which makes up about 13% of stroke cases, according to the American Heart Association.

“Those are the two major causes: Either the vessel is blocked, or the vessel breaks and bleeds,” said Dr. Egan, noting a stroke “ends up causing damage to brain cells. And brain cells are obviously important for the function of the body.”

“The most common modifiable risk factor is high blood pressure—hypertension—and it contributes to more preventable strokes than any other modifiable risk factor,” Dr. Egan said. “That said, atrial fibrillation carries a higher risk than hypertension, but doesn’t cause as many strokes as hypertension since it is much less common.”

“There are additional risk factors that are modifiable such as people who have heart disease or who have had a heart attack—or what we call coronary heart disease—where there’s a problem with blood supply to the heart,” he said.

“High blood cholesterol is certainly a risk factor. Smoking, poor diet, sedentary lifestyle and obesity are also risk factors for ischemic stroke,” Dr. Egan said, noting risk factors for stroke also include “excess alcohol intake and illegal drug use.

“Those are some of what we call modifiable risk factors,” Dr. Egan added. “The main nonmodifiable risk factor is age. With each passing year, we’re at higher risk for stroke, but there’s not much we can do about that.”

Additionally, “if you have a family history of stroke, you’re more likely to have a stroke. That may be in part because of inherited risk factors that we see like hypertension or type 2 diabetes, but also abnormalities such as blood clotting,” he said. “Some blood clotting abnormalities are inherited, so family history is one that’s worth paying attention to.”

“Another major risk factor is Black adults have a significantly higher risk of stroke,” Dr. Egan said, noting the risk of having a first stroke is nearly twice as high for Black adults as for white adults. Also, Black adults and Pacific Islander adults have the highest rates of death due to stroke, according to the CDC.

“We’re seeing strokes increase in younger people because of the increase in risk factors with obesity, hypertension and diabetes,” Dr. Egan said. “Also, the risk for atrial fibrillation rises strongly as a function of age and is more common in people with overweight or obesity.”

“Atrial fibrillation is a very strong risk factor for stroke that can be minimized with the right blood thinners,” he said, noting that “somebody in their 20s or 30s who has this sudden onset of symptoms should also get immediate medical attention because they could have a stroke.”

Stroke symptoms “typically do appear suddenly. So, when the blood vessel breaks or is blocked, the brain experiences symptoms very quickly,” Dr. Egan said. “If the brain doesn’t get its normal blood supply, symptoms develop very rapidly.”

“The thing with stroke is typically we’re talking about sudden onset—not something that occurs over days,” he said, noting the effects of a stroke can linger for “days, weeks and years.”

The difference between a transient ischemic attack (TIA) and a “stroke is with the TIA, the symptoms are resolved within 24 hours,” Dr. Egan said. With “stroke, there’s going to be some residual or persistent neurologic deficit for more than 24 hours.”

But “if you have TIA, everything is not OK. You’re then at very high risk for having a stroke,” he said. “So, people shouldn’t relax if they had a TIA and all the symptoms resolved.

“They really ought to pay close attention and make sure they get good medical care because they’re at high risk of having a stroke,” Dr. Egan added.

“The most common signs and symptoms of stroke are summarized by the mnemonic, ‘BE FAST,’” said Dr. Devries.

“B is for balance. So, pay attention to a sudden loss of balance,” Dr. Egan said, noting that “ataxia, or the difficulty in coordinating the movements of the arm or the leg or the balance, that is among the more common things that occur.

“It was 61% of women and 75% of men. Now, there’s not always a problem with the balance in terms of not being able to walk straight,” he added. “But also, difficulty if you’re trying to move your leg and it’s not moving the way you want it to move. Those are very common.”

“E is for eyes. So double vision, loss of vision or blurry vision,” Dr. Egan said. “F is for face weakness or drooping. So, if you were with somebody, you could ask them to smile and see if the smile is symmetrical or if it’s lopsided.”

“A is for arm weakness and can occur in either arm. It could also be leg weakness, but the A stands for arm,” he said. “The S is for speech problems—either speaking or understanding what is spoken. And the T is for time to call 911 for emergency medical assistance immediately.”

Among women, stroke is the fifth-leading cause of death. Additionally, one in five women between 55 and 75 will have a stroke in the U.S. But one in five strokes are preventable, according to the Centers for Disease Control and Prevention.

“In women, stroke symptoms can be especially challenging to sort out,” said Dr. Devries. “That’s a big problem because not recognizing the seriousness of these stroke symptoms can lead to delayed diagnosis and treatment, and a poor outcome.”

“Symptoms of stroke especially common in women, include fainting, sudden general weakness, shortness of breath, confusion, agitation, and nausea and vomiting,” he said, adding that “although rare, even the new development of persistent hiccups can be the sign of a stroke.”

“Delays in stroke care are often long,” Dr. Egan said, noting that “calling your doctor first leads to a longer delay, so call 911 and not your doctor if sudden BE FAST symptoms develop.

“In one study, the average delay in patients who are white was about six hours and 10 hours in patients who are Black,” he added. “One of the things that we try to do is to get people when they have this sudden onset of these various symptoms to seek immediate medical attention because there are things that can be done to limit the damage that occurs.”

“If you experience or witness anyone with these symptoms, the single most important step is to immediately call 911,” Dr. Devries urged. “Definitely don’t drive yourself or ask a friend to take you to the hospital.

“Calling 911 is the absolute best option and will ensure the fastest, safest and most appropriate treatment,” he added, noting not to “delay to see if the symptoms resolve. Even if they improve or resolve completely, that doesn’t exclude the possibility that a stroke has occurred or is imminent.”

“The longer we wait, the more irreversible the damage is likely to be,” Dr. Egan warned. 

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For patients with symptoms that suggest a possible stroke, Dr. Devries warns, “don’t take an aspirin.”

That is because “some strokes are caused by bleeding in the brain and aspirin thins the blood,” he said, noting “this could cause further bleeding and damage.

“Only a physician, after examination of your test results, can determine if aspirin is appropriate,” Dr. Devries added.

“Strokes can be one of the most devastating health crises, but fortunately there’s a lot you can do to prevent them,” said Dr. Devries. “High blood pressure is a strong risk factor for strokes and making sure your blood pressure is checked and under control is essential.”

“Lowering systolic BP 10 mmHg reduces stroke by about 30%,” Dr. Egan noted. And using “statins, when indicated, reduce ischemic strokes by 10% to 20%.”

“Regular checks for cholesterol and blood sugar are also important,” Dr. Devries said.

“The benefits of controlling both BP and cholesterol are additive. In other words, more than 20% of strokes are preventable or at least delayable,” Dr. Egan said.

“In addition to regular health exams, lifestyle choices are key to preventing strokes,” Dr. Devries said. For example, “alcohol can raise blood pressure and increase the risk of stroke, so minimizing or avoiding alcohol is important.”

Additionally, he emphasized that “not smoking is essential for preventing strokes, heart attacks, many cancers, and so much more.”

“Dietary choices are another foundation of stroke prevention,” said Dr. Devries. “A diet filled with potassium-rich foods that lower blood pressure—including fruit, vegetables and beans together with whole grains, less meat and, optionally, fish—has been shown to significantly reduce the risk of stroke.”

“A healthy diet with fresh fruits, vegetables and grains like the Mediterranean diet is very good,” Dr. Egan said. “The DASH—dietary approaches to stop hypertension—diet, which is rich in fruits, vegetables, whole grains, natural foods and less processed foods is also good to follow too.”

“It is recommended that people get 7,000 to 10,000 steps a day,” Dr. Egan suggested, noting that “physical activity wouldn’t have to necessarily be walking.

“But walking is something that’s pretty easy to do and doesn’t require a gym membership or special equipment,” he added.

“There are several excellent treatments for stroke,” Dr. Devries said, noting that “depending on the kind of stroke, treatment may include medicine to lower blood pressure, blood thinners and procedures to remove blood clots.

“But regardless of the treatment, the best outcome is dependent on immediate medical attention,” he added. “If in doubt about your symptoms, don’t wait and wonder. Call 911.”

“About seven out of eight strokes are ischemic strokes and the quicker blood supply is restored to the brain, the less the damage and the better the recovery,” Dr. Egan said. “Because the brain is so sensitive to lack of blood supply, you’d like to get to the emergency department as quickly as possible.”

“Before you get to the stroke center, if they confirm by a CT scan and they’re sure it’s not a bleed, they could give intravenous clot busters,” he said, noting “intravenous clot busters are not nearly as good at restoring blood supply of the brain as going in and taking the clot out, but that’s generally done in specialized centers that have the expertise to do that.

“And ideally that’s done in three hours or less. Certainly, less than four and a half hours,” Dr. Egan said. “But each passing hour there’s irreversible damage that’s occurring. The sooner that can be done, the sooner you can get the clot buster or the removal of the clot, the better.”