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Stroke is preventable.
This article will discuss the common problems of stroke prevention in the elderly through seven small questions
.
Yimaitong compiles and organizes, please do not reprint without authorization
.
01 Which diet can reduce the risk of stroke in the elderly? Eating patterns that are effective in preventing stroke include a vegetarian diet and a Mediterranean diet
.
The 46-month follow-up results of the Lyon Diet Heart Study showed that the Mediterranean diet and canola margarine instead of butter can reduce stroke and myocardial infarction events by> 60%
.
In primary prevention, the Mediterranean diet plus nuts can reduce the 5-year stroke risk by 46%
.
A meta-analysis showed that both cholesterol and egg intake increased the risk of cardiovascular disease in a dose-dependent manner
.
Egg yolk is high in cholesterol.
Red meat and egg yolk also contain trimethylamine precursor, which is oxidized to trimethylamine N-oxide (TMAO) in the liver
.
The content of carnitine in red meat is 4 times that of white meat, and the content of phosphatidylcholine in eggs is very high
.
Studies have shown that TMAO levels increase the risk of stroke/myocardial infarction/vascular death by 2.
5 times in 3 years
.
An egg can nearly double TMAO levels, and changing from red meat to white meat or a meatless diet can significantly reduce TMAO levels within one month
.
Both TMAO and p-cresol sulfate are independent predictors of atherosclerotic burden, which can be eliminated by the kidneys, but renal function declines with age
.
Therefore, people with impaired renal function, including the elderly, should avoid eating egg yolks and limit meat intake
.
02 Are there all senior citizens suitable for the new blood pressure goal? For elderly hypertensive patients, there are two categories of people who suffer from lower systolic blood pressure targets: patients with bilateral carotid artery stenosis and those with harder blood vessels, diastolic blood pressure (DBP) <60mmHg and pulse pressure (PP)> 60mmHg ( DPB <60 / PP> 60) patients
.
In the brain, the blood pressure gradient is large: when the blood pressure in the brachial artery is 117/75 mm Hg, the blood pressure in the calf artery is 113/73 mm Hg, and the blood pressure in the small branches of the posterior parietal cortex is only 59/39 mm Hg
.
Studies have shown that DBP<60/PP>60 doubles the risk of subclinical myocardial ischemia
.
Another study showed that DBP<60/PP>60 increased the risk of stroke recurrence by 5.
8 times
.
Therefore, frail elderly people with pulse pressures> 60 mm Hg should not target systolic blood pressures of <120 mm Hg
.
03 Is the lipid-lowering treatment suitable for the elderly? Lipid-lowering therapy significantly reduces the risk of stroke
.
A recent meta-analysis of 28 statins showed that 8% of patients were older than 75 years old at the time of enrollment, and statins can significantly reduce strokes of any type, with no significant difference in each age group
.
In observation studies, statins may not cause adverse reactions such as liver toxicity, renal damage, cataracts, etc.
, and may not cause cerebral hemorrhage
.
The increased risk of cerebral hemorrhage reported in the SPARCL trial may be due to improper analysis of the study’s intention to treat
.
In SPARCL participants who actually took atorvastatin, there was no increase in cerebral hemorrhage
.
The only treatment-related adverse effects of statins observed in randomized trials are a slight increase in the risk of myopathy and diabetes, both of which may be due to impaired mitochondrial function caused by ubiquinone depletion
.
However, a meta-analysis of patients> 65 years of age showed that statins did not increase muscle-related adverse events
.
Studies have shown that ezetimibe can be used to reduce the dose of statins while effectively reducing LDL-C
.
The 2019 European Dyslipidemia Guidelines recommend the addition of ezetimibe to patients who cannot meet the standard with statins alone
.
Therefore, blood lipids should be lowered in the elderly for secondary prevention, and low-dose statins combined with ezetimibe can also be tried
.
In fact, the lower the LDL-C, the better
.
Statins can be used for patients with myopathy, while ezetimibe can be used for patients with severe diarrhea
.
For high-risk patients who cannot take statins, other new therapies can be considered, such as drugs targeting PCSK9
.
04 Is it appropriate for the elderly to use antiplatelet drugs? For patients with atherosclerosis, antiplatelet drugs can be used for secondary prevention
.
However, there is still controversy about the use of aspirin in primary prevention, especially in the elderly
.
The American Heart Association recommended in 2019 that it is not advisable to routinely take low-dose aspirin to prevent cardiovascular disease for the elderly over 70 or adults at risk of bleeding
.
However, many elderly people have a history of vascular disease and should be treated with antiplatelet drugs
.
Some studies claim that aspirin resistance is due to enteric coating, so uncoated or chewable aspirin may be more effective
.
Since clopidogrel is a prodrug that needs to be metabolized by CYP2C19 to its active form, in about 30% of Europeans and >50% of Chinese patients, the loss of activity of this enzyme reduces the efficacy of clopidogrel
.
Ticagrelor does not need to be activated.
The activation of prasugrel does not involve cytochrome-based enzymes, so they may be more effective than clopidogrel
.
In addition, some bleeding complications of antiplatelet therapy can be avoided by optimizing medical services
.
Controlling blood pressure will actually eliminate intracerebral hemorrhage
.
Detection and treatment of Helicobacter pylori infection may also eliminate many gastrointestinal bleeding
.
05Is it suitable for the elderly to use anticoagulants? For cardiogenic stroke, older people can benefit from anticoagulant drugs more than young people, but the proportion of anticoagulant therapy is very small
.
Studies have shown that among patients with atrial fibrillation, only 18% of TIA/stroke patients take warfarin, and only 10% of them have adequate anticoagulation
.
The emergence of direct oral anticoagulants (DOAC) has changed the above phenomenon
.
The efficacy of DOAC is better than that of warfarin, but the bleeding risk is equivalent to that of aspirin
.
A meta-analysis showed that the relative benefits of DOAC in stroke prevention and systemic embolism are consistent
.
The incidence of stroke/systemic embolism in the elderly is higher, and the absolute benefit of DOAC is greater
.
Therefore, DOAC should be widely used in elderly people with atrial fibrillation
.
However, it should be noted that Dabigatran is mainly excreted through the kidneys, so it may be the least suitable for the elderly (Table 1)
.
Table 1 Features of direct oral anticoagulants 06 Can elderly people reduce the risk of stroke by taking vitamin B? At present, a large number of studies have proved that vitamin B does reduce the risk of stroke and is related to the reduction of tHcy
.
The CSPPT (Chinese Stroke Primary Prevention Trial) study showed that folic acid reduced the risk of ischemic stroke for all participants by 24%; patients with LDL-C≥2mmol/L reduced by 34%; patients with tHcy≥15 and low platelet counts reduced It’s 73%
.
However, vitamin B12 supplements should be in the form of methylcobalamin or oxocobalamin, not cyanocobalamin
.
07 Should the elderly undergo carotid artery stent or endarterectomy? Patients with carotid artery stenosis are at high risk of cardiovascular events (such as myocardial infarction), so they should all receive intensive medication
.
However, compared with carotid endarterectomy (CEA) or stenting (CAS), most patients with asymptomatic carotid stenosis get better results through drug treatment (including life>
.
A meta-analysis showed that for all patients with asymptomatic carotid stenosis, CAS (≈4%) has a higher 10-year risk of stroke or death than CEA (≈2.
8%)
.
These risk differences are dominated by the perioperative risk; after the perioperative period, the risks of CEA or CAS are basically the same
.
Another 2016 meta-analysis found that among patients over 75 years of age, the risk of stroke from CAS is much higher than that of CEA
.
Therefore, healthy adults with symptomatic carotid artery stenosis should be recommended for interventional therapy
.
For asymptomatic stenosis, it is also reasonable to assess the suitability of CEA or CAS based on high-risk features (such as decreased cerebrovascular reserve, transcranial Doppler showing microembolism, or intraplaque hemorrhage on magnetic resonance imaging)
.
Summary New information about the interaction of the gut microbiome and atherosclerosis has important dietary implications
.
Healthy, independent seniors will benefit from a plant-based diet, lipid-lowering therapy, appropriate blood pressure control, antiplatelet therapy or anticoagulants, B vitamins to reduce plasma total homocysteine and the effect of carotid artery stenosis Appropriate intervention
.
Original index: J.
David Spence, M.
Reza Azarpazhooh, Susanna C.
Larsson, et al.
Stroke Prevention in Older Adults Recent Advances.
Originally published 30 Oct 2020.
doi.
org/10.
1161/STROKEAHA.
120.
031707.
This article will discuss the common problems of stroke prevention in the elderly through seven small questions
.
Yimaitong compiles and organizes, please do not reprint without authorization
.
01 Which diet can reduce the risk of stroke in the elderly? Eating patterns that are effective in preventing stroke include a vegetarian diet and a Mediterranean diet
.
The 46-month follow-up results of the Lyon Diet Heart Study showed that the Mediterranean diet and canola margarine instead of butter can reduce stroke and myocardial infarction events by> 60%
.
In primary prevention, the Mediterranean diet plus nuts can reduce the 5-year stroke risk by 46%
.
A meta-analysis showed that both cholesterol and egg intake increased the risk of cardiovascular disease in a dose-dependent manner
.
Egg yolk is high in cholesterol.
Red meat and egg yolk also contain trimethylamine precursor, which is oxidized to trimethylamine N-oxide (TMAO) in the liver
.
The content of carnitine in red meat is 4 times that of white meat, and the content of phosphatidylcholine in eggs is very high
.
Studies have shown that TMAO levels increase the risk of stroke/myocardial infarction/vascular death by 2.
5 times in 3 years
.
An egg can nearly double TMAO levels, and changing from red meat to white meat or a meatless diet can significantly reduce TMAO levels within one month
.
Both TMAO and p-cresol sulfate are independent predictors of atherosclerotic burden, which can be eliminated by the kidneys, but renal function declines with age
.
Therefore, people with impaired renal function, including the elderly, should avoid eating egg yolks and limit meat intake
.
02 Are there all senior citizens suitable for the new blood pressure goal? For elderly hypertensive patients, there are two categories of people who suffer from lower systolic blood pressure targets: patients with bilateral carotid artery stenosis and those with harder blood vessels, diastolic blood pressure (DBP) <60mmHg and pulse pressure (PP)> 60mmHg ( DPB <60 / PP> 60) patients
.
In the brain, the blood pressure gradient is large: when the blood pressure in the brachial artery is 117/75 mm Hg, the blood pressure in the calf artery is 113/73 mm Hg, and the blood pressure in the small branches of the posterior parietal cortex is only 59/39 mm Hg
.
Studies have shown that DBP<60/PP>60 doubles the risk of subclinical myocardial ischemia
.
Another study showed that DBP<60/PP>60 increased the risk of stroke recurrence by 5.
8 times
.
Therefore, frail elderly people with pulse pressures> 60 mm Hg should not target systolic blood pressures of <120 mm Hg
.
03 Is the lipid-lowering treatment suitable for the elderly? Lipid-lowering therapy significantly reduces the risk of stroke
.
A recent meta-analysis of 28 statins showed that 8% of patients were older than 75 years old at the time of enrollment, and statins can significantly reduce strokes of any type, with no significant difference in each age group
.
In observation studies, statins may not cause adverse reactions such as liver toxicity, renal damage, cataracts, etc.
, and may not cause cerebral hemorrhage
.
The increased risk of cerebral hemorrhage reported in the SPARCL trial may be due to improper analysis of the study’s intention to treat
.
In SPARCL participants who actually took atorvastatin, there was no increase in cerebral hemorrhage
.
The only treatment-related adverse effects of statins observed in randomized trials are a slight increase in the risk of myopathy and diabetes, both of which may be due to impaired mitochondrial function caused by ubiquinone depletion
.
However, a meta-analysis of patients> 65 years of age showed that statins did not increase muscle-related adverse events
.
Studies have shown that ezetimibe can be used to reduce the dose of statins while effectively reducing LDL-C
.
The 2019 European Dyslipidemia Guidelines recommend the addition of ezetimibe to patients who cannot meet the standard with statins alone
.
Therefore, blood lipids should be lowered in the elderly for secondary prevention, and low-dose statins combined with ezetimibe can also be tried
.
In fact, the lower the LDL-C, the better
.
Statins can be used for patients with myopathy, while ezetimibe can be used for patients with severe diarrhea
.
For high-risk patients who cannot take statins, other new therapies can be considered, such as drugs targeting PCSK9
.
04 Is it appropriate for the elderly to use antiplatelet drugs? For patients with atherosclerosis, antiplatelet drugs can be used for secondary prevention
.
However, there is still controversy about the use of aspirin in primary prevention, especially in the elderly
.
The American Heart Association recommended in 2019 that it is not advisable to routinely take low-dose aspirin to prevent cardiovascular disease for the elderly over 70 or adults at risk of bleeding
.
However, many elderly people have a history of vascular disease and should be treated with antiplatelet drugs
.
Some studies claim that aspirin resistance is due to enteric coating, so uncoated or chewable aspirin may be more effective
.
Since clopidogrel is a prodrug that needs to be metabolized by CYP2C19 to its active form, in about 30% of Europeans and >50% of Chinese patients, the loss of activity of this enzyme reduces the efficacy of clopidogrel
.
Ticagrelor does not need to be activated.
The activation of prasugrel does not involve cytochrome-based enzymes, so they may be more effective than clopidogrel
.
In addition, some bleeding complications of antiplatelet therapy can be avoided by optimizing medical services
.
Controlling blood pressure will actually eliminate intracerebral hemorrhage
.
Detection and treatment of Helicobacter pylori infection may also eliminate many gastrointestinal bleeding
.
05Is it suitable for the elderly to use anticoagulants? For cardiogenic stroke, older people can benefit from anticoagulant drugs more than young people, but the proportion of anticoagulant therapy is very small
.
Studies have shown that among patients with atrial fibrillation, only 18% of TIA/stroke patients take warfarin, and only 10% of them have adequate anticoagulation
.
The emergence of direct oral anticoagulants (DOAC) has changed the above phenomenon
.
The efficacy of DOAC is better than that of warfarin, but the bleeding risk is equivalent to that of aspirin
.
A meta-analysis showed that the relative benefits of DOAC in stroke prevention and systemic embolism are consistent
.
The incidence of stroke/systemic embolism in the elderly is higher, and the absolute benefit of DOAC is greater
.
Therefore, DOAC should be widely used in elderly people with atrial fibrillation
.
However, it should be noted that Dabigatran is mainly excreted through the kidneys, so it may be the least suitable for the elderly (Table 1)
.
Table 1 Features of direct oral anticoagulants 06 Can elderly people reduce the risk of stroke by taking vitamin B? At present, a large number of studies have proved that vitamin B does reduce the risk of stroke and is related to the reduction of tHcy
.
The CSPPT (Chinese Stroke Primary Prevention Trial) study showed that folic acid reduced the risk of ischemic stroke for all participants by 24%; patients with LDL-C≥2mmol/L reduced by 34%; patients with tHcy≥15 and low platelet counts reduced It’s 73%
.
However, vitamin B12 supplements should be in the form of methylcobalamin or oxocobalamin, not cyanocobalamin
.
07 Should the elderly undergo carotid artery stent or endarterectomy? Patients with carotid artery stenosis are at high risk of cardiovascular events (such as myocardial infarction), so they should all receive intensive medication
.
However, compared with carotid endarterectomy (CEA) or stenting (CAS), most patients with asymptomatic carotid stenosis get better results through drug treatment (including life>
.
A meta-analysis showed that for all patients with asymptomatic carotid stenosis, CAS (≈4%) has a higher 10-year risk of stroke or death than CEA (≈2.
8%)
.
These risk differences are dominated by the perioperative risk; after the perioperative period, the risks of CEA or CAS are basically the same
.
Another 2016 meta-analysis found that among patients over 75 years of age, the risk of stroke from CAS is much higher than that of CEA
.
Therefore, healthy adults with symptomatic carotid artery stenosis should be recommended for interventional therapy
.
For asymptomatic stenosis, it is also reasonable to assess the suitability of CEA or CAS based on high-risk features (such as decreased cerebrovascular reserve, transcranial Doppler showing microembolism, or intraplaque hemorrhage on magnetic resonance imaging)
.
Summary New information about the interaction of the gut microbiome and atherosclerosis has important dietary implications
.
Healthy, independent seniors will benefit from a plant-based diet, lipid-lowering therapy, appropriate blood pressure control, antiplatelet therapy or anticoagulants, B vitamins to reduce plasma total homocysteine and the effect of carotid artery stenosis Appropriate intervention
.
Original index: J.
David Spence, M.
Reza Azarpazhooh, Susanna C.
Larsson, et al.
Stroke Prevention in Older Adults Recent Advances.
Originally published 30 Oct 2020.
doi.
org/10.
1161/STROKEAHA.
120.
031707.
