Cardiovascular Health of US Stroke Survivors Is Worsening

LOS ANGELES, CA—The cardiovascular health of people who have had a stroke is moving in the wrong direction, according to data from the National Health and Nutrition Examination Survey (NHANES).

Between 1988 and 2014, the proportion of stroke survivors who met no more than one of the American Heart Association’s “Life’s Simple 7” metrics used to define ideal cardiovascular health rose from 18% to 35%, Amy Lin, a medical student at the University of Southern California in Los Angeles, reported at the International Stroke Conference here.

The concerning trend was driven by an increasing rate of obesity and declines in physical activity and diet quality.

“Complex secondary stroke prevention strategies that affect behavior change are needed,” Lin said during her presentation.

Speaking with TCTMD, senior author Amytis Towfighi, MD (University of Southern California), pointed out that many patients don’t know what they should be doing after a stroke and that clinicians need to address that lack of health literacy.

“The main things are to not only prescribe medications but also to help patients improve their lifestyle, their self-management skills, and their medication adherence, and prepare them to know what their levels are of these different factors and what their goals should be,” Towfighi said.

Some Positives, but Mostly Negatives

The Life’s Simple 7 metrics, which are used as a way to track and promote cardiovascular health, encourage people to:

• Manage blood pressure
• Control cholesterol
• Maintain a normal plasma glucose
• Stop smoking
• Maintain a healthy body mass index
• Remain physically active
• Eat a healthy diet

To see how well US stroke survivors have been adhering to this framework, Lin, Towfighi, and colleagues examined cross-sectional data on about 1,600 adult patients with a self-reported prior stroke who were included in an NHANES survey between 1988 and 2014.

Overall, less than 1% of patients achieved the ideal state for all seven metrics. Accompanying the large increase in the percentage of patients meeting no more than one of the criteria was a slight decline in the proportion meeting four or more (from 17% to 15%).

News was mixed when looking at the individual metrics. Gains were made in control of blood pressure and cholesterol, mirroring trends in the general population, but glucose control, body mass index, physical activity, and diet quality deteriorated. Particularly striking, Towfighi said, was the increase from 45% to 71% in the percentage of patients performing no physical activity at all.

The stroke field in general is kind of behind the times in terms of working on behavioral modification and lifestyle change after stroke. Amytis Towfighi

The negative trends in physical activity and diet contrast with what was seen in the general population, where there were few changes in those metrics over the same time period. Towfighi said the discrepancy could be related the limitations of and loss of independence in patients who have had a stroke, or to the existence of more cardiovascular risk factors in this population to start with.

The researchers also found that the significant predictors of achieving none or only one of the Life’s Simple 7 metrics were black race, poverty, and lower education. That’s to be expected, Towfighi said, because socioeconomically disadvantaged populations are more likely to have a poor risk-factor profile. Future research, she added, should focus on how to reduce these disparities.

Getting Back on Track

The findings are not surprising because they’re consistent with what clinicians are seeing on a daily basis, according to Nada El Husseini, MD (Wake Forest Baptist Medical Center, Winston-Salem, NC), who was not involved in the study.

The mixed results when looking at individual metrics makes sense, too, because there are effective medications that can be given for controlling blood pressure and cholesterol but reining in the other risk factors like obesity, poor diet, and low physical activity is more challenging, she told TCTMD.

“It’s the more complex interventions that we haven’t made good strides in,” El Husseini said. “I think we’re pretty good at giving pills, but these other more complex interventions need more time and commitment and probably other policies to address.”

On a public health level, she said, policies should be implemented to make healthy food options like fruits and vegetables more affordable and to help people make good choices, possibly by requiring calorie counts to be posted and by doing more educational outreach about the importance of improving diet and increasing activity levels.

Also, El Husseini suggested, more interventions are needed on the institutional level to improve follow-up and help patients adhere to the changes needed after a stroke. “They have their appointments to go to, they cannot drive, they don’t know what is a good diet, they don’t know what is a good exercise regimen, they can barely walk, and they are falling because of the stroke,” she said. “I think having more clinics to define what is a good exercise regimen for stroke patients, what is a good diet, how to best control diabetes, and how to follow up on these patients is important.”

Towfighi touched on similar issues but also underscored the need for further research to define the best interventions for patients who have had a stroke. She noted that these patients are not typically advised to enter programs akin to cardiac rehabilitation.

“The stroke field in general is kind of behind the times in terms of working on behavioral modification and lifestyle change after stroke,” Towfighi said. “And I think we can draw upon the cardiac literature and other literature, but [we need to determine] how is it different in patients with stroke and can we apply the same things.”