232 SECTION 3 Preventive medicine and public Health C. Stroke(Cerebrovascular Accident) D. Cardiovascular Disease Stroke, or cerebrovascular accident (CVA), is the fourth Cardiovascular disease has long been the leading cause of leading cause of death in the United States after heart disease death in both men and women in the United States and ncer, and lung disease and a major cause of long-term remains so at this time. It exerts a comparable toll in devel morbidity. The incidence rate of stroke in those age 50 and oped countries worldwide and causes a high older had declined in the United States, principally because number of deaths globally. of better detection and treatment of hypertension, the major Risk factors for heart disease vary by culture and circum isk factor. The morbidity of stroke has been somewhat stance. In some parts of the world, infectious disease, such attenuated through the use of thrombolytic therapy that can s streptococcal pharyngitis leading to rheumatic fever, or restore blood flow and salvage brain tissue imperiled by isch- Chagas disease resulting from infection by Trypanosoma emia Hemorrhagic stroke is a potential side effect of such cruzi in South America, remains an important cause of therapies and can occur independently of them. Hemor- heart disease. The focus here is preferentially on the epide hagic stroke is much less common than ischemic stroke, less miology of heart disease, specifically coronary artery disease redictable, and in general less preventable disease, in the United States an A marked rise in the rate of stroke in children age 5 to 14 omparably developed nations, in which the role of infection ears has been observed recently in the United States. The is minor(although not inconsequential). Chronic inflam- explanation is uncertain, but childhood obesity is cited as a mation is now known to propagate the progression of likely candidate. atherosclerotic plaque, implicating such conditions as Risk factors for stroke overlap substantially with risk periodontal disease(see later) ctors for cardiovascular disease(see next). Medical condi The principal determinants of cardiovascular risk tend to tions(e.g, diabetes) that increase the risk of heart disease be lifestyle behaviors. In particular, tobacco use, dietary similarly increase the risk of stroke. Atrial fibrillation is a risk pattern, and physical activity level are of considerable impor- factor for stroke, generally managed with anticoagulation. tance and greatly influence the probability of future cardiac The main modifiable risk factor for stroke is hypertension. events (e.g, unstable angina, heart attacks, sudden cardiac Patient adherence to management guidelines for blood pres- death). To some extent, however, such effects are indirect sure reliably translates into reduced stroke risk and, at the Poor diet and lack of physical activity tend to contribute te population level, reduced stroke incidence. dyslipidemia and hypertension, which in turn raise cardio- Revascularization, such as carotid endarterectomy after vascular risk. It is these downstream effects"of diet and a transient ischemic attack, constitutes secondary stroke pre- physical activity patterns that are incorporated into quanti vention. Thrombolytic and anticoagulant therapies to limit fied estimates of future risk, such as the framingham cardiac stroke-related injury to the brain and rehabilitation pro- risk score. grams to preserve and restore function constitute the main Box 19-5 summarizes cardiovascular risk factors and pre stays of tertiary prevention. Updated information about vention strategies. Many risk factors contribute to cardiovas stroke management and prevention is available from the cular disease, including age, gender, hypertension, smoking, CDCand the American Stroke Foundation. As of January and dyslipidemia. Of the modifiable risk factors, a serum 2012, the USPSTF recommends against screening for carotid holesterol level greater than 181 mg/dL, systolic blood pres stenosis in asymptomatic individuals. 5 sure greater than 120 mm Hg, smoking, and history of Box 19-5 Summary of Cardiovascular Disease Risk Factors and Prevention Risk Factors Stress management Weight control Pharmacotherapy for risk factor modification (e. g, hypertension, Risk factor screening(e.g, cholesterol, blood pressure) Modifiable Dys Secondary Prevention Hypertensio Risk factor management, as for primary prevent Diabetes/prediabetes(including insulin resistance) Revascularization(angioplasty; coronary artery bypass Obesity, in particular abdominal (visceral) adiposity Lack of physical activity Tertiary Prevention Smokin Risk factor management as for primary prevention to prevent Revascularization to preserve/restore function Primary Prevention cardiac