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UVA Health neurologist Dr. Bradford Worrall recently spoke to UVA Today about the risk of stroke at middle age, especially for African American men. He shared his best advice for avoiding the condition, as well as how to minimize the damage if you do have an attack.
Q. What happens when a person has a stroke?
A. Stroke is a general term that applies to acute loss of neurologic function due to a problem with a blood vessel in the brain. The most common form is ischemic, accounting for 85% of all strokes. This happens when the flow of blood to the brain is blocked. Victims may experience numbness or paralysis – often in the face, arms or legs. They can have trouble speaking and suffer other cognitive impairment.
A transient ischemic attack, or a TIA, is a warning for an ischemic stroke much like the way chest pain is a warning for a heart attack.
The other cause of stroke is bleeding in the brain, when a blood vessel ruptures and leaks blood directly into the brain or into one of the layers around the brain.
Q. What are some basics we need to know about stroke and middle age?
A. First, it is important to recognize that, while we typically think of stroke as a condition that affects older people, in reality stroke can occur any time during the lifespan. Second, it is worth noting that while we have seen a drop in the stroke occurrence in older patients, the incidence of stroke actually increased in middle age (defined differently in different studies but generally between 45 and 59 years of age). This is happening not only in the United States, but across the globe.
Stroke at any age can be devastating, but it is particularly so in middle age when people are frequently at the peak of their productivity.
Q. Why are African Americans more at risk?
A. We have a stark disparity in the U.S. regarding stroke. People of African ancestry in the U.S. are, and have been for many years, at higher risk compared with other ancestral groups. To put it bluntly, African Americans face substantial higher risk of having a first stroke, higher risk of dying from stroke, higher risk of having a recurrent stroke, and higher risk of developing dementia and cognitive problems after stroke.
In all racial and ethnic groups, men have higher risk of stroke at any age. However, since women generally live longer than men, more women experience stroke than men.
For African American men, the high-risk disparity of stroke, stroke death, stroke recurrence and stroke-related cognitive problems is greatest in middle age. By the time people are in their 70s, the stroke health disparity has substantially decreased.
We do not fully understand all of the reasons for the disparity. In general, risk of stroke is influenced by age, sex, family history, smoking status, diabetes, blood pressure, physical activity level and an irregular heartbeat called atrial fibrillation.
Q. Are identifying high blood pressure and managing it key?
A. Blood pressure is the single most important stroke risk factor at a population level. Hypertension is very prevalent. The evidence that controlling blood pressure has a substantial effect in lowering risk of stroke is overwhelmingly strong.
The importance of hypertension in driving the stroke health disparities has increasingly been recognized. A crucial study called the Reasons for Geographic and Racial Differences in Stroke, or REGARDS, showed that African Americans were more likely than European Americans to be aware of their diagnosis of hypertension, more likely to be on treatment for hypertension and taking their medications, but less likely to have their blood pressure under control.
Furthermore, there is evidence that the adverse effect of high blood pressure may be greater in African Americans compared to European Americans. Indeed, a 10 millimeters of mercury increase in systolic blood pressure (the top number) is associated with an 8% increased risk of stroke in European Americans, but a staggering 24% increased risk in African Americans.
Said another way, an African American man with a blood pressure of 140/90 may be at three times the stroke risk of a man of European ancestry with the exact same blood pressure.
Q. Why is blood pressure control sometimes a problem with Black men?
A. There is so much that we still do not know. I mentioned that awareness, treatment and adherence may in fact be greater in the Black community than in the white community. This does not mean that for certain individuals that awareness, access to care and adherence are not problems.
What it does mean is that we need to address issues beyond these factors if we are really going to reduce the risk endured by African Americans, especially African American men. We must consider additional contributors such as social determinants of health, individual experiences of racism, institutionalized racism, etc. We know that race is a social construct, not a biological “reality.” Thus, there are factors beyond the DNA sequences that they inherited that put African American men at increased risk.
Notably, the Center for Health Equity and Precision Public Health is a distinguishing effort that we now have at UVA. It’s trying to tackle the reasons behind health disparities like what we see in stroke.
Q. What advice do you have for our readers in terms of prevention?
A. If you have high blood pressure, work with your primary care provider to not only treat, but also control, your blood pressure. The goal for most people is less than 130/80. If you have diabetes or high cholesterol, also work with your primary care provider.
Diet plays an important role in managing high blood pressure, diabetes and cholesterol. A Mediterranean diet may lower risk.
If you smoke, stop! Know your risk factors, know your goals, and know how successfully you are responding to treatment.
Modest exercise can have a HUGE effect. Exercising as little as 30 minutes per day, four days a week at an intensity to make you sweat – walking like you are late for an appointment – can be very effective in reducing stroke risk.
Q. In the instance of a stroke, what can families do right away to reduce the possible damage?
A. Call 911 right away. Do not call me, or your primary care provider, or your cousin the cardiology nurse; call 911. All of those other calls can be made once you are in the Emergency Department.
There are some simple tools like BE-FAST that you can review now that may help.
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