International Journal of Nutrition, Pharmacology, Neurological Diseases

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 12  |  Issue : 3  |  Page : 120--125

Analysis of Stroke-Risk Factors Among Stroke Survivors


Daalshini Murugan1, Suresh Kumar Selvaraj2, Arulmozhi Devi Anandan2, Shenbaga Sundaram Subramanian3, Shazia Neelam3, Makesh Babu Subramanian4, Dhivakar Murugan4, Syed Abudaheer Kajamohideen5,  
1 Victoria Physiotherapy Centre, Kuala Lumpur, Malaysia
2 Department of Physiotherapy, Faculty of Health Sciences, MAHSA University, Selangor, Malaysia
3 Chettinad School of Physiotherapy, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India
4 Sree Anjaneya College of Paramedical Sciences, Malabar Medical College Hospital & Research Centre Campus, Calicut, Kerala, India
5 Senior Lecturer, AIMST University, Malaysia

Correspondence Address:
Shenbaga Sundaram Subramanian
Chettinad School of Physiotherapy, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu 603103
India

Abstract

Introduction: Stroke, also known as cerebrovascular accident, is the sudden loss of neurologic function caused by an interruption of the blood flow to the brain. It is the third most common cause of mortality and the leading cause of long-term disability worldwide. Ischemic and hemorrhagic are two types of strokes caused by the blockage or rupture of the blood vessel. Adverse consequences on stroke survivors’ physical, psychosocial, emotional, social, and economic status place stroke among the leading causes of diminished quality of life. Individuals who have suffered a previous stroke are at the risk of recurrence. Perhaps, early prevention by identifying the risk factor may minimize the implications of stroke in the citizen and prevent recurrent stroke. Methods: Cross-sectional study of the qualitative approach was undertaken. A case sheet of 100 subjects who fulfill with the inclusion and exclusion criteria was included using the convenience sampling method. This study was performed within 3 months. Patients’ information was collected from their case sheets and filled into the study data collection form. The collected study data were analyzed using descriptive statistics of mean ± standard deviation, mode, and percentage. Results: Hypertension, diabetes mellitus, and cholesterol are the most common risk factors. Constantly hypertension is the highest among the overall stroke survivors, stroke subtypes, and in different age groups. However, the sequences of stroke-risk factors associated with stroke subtypes and different age groups vary. Conclusion: The study’s objectives have been achieved by addressing the common risk factors in overall stroke survivors, in stroke subtypes, and other age groups.



How to cite this article:
Murugan D, Selvaraj SK, Anandan AD, Subramanian SS, Neelam S, Subramanian MB, Murugan D, Kajamohideen SA. Analysis of Stroke-Risk Factors Among Stroke Survivors.Int J Nutr Pharmacol Neurol Dis 2022;12:120-125


How to cite this URL:
Murugan D, Selvaraj SK, Anandan AD, Subramanian SS, Neelam S, Subramanian MB, Murugan D, Kajamohideen SA. Analysis of Stroke-Risk Factors Among Stroke Survivors. Int J Nutr Pharmacol Neurol Dis [serial online] 2022 [cited 2022 Dec 8 ];12:120-125
Available from: https://www.ijnpnd.com/text.asp?2022/12/3/120/357249


Full Text



 Introduction



According to World Health Organization definition of stroke is; “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin.“[1]. The stroke can be classified into two types: ischemic stroke and hemorrhagic stroke; the rate of ischemic stroke is higher than the rate of hemorrhagic stroke (85% and 15%, respectively). When the brain receives an inadequate oxygen supply, the surrounding tissues lose their viability and eventually develop an ischemic stroke. Apart from ischemic stroke, 10% to 15% of cases are reported as hemorrhagic stroke. During the hemorrhagic stroke, the interruption of blood flow to the brain mainly happens when the blood vessels get ruptured. This eventually results in the accumulation of blood in the brain leading to midline shift.[2] Stroke is one of the primary leading factors of mortality and disability worldwide in both developed and developing countries. In 2016, stroke documented 116.4 million disability-adjusted life years (DALYs) and 5.5 million deaths worldwide. Approximately 25.7 million stroke survivors, 6.5 million deaths, 113 million DALYs, and 10.3 million new cases of strokes were reported. According to the 2021 Heart Disease and Stroke Statistics Update Fact Sheet published by American Heart Association, it is reported 6.6 million deaths due to stroke worldwide. Stroke-risk factors are classified into modifiable and nonmodifiable. Age, sex, race/ethnicity, and family history diagnosed with stroke are nonmodifiable stroke-risk factors. In contrast, hypertension, smoking, alcohol, obesity, physical inactivity, diabetes mellitus (DM), hyperlipidemia, nutrition, and cardiac disease are the modifiable risk factors.[3] Age acts as a predominant influencer to the stroke-risk factors. The incidence of stroke doubles after 55 years for each decade and over 70% of all strokes occur above 65. Another report says ischemic and hemorrhagic stroke incidences substantially increased (1151–1216 per 100,000) in people >75 years old. Thus, patients over the age of 65 have a higher rate of mortality and morbidity and a reduced probability of functional recovery than their younger counterparts.[4] Gender is another nonmodifiable risk factor of stroke, and the female population is most affected compared to the male population. Statistically, it shows that females are 51% and males are 49% affected. Women are more likely to develop a stroke than males because they have more episodes and are less likely to recuperate. Even though men have greater age-specific stroke rates than women, due to their longer lifespan, women experience more stroke incidents and significantly higher occurrence at older ages.[5] Racial disparity is another nonmodifiable risk factor. According to a study, the risk of stroke incidents in African Americans is double that of their white counterparts. It clearly shows that racial-ethnic group disparity has highly influenced mortality associated with stroke. Genetic factors are also known as nonmodifiable risk factors for stroke, with family history highlighting the risk of stroke.[6] The cerebral circulation is adversely affected by hypertension, as it becomes the main reason for the composition of a blood vessel to change. It stimulates the growth of atherosclerotic plaques in cerebral arteries and arterioles. This causes an arterial blockage and ischemic stroke, allowing lipohyalinosis to occur in the penetrating arterioles. This will accumulate fluid and further up into gliosis in white matter tracts, resulting in bleeding. The prevalence of stroke in patients with hypertension is directly proportional to age. This is proven by the study saying that 20% of a risk population who can experience a stroke are patients with hypertension, and they are 50 years old.[7] Hyperlipidemia is another modifiable risk factor that is a key to increase stroke-risk incidences. Triglycerides, cholesterol, cholesterol esters, phospholipids, and/or plasma lipoproteins, including low-density lipoprotein (LDL) and high-density lipoprotein (HDL) levels, are a form of plasma lipids. An individual with a record of high levels of total cholesterol and LDL cholesterol is more likely to experience an ischemic stroke, and those with a low level will encounter intracerebral haemorrhage (ICH) (Daniel, 2019). In conjunction, being obese or obese is one of the factors in the occurrence of stroke. As stated in the International Obesity Task Force, obesity has been classified with different body mass index (BMI) readings. The levels are preobesity (25–29.9), obesity class I (30–34.9), obesity class II (34.9–39.9), and obesity class III (40 or above). It was justified that if a BMI of an individual is elevated to one unit, the prevalence of stroke risk increases 6%, correspondingly.[8] Next, modifiable stroke-risk factors are DM. Diabetes develops when the person’s body metabolism cannot generate or react to insulin. This defect causes an abnormal carbohydrate metabolism and an elevation of glucose levels in the blood and urine. In time, this will result in a buildup of deposits and clots on the walls of blood vessels, potentially interrupting blood supply or oxygen to the brain.[9] Cigarette smoking is a well-known risk factor for all types of stroke. On average, smoking kills one person every 6 seconds worldwide, and tobacco users lose 15 years of life expectancy. It is clearly stated that in developed and underdeveloped countries, smoking in males is about 42% and 48%, respectively, whereas for females, it is approximately 24% and 7%, respectively.[10] In addition, physical inactivity is also a stroke-risk factor; physical inactivity causes deteriorations in multiple mechanisms that cause stroke-like uncontrolled sugar levels in the body, increased plasma triglycerides, HDL cholesterol, and irregular blood pressure.[11] Nutrition plays an essential role in stroke risk. About 80% of stroke risk can be lower with a proper healthy lifestyle. An improper diet like taking too much salt in the meal might affect the blood pressure and develop fibrosis in most organs like the heart, kidneys, and arteries tissue. This will result in escalating cardiovascular and stroke risks.[12] Alcohol consumption is another risk factor in stroke; a heavy alcohol consumer (>4 drinks/day) appears to have more chance of experiencing an ischemic stroke as the stroke-risk rate is significantly high. Last but not least, the contraceptive pill also contributes to the rise of stroke cases. The oral contraceptive pill contains progesterone and estrogen, which helps in birth control and menstrual-related problems. Females taking the oral contraceptive pill are more likely to experience an ischemic stroke, which is due to the estrogen contained in the pill.[13] There is no study regarding stroke-risk factors assessment performed in Malaysia. Perhaps, as the initial step, identifying the risk factors may minimize the implications of stroke in the citizen and prevent recurrent stroke. Thus, this study aims to identify and analyze the risk factor among stroke survivors in Malaysia.

Procedure and Methodolgy

This study was a setup based on a qualitative approach using a cross-sectional study design, approved by the Local Ethics Committee of the School of Physiotherapy, Faculty of Health Sciences, MAHSA University. The ethical approval was obtained from MAHSA University before the study implementation. The case sheet comprised the following details was included in this study. Patients who were diagnosed with a stroke, patients who had a risk factor of stroke from the year 2015, and patients who were associated with other neurologic conditions were excluded from the study. The sample size for this study was calculated using the formula S = 4pq/d2. The value of p indicates the anticipated proportions (from the previous study), the value of q is (1 − p), and the d is the relative precision (allowance errors 5–20%). By using this formula, 100 stroke survivors were recruited in this study. A nonprobability used the convenient sampling method for this study to gather the 100 case sheets of stroke survivors from PY Physiotherapy and Rehabilitation. Information on the stroke survivors’ demographic data such as name, age, types of stroke, and their first onset of stroke was retrieved from the case sheets.

Necessary safety and precautionary measures have been taken before and throughout the research process since the pandemic of coronavirus disease 2019. The data collection was agreed to be carried out virtually through Google meet to prevent the spreading of the virus. The standardized data extraction form consists of a table of risk factors designed to tick at the individual risk factors based on the patients’ encounters. The cases that have been recruited in the study were from the past 5 years. It took approximately 2-month time to complete the entire data collection of the study.

 Results



In this study, statistical analysis was performed using SPSS software (IBM, version 20) to interpret mean, mode, standard deviation, and frequency of distribution. The mode was used to evaluate the gender and stroke subtypes; meanwhile, overall age and the subgroup age were used mean and standard deviation. For the main component of this study, risk factors were analyzed using the mode and percentage for precise value.

In the standardized data extraction form, there were 10 stroke-related risk factors such as hypertension, DM, smoking habit, alcohol intake, cholesterol, physical inactivity, obesity, cardiac diseases, family history, and contraceptive pills intake were used [Table 1] and [Figure 1]. These risk factors have been used to identify in the selected 100 stroke survivors. [Table 1] shows the list of risk factors with the number of stroke survivors having it. [Figure 1] shows the pie chart of risk factors distributions. Ninety-two out 100 stroke survivors have hypertension which records the highest among all other risk factors (22%). The second highest risk factor is cholesterol which has been recorded in 69 stroke survivors (17%). The next risk factor is DM which has been documented in 62 stroke survivors (15%). Cardiac diseases were the fourth highest risk factor, which have been identified in 42 stroke survivors (10%). Besides, 38 out of 100 stroke survivors (9%) were presented with history of family members having stroke. The following risk factor is alcohol intake which has been noticed in 35 stroke survivors (8%). Furthermore, smoking habit and physical inactivity have been found in 30 and 31 stroke survivors, respectively, where both have the same value of 7%. Looking into the least number of risk factors, obesity is the second least among all other risk factors which have been recorded from 18 stroke survivors (4%) and the last in list is conceptive pills. Only five stroke survivors (1%) were documented under this risk factor.{Table 1}{Figure 1}

The risk factors have been classified among different age groups, as shown in [Table 2] and [Figure 2]. The distribution of stroke-risk factor in the age group 20 to 39 clarifies that hypertension has been identified with the most significant number of stroke survivors (20%). The second highest is cholesterol; six out of nine stroke survivors (15%) had cholesterol. Both alcohol intake and contraceptive pills have recorded the same number of stroke survivors. Five out of 9 stroke survivors (13%) are the third highest risk factors in the age group 20 to 39.{Table 2}{Figure 2}

The distribution of stroke-risk factor in the age group 40 to 59 is shown in [Table 3] and [Figure 3]. The top three risk factors in this age group are hypertension, cholesterol, and DM. From the total of 41 stroke survivors, 36 stroke survivors (21%) were presented with hypertension, 31 stroke survivors (18%) had cholesterol, and 24 stroke survivors (14%) had DM.{Table 3}{Figure 3}

[Table 4] and [Figure 4] describe the distribution of stroke-risk factors in age group 60 to 79. Hypertension is the leading risk factors in the age group because in total of 42 stroke survivors only 2 of them were not presented with hypertension. About 22% of the total population in this age group has hypertension. Next, DM is the second leading in this group as it was recorded with 30 stroke survivors (17%). Twenty-nine stroke survivors (16%) were identified with cholesterol.{Table 4}{Figure 4}

The distribution of stroke-risk factors in age group 80+ is shown in [Table 5] and [Figure 5]. The risk factor hypertension is highly identified among the eight-stroke survivors in this age group. It contributes 27%, whereas the next highest risk factors DM and physical inactivity contribute 14% and 13%, respectively. Cholesterol, cardiac diseases, family history, and alcohol intake are the risk factors with the same number of stroke survivors, contributing 10% each in this group.{Table 5}{Figure 5}

 Discussion



The motive of our study is to analyze the risk factors among stroke survivors. A stroke is a medical emergency that is caused by a disturbance occurring in the blood flow to the brain. Identification of risk factors plays a vital role in stroke prevention. This study was carried out by using case sheets of 100 stroke survivors from PY Physiotherapy and Rehabilitation. Information such as demographic data and patients’ associated risk factors were derived from the medical reports and used for data analysis to provide accurate results for the untitled project. The majority populations of this study were males. This shows a contrast result from a statistical report by Kurubaran (2020), which says that females are highly affected by stroke compared to males. Following that, Mahdi et al. (2018) also prove that more than 50% of his study population is male. We are looking into the next component, which is types of stroke, those stroke survivors who are involved in the current study are mostly diagnosed with ischemic stroke 70%. In line with that, the subjects who were recruited in the study by Awad et al. (2010) were also mostly diagnosed with ischemic stroke. Similar to the study by Mozaffarian et al. (2015), the 100 stroke survivors of our study have been classified into four different age groups: 20 to 39, 40 to 59, 60 to 79, and 80+. Interestingly, the stroke survivors who have been categorized into age groups (40–59) and (60–79) is higher in our study compared to the previous study. The mean age of our study is 58.68 years old, which is slightly higher than the previous prospective observational study of risk factors carried out in 2019 as it has resulted in the mean age of 55.1 ± 14.0. Stroke-risk factors are key considerations of the incidence of stroke. In general, risk factors such as hypertension, cholesterol, and DM are the topmost risk factors that have been recognized in the 100 stroke survivors of this study. This result is similar to the previous study carried out in Gorgan, suggesting that overall stroke-risk factors hypertension, DM, and dyslipidemia were the major risk factors that have been noticed. Apparently, there are few existing studies that have been carried out on stroke-risk factors among stroke subtypes. Our study is proportionately different since the previous study published by Chung et al. (2021) has figured out the associated risk factors in ischemic stroke only. Our study focuses on the risk factors associated with both ischemic and hemorrhagic strokes. Nevertheless, the outcome of the current study says that hypertension is a common risk factor in both ischemic and hemorrhagic strokes, which is similar to Mahdi et al. (2018). However, it is noticeable that there are few variations in the sequence of risk factors distribution among different age groups in the present study. The difference is one person’s lifestyle associated with different ages such as lack of energy in older age and hormonal factors in young women are determinants of stroke risk in different age groups. Stroke-risk factors consist of modifiable and nonmodifiable risk factors. In this study, the chosen stroke-risk factors are mostly modifiable, and through this study, we were able to identify the most common risk factors in overall stroke survivors, stroke subtypes, and different age groups. Perhaps, with this identification of risk factors, we are able to move a step closer in knowing the high-risk population. Furthermore, this will help to customize the future treatment and education program for the specific population. It is feasible to minimize or delay recurrent stroke by identifying the high-risk group and focusing on modifiable risk factors in them. The only limitation found in this study was the data collection had not been carried out in a wide spectrum. As for the further recommendation, the study should emphasize national wide with a huge number of samples.

 Conclusion



In a nutshell, the majority of stroke survivors in this study are males and those who diagnose with ischemic stroke. Looking into the age group, the age groups 40 to 59 and 60 to 79 have the highest number of stroke survivors. Evidently, hypertension, cholesterol, and DM are the topmost risk factors that have been noticed in the overall population of stroke survivors. However, the sequences of stroke-risk factors associated with stroke subtypes and different age groups vary from one another. This could be because of their lifestyle choices and social factors which influence them.

Acknowledgment

The authors acknowledge PY Physiotherapy and Rehabilitation Center, Malaysia for providing infrastructural facilities.

Authors’ contributions

DM did the experiment and collected the data. SKS was a guide. ADA was a co-guide. SSS helped to frame the title and methodology and was the first guide. SN drafted and critical revision of the study. MBS and DM were interpreted and analyzed the data.

Ethical clearance

Ethical clearance for this study was got approved by the Institutional Human Ethical Committee.[18]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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