Journal of Neurology & Neurophysiology

Identify the Stroke Risk Factors among Stroke Patients at the Hospital

Birhanu Alemu^1*, Jill Hamilton², Telisa Spikes³ and Rebecca Gary^{4 *}Correspondence: Birhanu Alemu, School of Nursing & Midwifery, College of Health Science, Addis Ababa University, Ethiopia, Tel: 251911910373, Email:

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Introduction

The incidence and outcome of stroke are influenced by socioeconomic status. There are few reports of population-level studies on these determinants [1]. Other studies have defined stroke as the sudden onset of focal neurological deficit attributable to a vascular cause [2].

Social Determinants of Health (SDOH) have previously been associated with incident stroke. Although SDOH often clusters within individuals, few studies have examined associations between incident stroke and multiple SDOH within the same individual [3].

According to the World Health Organization (WHO), stroke is a focal or global disorder of cerebral blood circulation that is ischemic or hemorrhagic with symptoms lasting 24 hours or more or leading to death [4].

Literature Review

Overall burden of stroke

Stroke is a leading cause of disability and death worldwide. Accounts for 42% of disability-adjusted life years and causes long-term disability in nearly 50% of survivors [5]. In 2020, strokes were the second leading cause of death after ischemic heart disease. According to WHO, estimates (2020), 15 million people worldwide experience a stroke each year. It is estimated that stroke mortality is seven times higher in low-income countries than in high-income countries. Sub-Saharan Africa (SSA) is experiencing an epidemiological shift, with increasing morbidity and mortality from noncommunicable diseases competing with the already growing infectious disease burden [6]. The burden of stroke is high in sub-Saharan Africa, where incidence and prevalence range from 15 to 159 and 15 to 815 per 100,000 person-years, respectively [7].

Another study showed that the burden of stroke in LMICs increased due to changes in socio-demographics and lifestyles. Seventy percent of strokes and 80-85% of stroke-related disabilities and deaths occur in low- and middle-income countries. The outcome of a stroke depends mainly on the presence and severity of post-stroke complications [8]. Although the burden of stroke in Ethiopia is unknown, it is believed to be increasing, and stroke accounts for 2.5% of all hospital admissions and 13.7% of all medical admissions. According to the latest data released in 2017, the number of stroke deaths in Ethiopia reached 39,571, or 6.23% of all deaths. The ageadjusted stroke death rate is 89.82 per 100,000 populations [9].

Risk factors of stroke

The main risk factors for stroke are common to other Non-Communicable Diseases (NCDs) and most are modifiable with effective interventions. These include high blood pressure, smoking, high blood sugar, lack of exercise, being overweight, and obesity [10].

Stroke risk factors can be categorized as modifiable and non-modifiable. Age, gender, family history, and race/ethnicity are non-modifiable risk factors; while hypertension, smoking, diet, and physical inactivity are among the modifiable risk factors identified. Different risk factors apply to an African population when developing a stroke. Africa could be increasingly affected by the high burden of strokes and other vascular diseases resulting from changes in the field of health according to constantly changing social, economic, and demographic models [11]. Various studies conducted in different parts of the world have revealed that the factors associated with stroke are age, sex, smoking, low physical activity, obesity, alcohol, nonadherence to antihypertensive drugs, uncontrolled blood pressure, diabetes, and cholesterol levels. But the above factors are different in [12].

It is a preventable and treatable disease respectively by preventing modifiable risk factors and recognizing the warning signs [13].Important risk factors for stroke are age, ethnicity, hypertension, diabetes mellitus, smoking, metabolic syndrome, and atrial fibrillation. There are many subtypes of stroke, and some subtypes are strongly age-related, such as atherosclerosis, atrial fibrillation, and small vessel disease. Also, older patients with ischemic stroke often have worse outcomes than younger patients [14]. 80% of stroke survivors had high blood pressure, the most common risk factor for stroke. Compared to men, women were more likely to suffer from diabetes, obesity, high LDL-C, and atrial fibrillation (p<0.05). Men drank and smoked much more often than women (P < 0.05) [15].

Ethiopia has also shared the global problem and strokes are becoming more common. The Burden of Disease study reported that there were 52,548 strokes and 38,353 deaths in Ethiopia in 2016. Previous studies have shown hospital mortality ranged from 11% to 44% [16]. Stroke is a public health problem in Ethiopia. Despite the high prevalence of stroke in Ethiopia, data on drug treatment, treatment outcomes, and risk factors for poor stroke outcomes are scarce [17]. There are limited data on risk factors for stroke in sub-Saharan Africa, including Ethiopia. Therefore, this research would fill the information gap by estimating stroke risk factors through a literature review.

Methodology

Aim

Risk factors are of paramount importance, as intervention strategies aimed at reducing these factors can subsequently reduce the risk of stroke. Early detection and modification of risk factors are imperative. A literature search served as the basis for identifying risk factors in stroke patients.

Search strategy

A literature search was performed using PubMed and the Woodruff Health Sciences Center Library Health Database. PubMed is an American search engine. National Library of Medicine (NLM) and includes over 33 million citations from biomedical literature, life science journals, and online books.

Search terms/phrases

The database searches used Boolean terms “OR” and “AND” with combinations of the following search term: magnitudes of stroke, stroke risk factors, predictors of stroke, health outcome, and adult stroke patients.

Inclusion/ exclusion criteria

The literature search selected English-language journal articles from recent work on stroke risk factors between January 2012 and September 2022.

The following studies may be included:

• Abstract and free full text and full-text

• Year of publication 10 years (2012-2022)

• Conducted in low and middle income countries, type of article journal article

• Human species

• Adult age 19+ years

Searches that did not address the following topics: stroke risk factors and extent of stroke were excluded. Systematic reviews, literature reviews, and case reports were excluded from the report.

The final number of articles that will be discussed in the text

In this search, a total of 980 published were identified. After articles were removed by duplications, titles, and reading the abstract, 172 studies were assessed for eligibility criteria. Consequently, 152 studies were excluded due to the outcome of interest was not reported, having data that were not extractable and conducted in other countries. Finally, a total of 20 studies that satisfy the eligibility criteria were included in this literature review. The detailed descriptions of the included studies are presented in (Figure 1).

Figure 1: The flow chart diagram that describes the selection of studies included in this study: Prisma Flow Diagram- PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers, and other sources

Results

To maximize the body of information on the magnitude of stroke risk factors, we selected about twenty articles to be included in the study. This helps authors gather information from the global to the national level. As a result, seventeen original papers consisting of stroke risk and severity factors were obtained through PubMed searches.

A further manual search of the available reference lists yielded three additional articles, bringing the number of articles meeting the criteria for this review to twenty. A total of twenty studies were reviewed. The researched articles were published between 2012 and 2022 in electronic databases – PubMed/Medline.

There were four global articles; four African articles and the rest were national articles. The articles available worldwide indicated that most of the risk factors were associated with high blood pressure and hypertension. The most common risk factor was hypertension, followed by dyslipidemia and diabetes mellitus [18].

The African content study shows that hypertension was present in 80% of all strokes and was significantly associated with hemorrhagic stroke (p=0.03). Overall, 38% of the documented stroke burden was due to hypertension.

The literature indicates that the most frequently identified risk factor was hypertension (75.9%), followed by family history (33.6%), alcohol consumption (22.4%), smoking ( 17.2%), and heart failure (17.2%). The majority of patients 94 (84.7%) had at least one prior risk factor, of which hypertension accounted for 44.1%.

Moreover, more than half of them (333, 55.8%) had at least one comorbidity, of which the most common comorbidities were hypertension (219, 64.9%), atrial fibrillation (114, 34.2%) and diabetes mellitus (83, 24.9%).

Most articles used a prospective cohort study and data were collected through interviews. The literature review shows the magnitude of risk factors and stroke in stroke patients. The characteristics of the selected literature reviews are shown in (Table 1).

Table 1. Description of the characteristics and contributions of the selected research studies and literature reviews

Discussion

This bibliographic search, to gather comprehensible information, contains the synthesis of the studies collected from the global to the national level. In summary, the most common risk factor for stroke is uncontrolled blood pressure or hypertension followed by diabetes mellitus. 71% of first strokes (4326) were ischemic, and the most common pre-stroke risk factor was hypertension (3760, 65%).

Risk factors for stroke included hypertension, diabetes mellitus, smoking, obesity, dyslipidemia, alcoholism, heart disease, history of stroke or transient ischemic attack, migraine, hormonal contraception, low fruit and vegetable intake, low physical inactivity, and a family history of vascular disease. The result of another paper showed that uncontrolled systolic blood pressure is 3.2 times more likely to develop stroke and uncontrolled diastolic blood pressure is 2.2 times more likely to develop stroke.

Most of the study papers cite hypertension as the primary outcome finding, which occurs primarily in hemorrhagic stroke (158.84%) compared to patients with ischemic stroke (175.44.6%). Most studies report hypertension as the primary endpoint, which occurs mainly in hemorrhagic stroke (158.84%) compared to ischemic stroke patients (175.44.6%).

A history of hypertension was reported by 61% of stroke survivors. Similarly, another study conducted in Addis Ababa, Ethiopia reported that hypertension occurred in 65% of all study participants, regardless of the type of stroke. The expected result was observed in the study.

Most of the stroke patients were hypertensive patients. These findings were confirmed by identified study articles. Furthermore, some unexpected results have been found in the literature studies. About 24.5% of participants chew chat and drink alcohol, and 13% of them smoke cigarettes.

In this finding, chat chewing is an additional risk factor contributing to the causes of stroke, which need further attention in the study area as this practice is more prevalent in the study area, Ethiopia. This literature review shows several risk factors that have contributed to the cause of stroke. However, the study doesn't reveal how it causes strokes.

Moreover, these new findings require more attention in the prevention of stroke risk factors. The lack of Ethiopian context-specific data limits the formulation of well-designed responses and treatment of stroke. Much, therefore, remains to be done urgently to address the current challenges related to the risk factors and clinical profile of stroke in Ethiopia.

More research is needed to identify stroke risk factors and their associations in the future. Further studies are needed to understand the mechanisms of stroke risk factors.

Strengths

•This study has been classified from global to national.

•It contains decennial articles.

•It generates the most important and expected information.

Limitations

•This study was not without limitations. There is heterogeneity among the included studies.

•The study is based primarily on patient cases and cannot be externally validated for the general population.

Conclusions

Strokes are increasingly common in low and middle income countries like Ethiopia, posing challenges to health systems and communities. The most commonly identified risk factor was high blood pressure, and that was alarming. A better understanding of stroke risk factors is needed for the development and integration of early interventions and preventive measures to reduce the incidence and severity of stroke.

Implications for Nursing Research

A stroke can make daily activities difficult. These problems can be due to several stroke-related conditions, such as weak limbs, numbness or paralysis, communication problems, vision problems, and unilateral neglect issues.

Social Determinants of Health (SDH), such as income level and education, can serve as predictors of adverse health outcomes. In particular, these indicators can increase the patient's risk of stroke. SDOHs are often beyond the physician's control and can be a frustrating obstacle to patient care.

Acknowledgements

The author thanks, Dr. Jill Hamilton, RN, Ph.D. FAN, Dr. Telisa Spikes, and Professor Rebecca Gary, RN, Ph.D., FAHA, FAAN collaborate in the preparation of this paper.

Nell Hodgson Woodruff School of Nursing of Emory University in Atlanta, Georgia.

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