A 65-year-old man comes to the office for a follow-up visit. His friend recently died from a massive cerebrovascular event. The patient is worried about his individual risk for stroke. Medical conditions include hypertension, type 2 diabetes mellitus, hypercholesterolemia, and obesity. He is an active smoker with a 40-pack-year history. The patient does not use alcohol or illicit drugs. Family history is not contributory. Medications include low-dose (81-mg) aspirin, metformin, lisinopril, and atorvastatin. Blood pressure is 161/92 mm Hg. BMI is 30 kg/m². Examination shows no abnormalities. Laboratory results are as follows: Which of the following would provide the greatest benefit for decreasing this patient's risk for an ischemic stroke?

Question

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Explanation: Most ischemic strokes are related to atherosclerotic cerebrovascular disease. Major modifiable risk factors for ischemic stroke include: hypertension. hypercholesterolemia. diabetes mellitus. smoking. Patients at risk for stroke warrant a multifactorial care plan to address all risk factors, in addition to general recommendations regarding healthy habits (eg, regular exercise, weight loss). Of these risk factors, hypertension control has the largest potential benefit in primary prevention of stroke. Stroke risk rises sharply with blood pressure, with an approximate 2-fold increase in risk for every 20/10 mm Hg rise above 130/80 mm Hg. Therefore, all patients with elevated blood pressure should be counseled on lifestyle interventions for blood pressure control (eg, DASH [Dietary Approaches to Stop Hypertension] diet) and antihypertensive medications (as appropriate) to reduce the risk for stroke. Patients with diabetes should have a blood pressure target of 140/90 mm Hg, with many experts recommending a goal of 130/80 mm Hg if tolerated. (Choice A) Heavy drinking can increase stroke risk and should be reduced or stopped. Some studies have found a slightly lower risk for stroke in individuals who consume light to moderate alcohol (eg, 1 or 2 drinks/day for men); risk reduction via initiation of alcohol intake has not been proven and is not recommended. (Choice B) Hypertriglyceridemia's increased risk for stroke is related primarily to the presence of concurrent risk factors (eg, hypercholesterolemia). Fibrates (eg, fenofibrate) have not been shown to reduce stroke risk and are likely unbeneficial in this patient with a small elevation in triglycerides. Statins (eg, atorvastatin) are recommended by most treatment guidelines for patients age >40 with diabetes mellitus and have a modest triglyceride-lowering effect. (Choice C) Aspirin is generally recommended to prevent cardiovascular disease and stroke in patients at high risk for stroke (eg, 10-year risk >10%). However, there is no convincing evidence that risk reduction is greater with a high (325 mg/day) compared to a low (81 mg/day) dose. (Choice E) Although intensive glycemic control (eg, hemoglobin A1c <7.0%) is associated with a lower risk for microvascular complications (eg, nephropathy), its benefits in stroke risk reduction are unclear and likely less than in those with aggressive blood pressure control. Educational objective: The major treatable risk factors for ischemic stroke include hypertension, diabetes mellitus, smoking, and dyslipidemia. Hypertension is the most important modifiable risk factor for stroke. All patients with elevated blood pressure should be counseled on lifestyle interventions for blood pressure control (eg, DASH [Dietary Approaches to Stop Hypertension] diet) and antihypertensive medications (as appropriate) to reduce the risk for stroke. References: Guidelines for the Primary Prevention of Stroke (http://www.ncbi.nlm.nih.gov/pubmed/25355838) Primary and secondary prevention of ischemic stroke. (http://www.ncbi.nlm.nih.gov/pubmed/20357456)

A 65-Year-Old Man Comes to the Office for a Follow-Up