Joseph F. McCaffrey MD, FACS


How to Reduce Your Chance of Experiencing One of the Most Devastating Events Possible

Mr. Johnson's eyes showed his frustration as he tried to speak. What should have been words came out as meaningless sounds.

He listed to one side in his wheelchair, unable to use his weakened left side to straighten himself. The paralysis meant that he needed help with the most basic things -- getting out of bed, eating, getting dressed, going to the bathroom.

But perhaps most frustrating was that inability to talk. After 79 years of living a happy and productive life, it was almost too much to bear.

It's heart rending to see a person with a stroke. I've seen it too often.

Some strokes are fatal, and many consider that a blessing if they've seen the disabilities survivors have to live with. And although the risk of stroke increases with age, it can happen to anyone.

A stroke occurs when an area of the brain dies. Eighty percent are caused by a blockage of blood flow. Most of the rest are caused by bleeding in the brain.

Hardening of the arteries, the same process that causes heart attacks, underlies most strokes. As plaque builds up, it narrows the artery, reducing flow. This happens slowly. Since the body is remarkably adaptive, even a very marked narrowing might not cause any symptoms for some time.

However, plaque in the carotid artery (the main artery supplying the brain -- there's one on each side) is a ticking time bomb. At any time, it might cause the artery to clot off, starving the brain of blood.

Or a portion of the plaque might break off, traveling downstream in the blood flow until it wedges in a smaller artery, blocking it and causing the part of the brain supplied by that artery to die. Physicians call this an embolus.

The exact symptoms of a stroke vary with the part of the brain affected. The person may or may not lose consciousness. An arm or leg or both may become paralyzed or lose feeling. Damage to language processing areas can render the person's speech garbled or confused.

Another possible symptom is the sudden loss of vision in one eye. This symptom is caused by a tiny bit of plaque, that embolus I referred to earlier, lodging in the artery to the eye.

The first part of the retina to die is the area farthest from the blockage. Vision fades there, then the darkness spreads as more of the retina dies. The person experiencing this often describes it “as if a shade was pulled down”.

An Ounce of Prevention

Perhaps the most disturbing thing about strokes is that the vast majority should never occur. They're preventable. Right now, I want to let you know what you can do to protect yourself from this catastrophic event.

As I mentioned, most strokes are caused by the same underlying process that causes heart attacks. That means that the same factors that decrease your risk of heart attack also decrease your risk of stroke.

I'll review some of these but won't belabor them. I definitely want to point out other effective steps you can take that aren't talked about enough and you may not be aware of.

Stop Smoking

I'll avoid a long lecture. If you smoke, do whatever you need to do to stop. Simply put, it's one of the most self-destructive habits you can have. An increased risk of stroke is only one of a laundry list of negative consequences. Enough said.

Drink Alcohol in Moderation

The relationship between drinking alcoholic beverages and stroke remains a little unclear. It appears that one drink a day may slightly reduce the risk of stroke, while 3 drinks a day more than doubles the risk.1 It's another reason to refrain from heavy drinking.

Control Your Blood Pressure

High blood pressure contributes to both heart disease and stroke. It's also a major cause of kidney failure.

Most physicians recommend maintaining the systolic blood pressure at 120 mmHg and the diastolic blood pressure at 80 mmHg or lower. However, even small reductions in blood pressure (i.e., 9 mmHg systolic and 5 mmHg diastolic) can reduce the relative risk of stroke by about one third.

Ideally, you control your blood pressure with a healthy lifestyle. A diet emphasizing fruits and vegetables and low in salt intake helps. So does maintaining a normal weight and exercising regularly.

The balance between sodium and potassium in the body is important for blood pressure regulation. Most people get too much sodium from salt and not enough potassium. An easy way to add potassium as well as other nutrients to your diet is to regularly drink a no salt or low salt tomato-based vegetable juice with a little potassium chloride salt substitute added (No Salt and Nu Salt are widely available brands).

Magnesium contributes to blood pressure control as well. It won't do the job by itself, but is part of an overall program -- 500 mg a day is a reasonable dose for most people.

Lower Homocysteine Levels

Homocysteine has been getting a little more attention recently as an important risk factor for hardening of the arteries. Although studies have yet to definitely prove that lowering homocysteine levels prevents strokes, the treatment is simple and safe enough that there's little risk in lowering your homocysteine levels while further studies are being done.

Homocysteine levels can easily be measured with a blood test. You lower homocysteine by supplementing with vitamins __ namely folic acid, B6 and B12.

Keep Your Gums Healthy

This surprises many people, but more and more research shows a link between gum disease and vascular disease, including stroke. The connection seems to be caused by chronic activation of the body's inflammatory system by the gum disease.

Elevated levels of inflammatory factors circulating in the bloodstream slightly injure the lining of arteries. This starts a chain of events that leads to the development of plaque.

Eliminating the inflammation prevents the plaque. The answer is good dental hygiene.

As a baseline, regular professional cleaning both prevents gum disease and allows early treatment should you develop it. Schedule a regular cleaning every 6 months.

Next, use an electric tooth brush. It's both more effective and gentler on your teeth than manual brushing.

Flossing is the good habit people love to hate. For some reason, most people just don't do it. As you now know, the benefits of healthy gums go way beyond letting you keep your teeth. Floss regularly.

My teeth are very close together and I had trouble flossing until the Glide brand of floss came along. If you're having trouble, see if this helps you too.

Take Fish Oil Every Day

I've written about the many benefits of fish oil before. Reducing the risk of stroke is a big one. One study.6 showed a 52% reduction in strokes in women who eat fish at least 5 days a week.

Many people don't want to eat fish that often and unfortunately heavy metals and pesticides contaminate many fish these days. For these reasons, fish oil supplements make sense for most people. I recommend 1-2 grams twice a day, taken with meals.

Do You Need Low-Dose Aspirin?

Platelets are the body's first responders to a cut in a blood vessel. When an injury occurs, they clump together to form a temporary plug while the clotting process gets underway.

Unfortunately, as plaque builds up on the interior of vessels, it also can stimulate the platelets to clump. That clump can block the vessel right there or it might break off and cause damage downstream. To reduce the chance of that happening, physicians often recommend aspirin at the children's dose of 81 mg daily.

Aspirin interferes with the platelets ability to clump together. This reduces the chance of a blockage but comes at the expense of an increased risk of bleeding. Balancing the risk vs. the benefit varies from person to person, so it's a good idea to check with your doctor before taking it.

Aspirin's effect on platelets persists for up to 2 weeks after you stop taking it. If you have surgery scheduled, be sure to let your surgeon know you've been taking it.

How Medical Intervention Can Help

As a vascular surgeon, I'm keenly aware of surgery's role in preventing stroke. I'd much prefer that people never get to this stage. The reality is, people do.

Let me be clear. I consider surgery crisis intervention. It's much better never to need it.

But if someone has gotten themselves in a situation where plaque fills 75% or more of the main artery to their brain, they're in trouble. In this situation, surgery to clear the vessel may be their best option, even with the risks involved.

If someone you love finds themselves needing surgery, my best advice is to find a surgeon who is board certified and that you're comfortable with. The patient-physician relationship is always important. Given the dramatic nature of surgery, it's even more so. The surgeon should welcome your questions and explain the options clearly.

Past experience also counts. You should look for a surgical team who has a less than 3% rate of major complications. I wish I could say the complication rate is zero, but its not.

The good news is that successful surgery greatly reduces the long term risk of stroke, especially if the person changes their lifestyle. “If you do what you always do, you'll get what you've always gotten” applies here.

Live Life Well

As you review these suggestions, I'm sure you can't help but notice some recurrent themes from other health advice you've heard. The themes of eating right, exercising regularly, and maintaining a healthy weight replay over and over again in health literature for a simple reason. Lifestyle affects health.

I've reminded you of some things you already know and perhaps given you some new ideas as well. One of the things I hope you accept is the profound influence the choices you make today have on the quality of your life in the future.

Follow the suggestions I've made here and a more vital future is yours.

Live well.


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Stroke 1994; 25:1320-35.

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Perry IJ, et al. Lancet 1995; 346:1395-8.

Malinow MR. J Nutr 1996; 126(4 suppl):1238S-43S.

Schillinger T, Kluger W. Stroke. 2006 Sep; 37(9):2271-6.

Dumitrescu A. J Intern Med. 2005;43(1-2

Dörfer CE, Becher H J Clin Periodontol. 2004 May;31(5):396-401.

JAMA, 2001; 285: 304-312.

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