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34Preventive Care

ANSWERS

  1.  B The CHADS₂ score is a classification tool for predicting stroke risk in patients with atrial fibrillation. One point is given if any of the following are present: congestive heart failure, hypertension, age above 75 years, diabetes, and stroke or transient ischemic attack (TIA) history (gets 2 points). The CHA₂DS₂-VASc score can be considered an extension of the CHADS₂ scheme by considering additional stroke risk factors that may influence a decision whether or not to anticoagulate. The letters in that acronym stand for the same conditions as in CHADS₂, with additional components of: age older than 75 years gets 2 points, so now has subscript 2, vascular disease, age 65 to 74 years, and sex. Patients with a CHADS₂ score of 1 receive anticoagulation; males with a CHA₂DS₂-VASc score of higher than 1 and females with a CHA₂DS₂-VASc of higher than 2 receive oral anticoagulation (Meschia et al., 2014).

  2.  C Primary prevention seeks to prevent the onset of specific diseases via risk reduction, that is, by altering behaviors that can lead to disease. Primary prevention refers to control of risk factors that already exist in specific populations—people who smoke, people with diabetes, people with hypertension, and so on. Primordial prevention refers to strategies designed to decrease the development of disease risk factors—efforts to 35decrease the development of obesity, increase exercise, and provide a well-balanced diet; primordial prevention encompasses the entire population and is not limited to individuals with recognized risk factors. Secondary prevention refers to measures taken to limit risk of another event, such as stroke or transient ischemic attack (TIA). Tertiary prevention refers to efforts to soften the impact of an ongoing illness or injury that has lasting effects by helping to manage long-term, complex health problems in order to improve as much as possible a person’s ability to function, quality of life, and life expectancy.

  3.  A The American Heart Association/American Stroke Association guidelines recommend CEA for TIA and stroke patients with ipsilateral (same side as their TIA or stroke symptoms) carotid stenosis of 70% to 99%, and for patients older than 70 years. Patients younger than age 70 would also have the option of carotid artery stent (CAS). Note that choice C is wrong because an ABCD₂ score of 5 is a high–moderate score and indicates higher risk of subsequent stroke (Meschia et al., 2014).

  4.  B Knowledge of how to monitor heart rate and rhythm would be the most helpful for someone with a family history of atrial fibrillation, advancing age, but no documented dysrhythmia as yet.

  5.  C While each of these answers may raise an opportunity for lifestyle education, the combination of birth control pills and smoking is proven to be a significant risk for stroke, so that is the most important factor to address.

  6.  D The American Heart Association/American Stroke Association guidelines indicate that “smoking cessation is associated with a rapid reduction in risk of stroke and other cardiovascular events to a level that approaches but does not reach that of those who never smoked,” so it is still beneficial for persons to stop smoking even with a long history. There is no evidence of filtered cigarettes reducing stroke risk (Meschia et al., 2014).

  7.  A The INTERSTROKE study provided conclusive evidence that 10 risk factors account for 90% of strokes. “Five risk factors (hypertension, current smoking, abdominal obesity, high-fat diet, and physical inactivity) in the INTERSTROKE study accounted for more than 80% of the global 36 risk of ischemic stroke and intracerebral hemorrhage. With the addition of five other risk factors, the risk for all stroke rose to 90%. The ten risk factors noted are generally well known but their impact is sobering. Stroke risk reduction begins at a very young age with lifelong adherence to a healthy lifestyle.” The other five risk factors are diabetes, excess alcohol intake, increased psychosocial stress, depression, and cardiac causes (O’Donnell et al., 2016).

  8.  D A recently published review of 2000 to 2010 data has shown a surprising rise in stroke incidence in people aged 25 to 44 years. There are multiple suspected causes such as “the rise in the prevalence of type 2 diabetes mellitus, hypercholesterolemia, and obesity that has been observed in high-income countries.” In addition, cigarette smoking, alcohol abuse, and illicit drug use are frequent in young people and have tended to increase over time (Bejot, Delpont, & Giroud, 2016).

  9.  B Control of cholesterol and hypertension has been the largest contributor to the reduced incidence of stroke in the older than 65-year age group (Mozaffarian et al., 2015).

10.  C Atrial fibrillation can be modified—either correction to normal sinus rhythm or rate control and protection from clot formation—with an anticoagulant.

11.  B In the Atherosclerosis Risk In Communities (ARIC) study, Blacks had an incidence of all stroke types 38% higher than that of Whites. Possible reasons for the higher incidence and mortality rate of stroke in Blacks are a higher prevalence of hypertension, obesity, and diabetes (Meschia et al., 2014).

12.  C A positive family history of stroke increases risk by 30%. “The increased risk of stroke imparted by a positive family history could be mediated through a variety of mechanisms, including (a) genetic heritability of stroke risk factors, (b) inheritance of susceptibility to the effects of such risk factors, (c) familial sharing of cultural/environmental and lifestyle factors, and (d) interaction between genetic and environmental factors” (Meschia et al., 2014).

13.  A Even with modest reduction in cholesterol, there is reduced risk of stroke. There is no evidence that addition of fibrates is effective. There is 37no evidence of statins doubling the blood–brain barrier. There is no correlation between cholesterol levels and mortality (Meschia et al., 2014).

14.  D The recommendations are for moderate to vigorous activity 40 minutes/day, three to four times a week. Numerous studies have shown that physically active men and women generally have a 25% to 30% lower risk of stroke or mortality than the least active (Meschia et al., 2014).

15.  A Tight control of hypertension along with statin therapy has been shown to be the most effective primary prevention strategy for people with diabetes. The role of antithrombotics is unclear (Meschia et al., 2014, p. 3771).

16.  B While the incidence of atrial fibrillation is not remarkably different between men and women, it is more common in women over age 65 years and women have a higher incidence of stroke as a result of atrial fibrillation than men (Mozaffarian et al., 2015).

17.  D Prevention strategies are the same for TIA or stroke. Differences lie in whether the event is the first event or a subsequent event, which would trigger intensification of antithrombotic therapy.

18.  D Support for the caregiver is critical in prevention of readmission to acute care, and for prevention of need for institutionalization. So providing as much information as possible, staying educated about available resources, and communicating to the care team are all important factors.

19.  A In order to develop an effective and efficient education plan for the community, it would be helpful to determine the demographic makeup so that the focus can be on the highest need areas.

20.  C Patients with a high degree of stenosis, but have either anatomical (history of neck trauma/scarring) or medical (severe lung disease, cardiac disease) conditions that make surgery risky, are treated with stenting rather than endarterectomy. Patients older than age 70 years are recommended to have endarterectomy.

21.  A Long-term implantable monitors have been effective in finding 11% more cases of atrial fibrillation in patients diagnosed with cryptogenic stroke. There is no gender difference in effectiveness; the correlation between the duration of the atrial fibrillation and the risk for stroke has 38yet to be determined; long-term monitoring does not require daily calls or for a finger to be held against the phone (Kernan et al., 2014, p. 2187).

22.  B While more studies are needed, the guidelines indicate that the research evidence supports an antithrombotic as treatment for PFO without DVT in patients who were not already on an anticoagulant for another reason (Kernan et al., 2014, p. 2202).

23.  B For patients who require resumption of anticoagulation therapy because of a comorbid condition, waiting longer than 1 week is considered reasonable (Kernan et al., 2014, p. 2210).

24.  D For patient and family teaching materials to be most effective, they should be reviewed by the multidisciplinary team and checked for fifth- to sixth-grade level comprehension. This ensures that the majority of patients/families will be able to understand the information. Daily reinforcement will help to make the information more familiar, and monitoring for readiness to receive the information is key to ensuring best retention.

25.  A With limited personnel and resources, it is wise to focus community outreach efforts on the highest risk population—a strategy that has been recommended by the American Heart Association/American Stroke Association. Crispus Attucks, an African American, was the first American soldier to die in the Revolutionary War. His story has come to represent courage and strength, and many Black community centers have been named in his honor.

 

References

Bejot, Y., Delpont, B., & Giroud, M. (2016). Rising stroke incidence in young adults: More epidemiological evidence, more questions to be answered. Retrieved from http://jaha.ahajournals.org/content/5/5/e003661

Kernan, W. N., Ovbiagele, B., Black, H. R., Bravata, D. M., Chimowitz, M. I., Ezekowitz, M. D., . . . Wilson, J. A. (2014). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 45, 2160–2236.

Meschia, J. F., Bushnell, C., Boden-Albala, B., Braun, L. T., Bravata, D. M., . . . Chaturvedi, S. (2014). Guidelines for the primary prevention of stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 45, 3754–3832.

4039Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman M., . . . Turner, M. B. (2015). Heart disease and stroke statistics—2016 update: A report from the American Heart Association. Circulation, 133, e38–e360. doi:10.1161/CIR.0000000000000350

O’Donnell, M. J., Xavier, D., Liu, L., Zhang, H., Chin, S. L., Rao-Melacini, P., . . . Yusuf, S. (2016). Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case-control study. The Lancet, 376(9735), 112–123.