Thursday, February 25, 2010

Alarming trend of more strokes among younger people

From the Milwaukee Journal Sentinel:

A couple years ago, Brett Kissela was working a two-week stint in the neurology section at his hospital when it occurred to him that many of the stroke patients he was seeing were not much older than 50.

So he started looking at data from the Ohio-Kentucky area where he practices medicine and discovered an alarming trend that may be playing out across the country.

Stroke has been long thought of as an old person's disease, but in a little over a decade the percentage of people age 20 to 45 having strokes had jumped from 4.5% of the population to 7.3% of those living in the area.

Among whites, the incidence of stroke in that age group had more than doubled from 12 per 100,000 people a year to 25.

Among whites age 45 to 54, the annual incidence of stroke increased from 74 per 100,000 in 1993-'94 to 96 per 100,000 in 2005. Among African-Americans in that age group, strokes increased from 225 per 100,000 to 302.

The shift was so pronounced that in those dozen years, from 1993-'94 to 2005, the average age of the first stroke dropped from 71 to 68.

"This is scary," said Kissela, an associate professor of neurology at the University of Cincinnati Neuroscience Institute.

Additionally, decreases in stroke incidence were found in blacks over the age of 85 and whites older than 65.

Kissela's finding, which was presented Wednesday at an American Stroke Association conference in San Antonio, may be one of the more marked examples of how the nation's health is being assaulted by a closely related trio of ills: obesity, diabetes and high blood pressure.

The study involved the 1.3 million people living in the greater Cincinnati and northern Kentucky region. But Kissela and other doctors not associated with the research say it likely is indicative of what is occurring throughout America.

"It is pretty striking," said Brian Silver, a stroke neurologist at Henry Ford Hospital in Detroit.

The increasing numbers of people with obesity, diabetes and high blood pressure likely is pushing down the age that strokes are occurring in America, said Silver, who was not involved with the study.

Stroke once was a rare event in people in their 30s and 40s, but "we are having to accept it as part of our practice," Silver said.

Silver said the effect of the three conditions may be wiping out the health gains that have come from reductions in smoking.

The trend could have consequences for the cost of health care in the U.S.

Younger people are more likely to survive a stroke, resulting in the need for decades of care, said Marcus Chacon, an assistant professor of neurology at the University of Wisconsin School of Medicine and Public Health.

Mortality among stroke victims age 45 to 64 is 8% to 12%, he said.

"We may see more people surviving a stroke and ending up in a disabled state," he said.

He said half of stroke survivors will have weakness in a limb that restricts normal functioning; 25% will end up in a nursing home; one-third will suffer depression.

Chacon said high blood pressure poses the biggest risk of a stroke among younger people. High blood pressure increases the risk of stroke four times in people who are in their 50s, compared with two times for those in their 70s.

Diabetes, smoking, high cholesterol, physical inactivity, poor diet and oral contraceptives also can significantly increase risk.

In a given month, Chacon said, he admits seven to 10 stroke patients into UW Hospital. Usually, one or two of them are in their 50s, although patients in their 30s and 40s are fairly uncommon.

Diane Book, director of the stroke program at Froedtert Hospital in Wauwatosa, said higher rates of obesity, diabetes and high blood pressure likely are contributing to the incidence of stroke in younger people.

"Absolutely, we see a lot of young patients, more so than we used to," said Book, an associate professor of neurology at the Medical College of Wisconsin.

However, stroke is more likely to be diagnosed in younger people today than 10 years ago because doctors are looking for it more often and have better diagnostic equipment, she said.

In 1990s, MRI scans, which are superior to CT scans in diagnosing a stroke, were used less often, she said.

As a result, in the past, stroke was more likely to be misdiagnosed as multiple sclerosis, migraine or some other neurological disorder, she said.

In addition, today there may be more use of oral contraceptives, which significantly increases stroke risk in women, she said.

Studies indicate that oral contraceptive use increases stroke risk roughly two to three times, although the actual incidence of strokes attributable to the pill is small. Newer low-estrogen contraceptives are associated with lower rates.

The most recent national data indicate that 27% of females age 15 to 44 were using the birth control pill in 1995, compared with 31% in 2002. Use of the pill was significantly greater in white women than Hispanics and blacks, according to the Centers for Disease Control and Prevention.

Another factor contributing to the incidence of stroke may be the recession and a loss of health coverage, said Clarence Grim, a Milwaukee area physician and blood pressure expert.

Grim said the best stroke prevention is blood pressure control, but some research suggests that when the economy worsens and people lose coverage, they stop taking their blood pressure medicine and strokes increase.

"I suspect we are seeing this in Milwaukee and elsewhere now," Grim said.