The main strategy for reducing morbidity and mortality from cerebral stroke is a clear organization of its prevention, based on the identification and stratification of risk factors. Allocate non-modifiable, modifiable (correctable) and estimated risk factors.

Non-modifiable risk factors

Elderly age

Ischemic stroke- this disease is predominantly people whose average age is 73-75 years; 3/4 stroke of the brain occur after 65 years.
In connection with the increase in elderly and senile people among the population of Ukraine, an increase in the number of cases of cerebrovascular pathology, including cerebral stroke, is predicted in the next decade.

Brain stroke is more common in men aged 44-85 years than in women. Taking oral contraceptives and pregnancy contribute to a higher incidence of strokes in women under the age of 44 years.

Low birth weight

The frequency of cerebral stroke increases by 2 times among persons whose body weight at birth was less than 2.5 kg. These patients also have a higher mortality rate from stroke.

hereditary factor

A family history of stroke increases the likelihood of stroke by 30%. A number of genetic diseases are associated with stroke - cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, Marfan syndrome, neurofibromatosis types 1 and 2, Fabry disease.

Modifiable risk factors

blood pressure

Arterial hypertension is one of the most significant modifiable risk factors for ischemic stroke. The prevalence of arterial hypertension increases with age, and if at the age of 50 it is determined in 45% of the population, then by the age of 70 - in 70%.

A direct relationship has been established between the level of diastolic blood pressure and the risk of developing a cerebral stroke. An increase in systolic blood pressure by 10 mm Hg. Art. increases the relative risk of stroke in women to 1.9, in men to 1.7. Isolated systolic hypertension also increases the risk of stroke by 2-4 times. An increase in blood pressure by 7.5 mm Hg. Art. in normotonic patients, it doubles the risk of stroke.

Blood pressure control and normalization is one of the most effective measures to reduce the risk of stroke. In this regard, it is recommended that blood pressure be measured during professional examinations, dispensary visits, and the patient's initial requests for medical care to medical institutions. The maximum allowable level of blood pressure among the general population should not exceed 140/90 mm Hg. Art., among patients with diabetes - 130/80 mm Hg. Art. The safest target blood pressure for people over 75 is 140-150/90-80 mmHg. Art.. This blood pressure allows you to avoid adverse orthostatic reactions and at the same time maintain an optimal level of brain perfusion. Normalization of blood pressure is achieved by changing lifestyle, giving up bad habits and individual selection of antihypertensive drugs.

Smoking

Smoking is an independent risk factor for stroke, which remains widespread, increases the risk of stroke by 2 times. To a large extent, it increases in women who smoke compared to men. The risk of developing a cerebral stroke is twice as high in people who smoke more than 40 cigarettes a day as in those who smoke up to 10 cigarettes a day. Smoking is a predictor of severe atherosclerosis of extracranial arteries. Passive smoking is also a risk factor for stroke. Complete cessation of smoking reduces this risk by 50%, and after 5 years after quitting smoking, the risk of developing a stroke of the brain is practically the same as that of never smokers.

Diabetes

In diabetes mellitus, the risk of developing a stroke of the brain increases by 2-6 times. Diabetes mellitus occurs in 13-20% of patients with cerebral stroke. It leads to the development of atherosclerotic cerebral macro- and microangiopathy. The combination of arterial hypertension and diabetes mellitus is especially unfavorable for the development of cerebral stroke. Adequate therapy for type 1 and type 2 diabetes mellitus, which maintains blood glucose levels close to normal, can significantly reduce the risk of cerebral stroke. For patients with diabetes mellitus, strict control of blood pressure, the appointment of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are recommended. The use of statins in diabetes mellitus and dyslipidemia reduces the risk of stroke, especially with other concomitant risk factors. Aspirin is recommended for primary prevention in patients at high risk of developing cerebrovascular disease.
Atrial fibrillation.

Permanent atrial fibrillation is an independent risk factor for stroke. With atrial fibrillation, the likelihood of developing a cerebral stroke increases by 4-5 times. In patients with atrial fibrillation, the risk of cerebral stroke should be stratified. A moderate risk of cerebral stroke in atrial fibrillation includes age over 75 years, a combination of atrial fibrillation with one of the following atrial fibrillations: arterial hypertension, heart failure (echocardiographically determined systolic; left ventricular failure less than 35%, fractional shortening of systole less than 20%).

The high-risk group for ischemic stroke in atrial fibrillation includes patients with previous transient ischemic attack or cerebral stroke, its combination with two moderate atrial fibrillations. Long-term oral anticoagulant therapy with warfarin is recommended for all patients at high to moderate risk of embolism. In the presence of contraindications to canticoagulants, patients with atrial fibrillation should be prescribed aspirin 100-325 mg / day.

Patients with a low risk of cardioembolism in atrial fibrillation (age up to 60 years without additional risk factors) are recommended long-term use of aspirin 100-325 mg / day. All patients over 65 years of age at the initial visit to the doctor should determine the pulse rate followed by an ECG to rule out atrial fibrillation.

Dyslipidemia

Violations of the normal ratio of the main fractions of lipids (triglycerides; cholesterol, high and low density lipoproteins) in the blood serum are risk factors for the development of vascular diseases. An increase in cholesterol and low density lipoproteins is directly related to the incidence of coronary pathology, while high density lipoproteins have the opposite effect. An increase in cholesterol levels correlates with the degree and rate of progression of atherosclerosis of the brachiocephalic arteries. Mortality from cerebral stroke has been shown to be higher among men with high blood cholesterol levels. In order to prevent hyperlipidemia, it is recommended to control the level of cholesterol in the blood serum (the norm is less than 5 mmol / l). For patients with coronary heart disease, diabetes mellitus, lipid disorders are corrected by prescribing a special diet that lowers the level of low-density lipoproteins. The main source of saturated fat and cholesterol are fatty meats (lamb, pork), eggs and dairy products. In this regard, it is recommended to eat lean meats (beef, chicken fillet), fish and low-fat dairy products.

If within 6 months, patients with moderate or high levels of cholesterol or low-density protein in the blood serum fail to reduce the level to normal, then they should be prescribed statins.

Heart disease associated with an increased risk of cerebral stroke

Cardiogenic embolism is the cause of 20-25% of ischemic strokes and transient ischemic attacks. It usually occurs due to the formation of emboli in the cavities or on the valves of the heart. The proven risk factors for cardioembolism include diseases of the valvular apparatus of the heart (artificial heart valves, rheumatic, bacterial and non-bacterial damage to the valves, their calcification), diseases of the coronary arteries (myocardial infarction inside the heart thrombus, ventricular aneurysms, mpokinetic and akinetic areas of the myocardium).

Chronic infections and inflammatory processes

In the last decade, chronic infections, especially those caused by Chlamydia pneumonia, have been shown to damage the arterial endothelium, thereby increasing the risk of developing vascular disease. It has been established that an increase in C-reactive protein, a marker of inflammation, increases the risk of developing cardiovascular diseases. Patients with rheumatoid arthritis or systemic lupus erythematosus have an increased risk of developing a cerebral stroke. Patients with positive C-reactive protein and dyslipidemia are recommended to take statins.

Patients with risk factors for ischemic stroke should receive annual influenza vaccination.

Hyperhomocysteinemia. Patients with hyperhomocysteinemia may be prescribed a complex of B vitamins - pyridoxine (B6), cobalamin (B12), folic acid.

The main objectives of primary prevention are:

• identification of persons with an increased risk of cerebral stroke;
• diagnostics and assessment of the state of risk factors;
• development of an individual program for the prevention of correctable and potentially correctable risk factors.

A disease such as a stroke, the causes of which may be different, is becoming more common in people. It should be understood how to detect a stroke at the initial stages of its development, which leads to a stroke, is there any way to prevent its occurrence.

A significant increase in the number of patients affected by the disease is initially associated with their age. Proven: than older man the greater the risk of having a stroke.

What is a stroke and what are its types?

This disease can be otherwise called a stroke. As a result, blood flow to the brain is instantly suspended. Thus, the nerve cells of the brain die due to the lack of oxygen and the necessary nutrients. In other words, the brain interrupts its normal activity. Suppose a patient has a lesion in the part of the brain that controls any movement, then this can provoke paralysis. In the same way, damage to the parts of the brain responsible for thinking and speech abilities is possible.

In the event that a person does not receive timely medical care, this can lead to death. But if blood circulation to the brain resumes, then there is a chance to recover. The most important thing is to identify the signs of the disease in time and immediately visit a doctor. There are situations when people after a stroke are unable to move for a long time. In many cases, stroke treatment takes a long time. Today, stroke is one of the most common causes of death in people. In addition, this disease is in the first place among the diseases leading to disability.

Doctors distinguish the following main types of stroke:

• hemorrhagic;
• ischemic.

The first type of stroke occurs due to significant permeability of the walls of blood vessels or in the event of a rupture of the vessel. As a result, there is a focus in the area of ​​hemorrhage. This type of disease is the result of a ruptured aneurysm of blood vessels located at the base of the brain. As a rule, sad consequences are possible, leading to the death of a person. Its occurrence is noted after nervous tension and stress. It happens that before the onset of a stroke, a person may have a severe headache, dizziness appears. With a stroke, a person falls, sometimes may be in a coma. Blood pressure rises noticeably, and the pulse decreases. The person's breathing becomes hoarse and loud, the skin of the face becomes purple, and vomiting may occur. There is also a pendulum movement of the pupils of the eyes.

In addition, facial asymmetry and paralysis of the limbs can be observed. Such symptoms appear on the side opposite the affected area. In this situation, the person must be put on the bed, the clothes must be unbuttoned. In the room where the patient is located, access to fresh air should be provided. It is recommended to apply heating pads to the lower extremities of the patient, and to apply ice to the back of the head. Next, call an ambulance.

With ischemic stroke, blood circulation is disturbed, some changes occur in the central nervous system, and the general condition noticeably worsens. In other words, with this type of disease, blood flow does not flow to part of the brain, thereby brain cells are affected or die. This type is otherwise called a cerebral infarction. It occurs mainly in the elderly.

Causes of a stroke

The reasons for the occurrence of a stroke are:

• impaired blood supply (ischemia);
• blockage of blood vessels by an embolus (embolism);
• degenerative change in the vascular walls (atheroma);
• hemorrhage inside the brain;
• thrombosis.

With thrombosis, the process of the appearance of blood clots is observed.

With the appearance of thrombosis in the vessel itself, which provides nutrition to the brain, swelling of the brain tissue may occur.

It should be noted that thrombosis can occur in the morning or at night, as well as at the end of the operation. In addition, its occurrence can be observed after a heart attack has occurred. Thrombosis is thought to be the cause of many strokes seen in people over 50 years of age.

Sometimes thrombosis is observed in smoking men and women, people who are overweight. Today, young people who take cocaine also suffer from thrombosis.

With hemorrhage, a rupture of the cerebral artery occurs. This type of disease can overtake every person, regardless of age. It always raises blood pressure. This occurs as a result of the thickening of the artery, as a result of which an arrhythmia can be felt. Such a stroke occurs due to low or rapidly increased blood pressure. A stroke, which can have different causes, can be caused by diabetes, bad habits, and an inactive lifestyle.

Embolism is characterized by the appearance of a clot of fatty substances (emboli) in a vessel that cannot pass through it, which leads to impaired blood flow. The disease can manifest itself if the patient has an arrhythmia or has recently undergone heart surgery. When identifying the cause of a stroke, you should immediately consult a doctor.

Risk factors for stroke

The main factors in the occurrence of the disease are excessive consumption of alcoholic beverages and smoking. Such bad habits increase the likelihood of developing heart and vascular diseases. At the same time, alcohol leads to weight gain.

In addition, if a person takes medications without a doctor's recommendation, then he is already at risk. He may develop heart disease and then a stroke. The risk may increase if a person uses contraceptives containing high concentrations of estrogens.

It is necessary to constantly monitor your own level of cholesterol in the blood, since its content in large quantities can be the main reason for the development of a serious illness. In turn, an improper diet can lead to an increase in cholesterol. Pregnant women suffering from hypertension should also monitor their health.

Another cause of the disease is considered to be an inactive lifestyle, which provokes hypodynamia. Of course, people in such a situation are advised to exercise every day. They need to run outdoors. The implementation of the proposed recommendations will ensure a decrease in blood sugar levels and lower blood pressure.

In obese people, the risk of developing a stroke is quite high. As a result of being overweight, a person has a greater load on the heart, which causes diabetes. In turn, people with diabetes are also at risk of having a stroke. The cause of a stroke is the state of the human psyche. Any stressful situations, nervous breakdowns, constant worries are the causes of a stroke. As a rule, this applies to those people who have previously encountered this disease.

Stroke prevention

In order to prevent the occurrence of a second stroke, a person should completely change the previous order of life. This suggests that a person should give up smoking, alcohol forever and be physically active.

In addition, you should undergo a complete medical examination, the results of which can reveal the true cause of circulatory disorders and cure existing diseases.

Many doctors believe that you need to adjust the diet. Fatty foods are not allowed in the daily menu. It is not recommended to abuse potatoes and flour products. It is necessary to minimize the amount of previously consumed sugar and other sweets.

The diet should include fish, which contains fatty acids, which helps reduce the likelihood of a stroke. These substances perfectly normalize blood pressure and reduce the amount of cholesterol in the blood.

When it comes to coffee, it contains antioxidants. This drink prevents the formation of blood clots in the brain.

In the event that a person consumes four cups of coffee every day, then the likelihood of illness is reduced by about 17%. Pears and apples also have a positive effect on the body, improve work immune system and provide protection to the human body.

Infusions from medicinal plants also have a healing effect. One of them is prepared from marina root. The method of preparation is very simple: 2 teaspoons of finely chopped root are poured into a glass of boiling water and infused for about 4 hours. Then the solution is filtered and consumed during the day as agreed with the doctor.

Another effective remedy is made from bay leaf oil. To prepare it, add 3 tbsp. spoons of finely ground bay leaf in a glass of unrefined oil. Next, the resulting mixture should be infused for about a week. After the tincture is ready, you can apply it to the paralyzed areas several times a day.

All treatments must be carried out within a year. In this case, you need to take breaks. As a rule, each procedure should not last more than 10 days.

The effectiveness of such treatment is high, since if all the recommendations are followed, you can return the legs to working capacity and start walking again.

Recently, doctors are increasingly paying attention to the impact of lifestyle and human nutrition on his health. Food rich in vitamins makes us energetic, and eating too much fat can lead to an increase in body mass index and is one of the factors that increase the risk.

A proper diet is good for every person, but will not be sufficient for those who already have health problems.

Napalkov Dmitry Aleksandrovich, Doctor of Medical Sciences, Professor of the Department of Faculty Therapy No. 1 of the Medical Faculty of the First Moscow State Medical University named after I.M. Sechenov: "The dependence of cardiovascular problems on lifestyle is a proven fact. Lack of physical activity, unhealthy diet, bad habits are significant risk factors for morbidity and mortality. However, by paying attention to these aspects, everyone can protect themselves and their families from severe chronic diseases .

In case of serious disorders in the work of the cardiovascular system, nutrition and dosed physical activity will not help cure, but they will still have great importance. At the same time, it is necessary to take medicines prescribed by the attending physician to control diseases and reduce the risk of serious complications. However, you need to be careful when taking some drugs because of their possible interactions with food. For example, the well-known anticoagulant (vitamin K antagonist) used to prevent stroke in atrial fibrillation imposes great dietary restrictions. Raspberries, green tea, green vegetables, cabbage, eggs and other foods rich in vitamin K are undesirable, as they affect the effectiveness of treatment. But science does not stand still, a new generation of stroke prevention drugs, for example, based on direct thrombin inhibitors, does not require dietary restrictions.

Studies from around the world show the extent to which dietary habits influence the risk of stroke.

In particular, a mass study of thousands of women over 35 years (Nurses Health Study) showed that the usual diet of a European (including a large amount of meat, eggs, fried and salty foods, refined flour bread, fatty dairy products, sweet desserts, chips, etc. .) increases the risk of stroke by 58%. While the consumption of fruits, vegetables, fish and wholemeal bread reduce the risk of stroke by 30%.

To prevent atherosclerosis, gallstones and vascular problems, you should follow a diet that can control and even reduce blood cholesterol levels. Main products - oats, almonds, soybeans and cocoa beans. In addition, these foods are rich in magnesium, which, in sufficient quantities, can reduce the risk of stroke by 30%. The latest study of Swedish men by the Stockholm Institute showed that regular consumption of chocolate (up to 63 grams per week) also reduces the likelihood of a stroke (regardless of its type) by 17%.

In case of violation of blood circulation, narrowing or inflammation of blood vessels, atherosclerosis, antioxidants should be eaten. They are rich fruits and vegetables. For example, according to a study published in October 2012 in the journal Neurology, eating tomatoes and tomato products reduces the risk of stroke.

Bananas, rich in potassium, are also good for stroke prevention. As you know, the consumption of 1.5 grams per day of potassium reduces the risk of stroke by 28%. Participants in The Health Professionals Follow-Up Study who ate 9 servings of potassium-rich foods daily (fruits, vegetables, potatoes, prunes, raisins) had a 38% lower risk of stroke compared to those who ate 4 servings per day. day.

Hypertension is one and a half times less common in those who regularly consume low fat dairy products, according to a study of men in Puerto Rico. And a 22-year study of 3,100 Japanese men showed that those who consumed at least 2 glasses of milk a day had a 2-fold lower risk of stroke. Low-fat milk is a source of potassium, magnesium, and calcium, which naturally lower blood pressure.

You can improve blood circulation, reduce inflammation in the arteries and fight blood clots by including in the diet salmon and other fatty fish. They enrich the body with omega-3 fatty acids. In addition, by eating fatty fish, you can reduce the consumption of high-cholesterol meats (sausages, bacon, ham, etc.). A 12-year study of 5,000 adults aged 65 and over by Harvard Medical School found that eating fish 1-4 times a week reduced the risk of stroke by 27%.

Nina Maslova

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Ischemic stroke (IS), hemorrhagic stroke (HI), and transient ischemic attacks (TIA) are commonly referred to as acute cerebrovascular accidents. Stroke (I) is a heterogeneous clinical syndrome of brain injury associated with acute impairment of central or cerebral hemodynamics. The problem of preventing stroke (S) has become especially acute in recent decades, when the trend towards an increase in morbidity and mortality from acute cerebrovascular accident (ACV) became apparent. Currently, every 10th death in the world is associated with a stroke - only about six million cases annually. The burden of stroke (a complex of medical, social and financial problems) places an unbearable burden on the health systems of both economically developed and low-income countries. Treating a patient with a stroke costs about 10 times more than treating a patient with myocardial infarction. Stroke prevention (both primary and secondary) requires significant organizational efforts, new diagnostic methods, and expensive drugs. This affects the availability of medical care and the effectiveness of preventive care. As a result, the prevalence of I in low- and middle-income countries is about 2 times higher than in advanced economies. The incidence of stroke in China over the past 20 years has increased by 50% and almost all of this growth occurred during the period of economic development of the country. Mortality from a stroke (the ratio of deaths to the number of cases) depends on the state of emergency care and the ability of the healthcare system to provide further treatment of the patient and his rehabilitation. In recent years, in most economically developed countries, mortality in the acute period of stroke has decreased markedly, but within a year after stroke, almost 40% of patients still die. Mortality (the ratio of the number of deaths to the population) from stroke is closely related to the incidence and effectiveness of prevention measures. In the Russian Federation, mortality from stroke is an order of magnitude higher than in the United States (251 and 32 per 100,000, respectively). In general, mortality from diseases of the cardiovascular system in the Russian Federation is 7 times higher than in European countries with the same prevalence of diseases associated with atherosclerosis.

So, the number of stroke victims is growing along with the incidence, and the decrease in mortality does not reduce, but increases the burden of stroke. After all, the absolute number of patients requiring secondary prevention measures and expensive rehabilitation is increasing. The only way to reduce the severity of the problem of stroke is to reduce the incidence by increasing the effectiveness of prevention. But an increase in the cost of preventive programs (today in most countries of the world they account for about 3% of funds allocated to health care) is possible to a limited extent. Expansion and deepening of the scope of the survey to a level that allows you to determine the obvious and hidden mechanisms of diseases of the circulatory system, even the most developed economy will not withstand. The concept of risk factors (RF) is at the heart of the modern population strategy for the prevention of IH. The most important cardiovascular risk factors are: obesity, sedentary lifestyle, arterial hypertension, diabetes, tobacco smoking, alcohol abuse, lipid metabolism disorders - dyslipidemia. Managing these factors determines the success of prevention programs. How successful is this strategy in modern world? Kim A.S., Johnston S.C. (2013) analyzed the dynamics of the most significant cardiovascular risk factors (Table 1). As can be seen from the table, only arterial hypertension can be controlled more or less effectively: the average level of blood pressure decreased by 10 mm Hg. st in the US and 8 mm Hg. st in Japan.

Table 1. Major cardiovascular risk factors (median). 25-year dynamics in the population of the USA, Japan and China.

The number of patients with overweight and metabolic syndrome in most countries is steadily increasing. The population of developed countries is predominantly over-fed and leads a sedentary lifestyle. According to the latest WHO report (2014), Europe has the highest level of alcohol consumption per capita.

Given the complexity and cost of the diagnostic process, the lack of effectiveness of methods for the prevention of vascular accidents, the choice of a high-risk strategy seems to be the best solution to the problem. The essence of the idea is to reduce the number of patients requiring complex methods of diagnosis and treatment. The full potential of modern medical technologies should be directed to this limited circle of patients. There are not as many patients with a really high risk of stroke as one might think. It is possible to foresee a catastrophic development of events, to single out a relatively small group of those who are really in danger from a huge mass of patients, based on methods for assessing individual risk. The prevalence in the population of diseases of the cardiovascular system leading to stroke (atherosclerosis, arterial hypertension, cardiac ischemia) is very high, and severe complications occur relatively rarely - only in 1% of patients. This fact inevitably leads to the conclusion that in a patient suffering from “usual age-related” diseases, this is an unlikely event, which is caused by special circumstances and fatal changes in the nature of the disease, its behavior. In order to identify high-risk groups, one must rely on the exact knowledge that is obtained by analyzing the results of population-based studies such as the Framingham Heart Study. This long-term population study has shown the association of the most important risk factors with the incidence of I. It is well known, for example, that the annual risk of I increases with age. If in the age group of 45-54 years it is 1 case per 1000 people, then at the age of 75-84 years it is 1 case per 50 people. Similar data exist for other risk factors. Tobacco smoking increases the risk of I by 2 times. An increase in blood pressure by 10 mm Hg in relation to the norm - 2-3 times. In recent years, population risks have been refined not only for patients, but also for healthy people. Statistical analysis methods have established, for example, that the 10-year risk of cardiovascular events for a non-smoking white man aged 44-79 years who does not suffer from arterial hypertension (AH), dyslipidemia and diabetes mellitus is 5.3% (2.1% for a white woman ) . However, individual forecasting based on relative population risks is methodologically incorrect and extremely unreliable. These data are important only in order to obtain a “zero”, indicative point of population risk. Individual risk will never meet this point and may vary quite significantly due to the many characteristics and circumstances inherent in the individual.

The EURO SCORE scale is a generally accepted system for assessing cardiovascular risk based on the results of population studies.

On this scale, the 10-year risk of fatal vascular events can be as high as 20%, depending on the influence of the most important risk factors such as hypertension, smoking, age, and hypercholestrinemia (high risk). The visibility and emphasis on correctable risk factors is an undoubted advantage of this scale, stimulating patients to change their lifestyle. But the coincidence of an individual forecast with real events is unlikely. Recent recommendations for the treatment of hypertension define a moderate risk of serious vascular events as equal to or greater than 7.5% over 10 years. Thus, the ten-year risk gradations of I, myocardial infarction or vascular death are distributed approximately as follows: low risk is less than 7.5%, medium: 7 - 15%, high - more than 15%. The stratification of total cardiovascular risk into categories of low, medium, high and very high is also used in the ESH/ESC 2013 Guidelines. This prognostic system is based on AH, the most important hemodynamic syndrome pathogenetically associated with most vascular events.

Table 2 ESH/ESC 2013 total CV risk stratification

BP - blood pressure; AH - arterial hypertension; CKD, chronic kidney disease; DBP, diastolic blood pressure; SBP, systolic blood pressure;

Prior to 1994, blood pressure values ​​were the only criterion for assessing the degree of risk. Subsequently, the concept of total risk was introduced, which takes into account the negative impact of other factors that together determine a more severe prognosis. However, assessing the overall risk proved to be a difficult task, since the dependence of vascular events on risk factors is not linear. Numerous attempts to refine the forecast using mathematical formulas were unsuccessful - the methods turned out to be cumbersome and did not increase the accuracy of predictions. More and more additions had to be introduced, which in the latest versions of recommendations and guidelines cover more than 30 FRs. As a result, experts state that "any threshold for determining high cardiovascular risk is arbitrary." The predictive accuracy of the ESH/ESC risk stratification system is not high, but it allows, based on objective criteria, to identify a high-risk group. The disadvantage of this scale is that the range of patients is too wide, which falls into the high-risk category.

The sensitivity of the forecasting method depends on the choice of the leading syndrome that can lead to I. The closer the pathogenetic relationship of the analyzed syndromes with vascular events, the more accurate the forecast. For patients with cardiac arrhythmias, the CHA2DS2VASc scale is more reliable.

Table 3. CHA 2 DS 2 VAS c scale

CABG - coronary artery bypass grafting; TIA - transient ischemic attacks.

The scale is intended to determine the indications for prescribing anticoagulants in patients with atrial fibrillation, and its prognostic value seems to be significant. Together with the sum of points, the annual risk increases I: 1-2 points - 4.5%; 8-9 points - 18 - 24%. At the same time, the scale also takes into account other important risk factors (age, diabetes), which undoubtedly refines the prognosis. The introduction of points into the structure of the scale is a methodological technique that allows you to rank risks, giving them different weights. An example of such a prognostic system is the ESRS risk assessment scale for recurrent cardiovascular events.

Table 4. ESRS scale

CHF - chronic heart failure; MI - myocardial infarction.

A score of 3 or more indicates a 4% annual risk of serious complications, and this risk is assessed as high. Notably, the risk score for recurrent vascular events increases by an order of magnitude compared to the 10-year SCORE risk.

New prognostic systems are always focused on annual risk assessment and, as a rule, are associated with clinical, coagulopathic, and hemodynamic syndromes “responsible” for the development of stroke. Numerous clinical studies with a high degree of certainty have demonstrated a close relationship of representative syndromes with annual risk of AND. The value of this risk for hypertension is 4-7%, for arrhythmia - 2-12%, for hypercoagulation syndrome - 5-7%, for stenosing atherosclerotic processes of the main arteries of the brain - 4-12%. These generalizations allowed us to propose a "five percent" I risk scale.

Table 5. Five Percent Stroke Risk Scale

The scale is convenient for practitioners and is more accurate in comparison with systems based on age and nosological criteria. Low risk is defined as 5% or less (1 syndrome), moderate risk - 5 - 10% (2 syndromes), high risk - 10 - 15% (three syndromes), very high risk - 3 - 4 syndromes. The border of low and moderate risk serves as the basis for making a decision on preventive treatment (prescription of antithrombotic agents, statins and other drugs).

Current risk scoring systems show good sensitivity when used to estimate the likelihood of recurrent vascular events. This is not surprising, because more than 30% of patients affected by stroke have stroke or myocardial infarction for 5 years, and transient ischemic attacks (TIA) in 20% of patients lead to a stroke within a month.

ABCD scale ( Age, B load pressure, C linical Features, D uration of symptoms, D iabetes mellitus), which is used to assess the likelihood of stroke in patients with TIA, in addition to the main risk factors, it takes into account important dynamic characteristics of the disease: the duration of clinical manifestations.

Stroke risk score after TIA - ABCD

1. Age over 60 years - 1 point
2. Blood pressure on admission above 140/90 mm Hg - 1 point
3. Clinical symptoms: limb weakness on one side - 2 points, speech disorders without weakness in the limbs - 1 point
4. Duration of symptoms: 10-60 minutes - 1 point and more than 60 minutes - 2 points
5. Diabetes mellitus - 1 point

A special multicenter prospective study showed that the border of low risk on this scale is at the level of 3 points. The probability of developing I in patients who underwent TIA and received more than 3 points on the ABCD scale is 7 times higher.

Outcome 0-3 points: Low risk
Risk of stroke within 2 days: 1.0%
Risk of stroke within 1 week: 1.2%
Risk of stroke within 3 months: 3.1%

Outcome 4-5 points: Moderate risk
Risk of stroke within 2 days: 4.1%
Risk of stroke within 1 week: 5.9%
Risk of stroke within 3 months: 9.8%

Outcome 6-7 points: High risk
Risk of stroke within 2 days: 8.1%
Risk of stroke within 1 week: 11.7%
Risk of stroke within 3 months: 17.8%

Thus, in patients with obvious signs of cerebrovascular decompensation (TIA), the ABCD scale fairly accurately predicts I.

The prognosis is very important for substantiating the scope of the examination and the choice of medical or surgical treatment. Patients with a low risk of I do not need in-depth examination using imaging techniques of the heart, blood vessels and brain. This allows you to properly distribute healthcare resources and optimize the working time of specialists. On the other hand, patients belonging to the high-risk category should receive a full examination in a timely manner.

Depending on the degree of risk, the methods of preventive treatment also change. For example, antithrombotic therapy is not indicated in patients with a low risk of cardiovascular events. But patients with high risk gradations should receive aggressive complex treatment, including statins, anticoagulants, antihypertensive drugs, depending on the leading syndromes that can lead to stroke. It is equally important to examine these patients in detail using modern imaging techniques (duplex ultrasound, CT scan, MRI). Early diagnosis of cerebrovascular accidents, brain damage and timely surgical or endovascular treatment, if indicated, can prevent I. The doctor's task is to skillfully use prognostic criteria for the benefit of the patient and the prevention of cerebral catastrophe.

Bibliography

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2. Kim A.S., Johnston S.C. Temporal and geographic trends in global stroke epidemic. Stroke. 2013; 44:123-125.
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4. O`Donnell C.J., Elosua R. Cardiovascular risk factors. Insights from the Framingham Heart Study. Rev Esp Cardiol. 2008; 61(3): 299-310.
5. WHO report. Over 3 million deaths worldwide are alcohol-related. 2014. http://www.who.int/ru/
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7. Goff D.C. et al. 2013 ACC/AHA Cardiovascular Risk Guidline. http://content.onlinejacc.org/pdfAccess.ashx?url=/data/Journals/JAC/0
8. Conroy R.M., et al. SCORE project group. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J. 2003; 24(11): 987-1003.
9. 2013 ESH/ESC guidelines for the management of hypertension. Systemic hypertension. 2013; 10(3): 5-38.
10. Vilensky B.S. Modern tactics of struggle with a stroke. - St. Petersburg: OOO FOLIANT Publishing House, 2005.
11. Diagnosis and treatment of atrial fibrillation. Recommendations of the RSC, VNOA and AAA, 2012, Issue 2.
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16. Suslina Z.A., Fonyakin A.V., Geraskina L.A. et al. Practical cardioneurology. – M.: IMA-PRESS, 2010.
17. Schmidt G., Malik M., Barthel P et al. Heart rate turbulence after ventricular premature beats as a predictor of mortality after acute myocardial infarction. Lancet.1999; 353:130-196.
18. Tsivgoulis G., Stamboulis E., Sharma V.K. et al. Multicenter external validation of the ABCD2 score in triaging TIA patients. Neurology. 2010 Apr 27;74(17):1351-7.

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