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Original Article
ISSN (o):2321–7251

Risk factor assessment of stroke and its awareness among stroke survivors: A
retrospective study
Indira Kumari N 1, Veera Raghavulu B 2

1 - Associate Professor, Department of Pharmacology, Andhra Medical College, Visakhapatnam, A.P. 2- M. Pharmacy, PhD, AU
College of Pharmaceutical Sciences, Andhra University, Visakhapatnam.

Submission Date: 27-01-2015 Acceptance Date: 07-02-2015

How to cite this article:

Vancouver/ICMJE Style
N IK, B VR. Risk Factor Assessment of Stroke & its Awareness among Stroke Survivors: A retrospective study. Int J Res Health Sci
[Internet]. 2015;3(1):140-5. Available from http://www.ijrhs.com/issues.php?val=Volume3&iss=Issue1
Harvard style
N, I.K., B, V.R. Risk Factor Assessment of Stroke & its Awareness among Stroke Survivors: A retrospective study. Int J Res Health
Sci. [Online] 3(1). p.140-5 Available from: http://www.ijrhs.com/issues.php?val=Volume3&iss=Issue1

Corresponding Author:
Dr. Indira Kumari N, M.D, Associate Professor, Department of Pharmacology, Andhra Medical College, Visakhapatnam, A.P.
Email: drnik1957@gmail.com

Abstract:
Stroke is one of the leading causes of the death worldwide these days. About 1/5th of patients with an acute stroke die
within a month of event and at least 1/2nd of those who survive are left with physical disability. Identification and
management of risk factors remains pivotal in reducing morbidity and mortality from stroke. Methods: A retrospective
study was conducted with the objective of identifying various risk factors for stroke and assesses the awareness of the risk
factors for stroke. Results: The mean age of the patients was 59±13.06 (range 25 to 90 years). There were 73 males (mean
age 60.16±13.07) and 23 females (mean age 54.25±79). 33% patients (21 males and 12 females) were in the age group of
55-65 years. On analysis of risk factors according to the type of stroke, hypertension still remained the most common risk
factor for both ischemic and hemorrhagic stroke. This study reveals hypertension as the most common risk factor for
stroke followed by smoking, Diabetes Mellitus and Dyslipidemia. The knowledge of the risk factors for stroke in stroke
survivors was also very low and the knowledge varied among the subjects depending on their level of education.
Conclusion: Our findings strongly recommend that effective control of blood pressure, blood glucose and smoking may be
important avenues for stroke prevention in this population.

Key words: Stroke, Risk Factors, Hypertension

Introduction: Atherosclerosis in the major extracranial arteries

Stroke is a state of focal neurological deficit (Carotid artery and Aortic arch). About 20% of
of an abrupt onset, presumably of vascular origin and infarctions are due to embolism from the heart and a
it can be Ischemic (85%) or Haemorrhagic (15%). In furthur 20% are due to thrombosis in situ caused by
haemorrhagic stroke mortality rates are high (50%) intrinsic disease of small perforating vessels
while in Ischemic strokes, mortality is less (20%) [1]. (Lenticulostriate Arteries), producing the so-called
Cerebral Infarction is mostly caused by Lacunar infarctions [2].
thromboembolic disease secondary to

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The net result of thrombotic or embolic function diminishes the person in us. The present
stroke is an arterial occlusion, decreasing cerebral study was undertaken to elucidate the risk factors for
blood flow and causing ischemia distal to the site of stroke and identify the major risk factors pertaining
occlusion. Normal cerebral blood flow averages 50 to stroke and assess the awareness in stroke
ml/ 100gm/ min and this is maintained over a wide survivors.
range of blood pressures by a process called Cerebral
Auto regulation. If the local cerebral blood flow Materials and Methods:
decreases below 2 ml/ 100gm/ min, ischemia occurs. This retrospective study was conducted for a
If it decreases below 10 ml/ 100gm/ min and persists period of one year in King George Hospital,
too, irreversible damage to brain cells occur leading Visakhapatnam with the approval of the institutional
to infarction [1], resulting neurological deficits ethics committee and informed consent of the study
depend on the vessel involved and extent of population. The study population consisted of 100
obstruction to cerebral circulation. completed stroke patients. Patients diagnosed with
The risk factors for ischemic stroke reflect TIA were not included in the study. From the case
the risk factors for the underlying vascular disease records, data such as demographic details like age,
and they are of 2 types: a) fixed risk factors: - sex, signs and symptoms on admission, past history
1.Age, 2.Genetic (male > female) except at extreme of hypertension, diabetes, hyperlipidemia, stroke,
age group, 3.Race, 4.previous vascular event (MI, type of stroke (ischemic or hemorrhagic),
stroke, PVD), 5.Heredietary (high Fibrinogen). cardiovascular disorders, family history of stroke or
b) Modifiable risk factors: - 1.Blood pressure, cardiovascular disease, smoking history, alcohol
2.Cigarette smoking, 3.Hyperlipedemia, 4.Heart abuse, systolic and diastolic blood pressure recorded
disease (Atrial fibrillation, Congestive Cardiac at the time of admission, biochemical data such as
Failure (CCF), infective endocarditis), 5.Diabetes lipid profile (total cholesterol, triglyceride, HDL and
mellitus, 6.Excessive alcohol intake, 7.Oestrogen LDL cholesterol levels) and serum blood sugar levels
containing drugs (OC pills, HRT), 8.Polycythemia. and treatment given, were collected and recorded in
According to the India stroke factsheet the proforma specially designed for the study.
updated in 2012, the estimated age-adjusted The patients who were admitted in the Hospital with
prevalence rate for stroke ranges between 84/100,000 a compliant of Stroke were included.
and 262/100,000 in rural and between 334/100,000
and 424/100,000 in urban areas [3]. Major risk Table 1: Age and gender distribution
factors identified in India are Hypertension,
Hyperglycaemia, Tobacco use, Alcohol AGE IN MALES FEMALES TOTAL
consumption, High cholesterol, Heart diseases and YEARS (n=73) (n=27)
obesity for both sexes and in the young as well as the 25-35 3 (4.10%) 2 (7.4%) 5
elderly. A study from Chennai in southern India
revealed similar observations on hypertension, heart 35-45 7 (9.58%) 4 (14.8%) 11
disease of any type, diabetes, smoking and low HDL-
cholesterol as significant risk factors [4]. Individual 45-55 17 (23.28%) 6 (22.2%) 23
Indian studies have estimated that stroke increases
with age: the prevalence rates increases from 21 per 55-65 21 (28.76%) 12 (44.4%) 33
100,000 for the 20-40 age groups to 625 per 100,000 65-75 19 (26.02%) 2 (7.4%) 21
in above 60 year age group [5]. Similarly, the
incidence rates increase from 27-34 per 100 000 in >75 6 (8.21%) 1 (3.7%) 7
the 35-44 age group to 822-1116 per 100 000 in
above 75 age group [6, 7]. However, in India the
prevalence of stroke in younger individuals is high Risk factors of stroke: Knowledge of risk factors in
(18-32% of all stroke cases) compared with high stroke survivors and their care givers were assessed
income countries [6]. Because of the ageing by a questionnaire established on the risk factors for
population, the burden will increase greatly during stroke published previously [8]. These acknowledged
the next 20 years, especially in developing countries. risk factors include: Hypertension, Smoking,
Loss of brain function can be dehumanizing, and Diabetes, Heavy Alcohol consumption and
often makes individuals dependent on others for Dyslipidemia. Spontaneous responses were
ordinary daily activities. The loss of any brain

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investigated first. Then leading questions were asked patients, triglyceride levels in 15 patients and
to obtain responses. increased LDL levels in 22 patients. HDL cholesterol
Risk Factor Assessment: patients were decreased in 20 patients.
The risk factors for stroke were assessed by using Past History of Cerebrovascular Accident (CVA):
another questionnaire established by American Out of 100 patients, 11 patents had a prior attack of
Stroke Association [9]. In order to create awareness CVA, of which, 10 were males and 1 female and this
among stroke survivors and their care takers was their second admission to the hospital. 89% of
regarding their health management, printed the patients were diagnosed with first ever stroke.
information was provided and this printed Smoking and Alcoholism: 24 male patients had a
information includes life style modifications, habit of smoking and 27 male patients were
education for the patient and caretaker about the alcoholics. Smoking and alcoholism were
disease condition and the measures to be taken. comparatively higher in patients of elder age groups
Statistical Analysis: Analysis of data was carried (>40yrs)
out by Univariate Logistic Regression Analysis and Past History of Cardiovascular Disorders: Out of
Odds Ratio using SPSS (Statistical Package for 100 patients 15 patients had a previous history of
Social Sciences) software version (10.0). The 95% Cardiovascular Disorder of which 12 were males and
Confidence Interval (CI) was calculated using 3 were females. The incidents of various
standard statistical techniques. cardiovascular disorders in stroke patients were as
*P- value < 0.05 is considered Significant, **P – follows: Coronary artery Disease in 10 patients,
value < 0.01 is considered Significant. ***P – value Congestive Heart Failure in 1 patient and Myocardial
< 0.001 is considered highly Significant. infarction in 4 patients.
Overall Risk Factor Profile: In this study,
Results: hypertension was the profound causative risk factor
A total of 100 patients with completed stroke for stoke in 70 patients, followed by diabetes in 28
or cerebrovascular accident were taken up for the patients, smoking in 24 patients, dyslipidemia in 22
study. The mean age of the patients was 59±13.06 patients. The study also revealed alcoholism in 20
(range 25 to 90 years). There were 73 males (mean patients, the past history of cardiovascular disorders
age 60.16±13.07) and 27 females (mean age in 15 patients and previous history of cerebrovascular
54.79±12.49). Stroke incidence was predominant in accident in 11 patients. On analysis of risk factor
males. 33% patients (21 males & 12 females) were in according to the type of stroke, hypertension still
the age group of 55- 65 years. Among 100 patients, remained the most common risk factor for both
73 had ischemic stroke and 26 had hemorrhagic ischemic and hemorrhagic stroke (Table 2).
stroke. Mortality was higher with Hemorrhagic
Stroke. Table 2: Risk factors and type of stroke
Hypertension: Out of 100 patients, 70 patients were
hypertensive. Of these 55 had a past history of
hypertension, out of which 17 patients stopped taking RISK ISCHEMIC HEMORRHAGIC
medication for some reason and 38 were under FACTOR (n=74) (n=26)
antihypertensive treatment for the control of Hypertension 46 (62.16%) 24 (92.3%)
hypertension and yet their BP was above 150/100
mmHg. 15 patients were diagnosed to have Diabetes 26 (35.15%) 2 (7.69%)
hypertension on admission. These patients were
prescribed antihypertensive treatment. The incidence Smoking 18(24.32%) 6 (23.07%)
of stroke was high with hypertension when compared
to other risk factors. Dyslipidemia 18 (24.32%) 4 (15.38%)
Diabetes: 28 patients had a previous history of Past History of 11 (14.86%) 4 (15.38%)
diabetes, of which 25 were males and 3 were females Cardiac
and were found to have elevated RBS Levels Disorders
(>140mg/dL).
Past History of 10 (13.51%) 1 (3.84%)
Dyslipidemia: 24 patients in this study group had
CVA
dyslipidemia with a distribution of 14 males and 10
Alcoholism 12 (16.21%) 8 (30.76%)
females. Lipid profile in these patients was as
follows: Cholesterol levels were elevated in 18

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strongly that they had not received enough

The Univariate logistic regression analysis information previously and had not been made aware
and odds ratio (OR) were done to assess the by health care providers of the risk factors of stroke.
contribution of various risk factors in the incidence They recommended that written educational material
of stroke. Advancing age, Male gender, Smoking, and advice on simple things such as hypertension,
Diabetes and Dyslipidemia were significant risk diabetes and smoking, be provided for preventive
factors for stroke in this study population. Based on purposes for their family members. Stroke is a
odds ratio, hypertension was associated with 14 medical emergency. Immediate treatment can save
times risk (OR=14.08) for stroke. Diabetes increased lives and reduce disability. It is very important for
the risk of stroke by 3 fold (OR=3.08). Female people who are having stroke symptoms to get to a
gender, head ache and previous history of CVA were hospital as quickly as possible. A silent stroke is a
not significant risk factors (Table 3). stroke that does not have any outward symptoms, and
the patient is typically unaware they have suffered a
Table 3: Univariate logistic regression analysis of stroke. Despite not causing identifiable symptoms, a
riskfactors silent stroke still causes damage to the brain, and
places the patient at increased risk of stroke in the
Risk Factors Odds 95% future [10]. Conversely, those who have suffered a
Ratio Confidence P- Value major stroke are at risk of having silent strokes. A
Intervals transient ischemic attack should be considered an
Lower Upper emergency because there is no guarantee that the
situation will resolve and function will return. In this
Gender 1.0053 0.196 2.807
0.0035 retrospective study, we found the major risk factor of
** stroke and also awareness among stroke patients
Age 1.6102 0.3753 3.189 0.0016 which was poor. Diabetes and hypertension are
** considered to be traditional risk factor for stroke and
Hypertension 14.0870 5.6549 9.292 0.0401 * its subtypes. As expected, our study found that
hypertension is the most important risk factor for
Diabetes 3.0870 1.0217 2.769 0.0024** both ischemic and hemorrhagic strokes in both
Alcohol 1.5502 0.860 3.854 0.2758 genders. The risk of stroke in hypertensive patients is
substantially increased by the presence and levels of
Smoking 0.8975 1.074 9.393 0.0124 * smoking, Diabetes, Obesity, Coronary heart disease,
Dyslipidemia 0.5048 0.272 5.130 0.0418 * Transient Ischemic Attack and Atrial Fibrillations.
Smoking is a well – documented major risk
Heart disease 0.0753 3.648 36.982 0.6034 factor for stroke [11, 12], which was supported by our
Head ache 1.4792 0.7530 17.177 0.4379 study. It is well- known that, for those smokers with a
history of hypertension, the risk of stroke was
Past history 1.666 0.609 4.557 0.302
increased when compared with those having only
of CVA hypertension or only smoking.
*P-Value <0.05 is significant, **P – value < 0.01 is Alcohol is also one of the important risk
considered Significant. ***P – value < 0.001 is factor of stroke. But the risk of stroke associated with
considered highly Significant. alcohol was not significant in our study. Even though,
heavy alcohol consumption was found to be one of
Discussion: the risk factor for stroke but moderation of alcohol
The knowledge of the risk factors for stroke consumption to no more than 2 units per day could be
in stroke survivors was also very low. Furthermore, an effective means of improving BP control in treated
the knowledge varied among the subjects according hypertensives. However risk of stroke has been found
to their level of education. Some patients could easily to be increased in hypertensive patients who were
identify Hypertension, Smoking and Excessive also heavy drinkers [13, 14].
alcohol consumption as risk factors of the stroke, but Diabetes did not have a statistically
had little idea about other risk factors. Less educated significant impact on stroke in our study, where as
people and stroke patients had a low level of Atrial Fibrillations, Myocardial Infarction, Angina
knowledge of the risk factors of stroke. In the present have been found to be associated with increasing
study, the patients and their care givers reported stroke risk and was statistically significant in our

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study. However, the numbers of subjects who had The knowledge of the risk factors for stroke
histories of Myocardial Infarction, Atrial Fibrillations in stroke survivors was also very low. Furthermore,
and Angina, but were not hypertensive, were very the knowledge varied among the subjects according
small. Hypertensive patients with a history of to their level of education. Some patients could easily
Myocardial Infarction, Angina, Atrial fibrillations identify Hypertension, Smoking and Excessive
have an increase risk when compares with those alcohol consumption as risk factors of the stroke, but
without these factors. had little idea about other risk factors. Less educated
Dyslipidemia is one of the well – established people and stroke patients had a low level of
risk factor for cardiovascular disease is blood knowledge of the risk factors of stroke.
cholesterol, where as its relationship with fatal stroke In countries, like United States, 57-76% of
is more controversial. In a Meta – analysis of the general population could name spontaneously, at
prospective cohort studies conducted in the Asia – least two risk factors for stroke. A similar finding was
Pacific region, which confirmed the strong made in Australia. In that study, it was observed that
independent association between Triglyceride levels among the general population, 32% males and 28%
and cardiovascular disease previously reported, of females had more than one stroke risk factor, but
showed a positive association with ischemic stroke consultation with a local doctor or health professional
but not with Hemorrhagic stroke. The risk of stroke was reported by only 6% of males and 3% of females.
associated with dyslipidemia was found to be A significant association was observed between the
significant in our study. level of education and ability to identify the risk
The present study showed that stroke factors of stroke in both the groups.
survivors have very poor knowledge or awareness of In the present study, the patients and their
the risk factors of stroke. Most of the patients did not care givers reported strongly that they had not
think of their stroke as a serious illness. A lack of received enough information previously and had not
knowledge about stroke was one of the reasons for been made aware by health care providers of the risk
the delay in the early arrival. factors of stroke. They recommended that written
Table 4: Awareness of warning symptoms educational material and advice on simple things,
such as hypertension, diabetes and smoking, be
provided for preventive purposes for their family
Patients Illiterates Educated members.
(n=100)
Males Femal Males Female Conclusion:
Risk (n=56) es (n= 17) s This study reveals hypertension is the most
Factors n=20) (n=07) common risk factor followed by smoking,
Hypertensi 1 1 (5%) 3 2 dyslipidemia and cardiac diseases. Regular and
on (1.78% (17.64 (28.57 moderate degree of physical activity and strict
) %) %) control of hypertension, dyslipidemia and diabetes
Smoking 1 2 4 2 prevents a substantial proportion of stroke incidence.
(1.78% (10%) (23.52 (28.57 Public health campaigns to encourage primary
) %) %) prevention of hypertension should be the first target
Diabetes 1 1 (5%) 3 3 by quitting smoking, reducing salt intake, moderate
(1.78% (17.64 (42.85 physical exercise, healthy lifestyles etc. Poor
) %) %) awareness of stroke contributes to a delay in arrival
Alcohol 2 2 4 4 of patients for immediate effective treatment.
(3.57% (10%) (23.52 (57.14 Therefore few programs regarding stroke such as
) %) %) printed information, audiovisual programs and stroke
Hyperlipide 0 0 2 2 service programs are to be introduced to create
mia (11.7% (28.57 awareness.
) %)
Heart 0 0 0 0 Acknowledgement:
Disease Authors acknowledge the immense help
received from the scholars whose articles are cited
and included in references of this manuscript. The

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authors are also grateful to authors/editors/publishers obesity and risk of cardiovascular disease: The
of all those articles, journals and books from where Framingham Study”. J Clin Epidemiol. 1991;
the literature for this article has been reviewed and 44:183–190.
discussed. 12. Laupacis A, Cuddy TE. “Prognosis of
individuals with atrial fibrillation”. Can J Cardiol.
Source of Funding: Nil 1996; 12(Suppl A):14A–16A.
13. Jamrozik K, Broadhurst RJ, Anderson CS,
Source of Conflict: None
Stewart-Wynne EG. “The role of lifestyle factors in
the etiology of stroke. A population-based case –
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