Modifiable Stroke Risk Factors (Hypertension and Diabetes) Hypertension, diabetes mellitus, smoking, dyslipidemia, atrial fibrillation, and

sickle cell disease are well documented risk factors for stroke (Table 1).[1] Although factors such as atrial fibrillation, hypercoagulability, and hormone replacement therapy are relatively powerful risk factors for stroke, these risk factors will only be discussed briefly since this review will focus on strategies to lessen the stroke burden associated with hypertension and diabetes. Hypertension and Stroke Hypertension is a major risk factor for ischemic stroke and intracerebral hemorrhage. [1-4] Elevated systolic pressure is a "direct, continuous and inde pendent" risk factor for stroke.[1-4] Isolated systolic hypertension is a particularly strong risk factor for stroke in the elderly and in those with type 2 dia-betes.[5-8] Control of high blood pressure (BP), espe cially systolic hypertension, has been clearly shown to reduce the risk of stroke in several prospective controlled trials.[8-14] A goal BP of <130/80 mm Hg is currently advocated for hypertensive diabetic patients with an increased primary stroke risk.[15] Available data do not support a specific drug class for primary stroke prevention in the hypertensive diabetic[13,14] ; rather, tight BP control is emphasized. This generally entails multi-drug therapy. Clinical trial findings support the use of any of a number of drug classes (or combination thereof) including thiazidetype diuretics and/or blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers as components of a treatment plan.[12] Diabetes and Stroke The crude incidence of stroke among patients with diabetes is three times greater than in the general population,[16-22] with especially high rates reported in Sweden[16] and the southeastern United States.[22] In the Framingham Heart Study,[20] patients with glucose intolerance had double the risk of brain infarction compared with nondiabetics; the relative risk (RR) is greater in diabetic women than in men. The relative risk of stroke in persons with type 2 diabetes reaches a maximum in the 40-60-year-old group, with diabetic women comprising a greater proportion of patients with stroke than nondiabetic women.[21,22] Patients presenting with stroke are more likely to have undiagnosed type 2 diabetes.[23,24] Further, patients with glucose intolerance -- elevated glucose following oral glucose tolerance testing performed before the stroke or 3 months after the stroke -- also have a higher prevalence of stroke.[24] In the prospective Honolulu Heart Program,[18] the prevalence of thromboembolic, but not hemorrhagic stroke, was increased in individuals with serum glucose levels >120 mg/dL at 1 hour after a 50-g glucose load. Proteinuria appears to be a risk factor for stroke in people with impaired glucose tolerance as well as those with diabetes.[19] Finally, African Americans have an almost 2.4-fold increased incidence, and Caribbean Hispanics have an almost two-fold increased incidence of stroke, perhaps reflecting the greater propensity for both diabetes and hypertension in these groups.[1,4] Increased Morbidity, Mortality, and Disability From Stroke in Diabetic Patients

There is an increase in both short-term and long-term mortality in the diabetic patient who has had a stroke.[23,25,26] A Finnish study[27] evaluated survival of diabetic patients compared with a group of randomly selected nondiabetic patients and a group of age-and sex-matched nondiabetic controls with a stroke. After 5 years, only 20% of the diabetic persons were alive compared with 40% of the control groups. Twenty percent of the diabetic patients who had a stroke were first diagnosed when they presented with their stroke.[27] In part, the increased mortality following stroke in diabetic patients is related to hospital admission glucose levels. In several studies the cut-off glycemic level is 120 mg/dL.[26-29] A study from England[29] showed that only in those patients with a persisting blood glucose of <120 mg/dL did complete recovery from hemiparesis occur within the first month. Another group[26] reported that in diabetic patients less than 65 years of age, 70% of those with presenting glucose levels of 120 mg/dL, but only 30% with glucose >120 mg/dL, were able eventually to return to work.