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Original Paper
Public Health Genomics 2010;13:1320
DOI: 10.1159/000209879
Family History as a Risk Factor for
Early-Onset Stroke/Transient Ischemic
Attack among Adults in the United States
Mercy Mvundura
a
Henraya McGruder
b
Muin J. Khoury
a
Rodolfo Valdez
a

Paula W. Yoon
b


a
Office of Public Health Genomics and
b
Division for Heart Disease and Stroke Prevention, Centers for Disease Control
and Prevention, Atlanta, Ga. , USA
sions: Despite several limitations typical of self-reported
surveys, we find that in this sample of US adults, family his-
tory of stroke was significantly associated with the risk for
stroke and high blood pressure as well as related conditions.
Family history of stroke, alone or combined with other risk
factors, can be a useful tool in assessing stroke risk among
US adults. Copyright 2009 S. Karger AG, Basel
Introduction
Stroke is the third-leading cause of death and a leading
cause of serious disability in the US [1] . Researchers have
estimated that 700,000 Americans suffer a stroke each
year, with 500,000 of these experiencing a first-time event
[1] . In 2007, the estimated direct and indirect cost of
strokes in the US was USD 62.7 billion [1] .
Risk factors for stroke include hypertension, heart dis-
ease, atrial fibrillation, diabetes, hypercholesterolemia,
tobacco use and excessive alcohol use [2] . Another im-
portant risk factor is a family history of stroke. Several
Key Words
Family history Risk factors Stroke Transient ischemic
attack
Abstract
Background: Stroke is a major cause of morbidity and death
in the United States. We tested the association between fa-
milial risk for stroke and prevalence of the disease among US
adults and assessed the use of family history of stroke as a
risk assessment tool for the disease. Methods: Using data
from the 2005 HealthStyles survey (n = 4,819), we explored
the association between familial stroke risk (stratified as
high, moderate or low) and the prevalence of stroke and re-
lated health conditions. We evaluated the clinical validity
(sensitivity, specificity) of family history of stroke as an indi-
cator of stroke risk. Stroke and the related medical condi-
tions were self-reported. Results: Independent of other risk
factors, people with a high familial risk for stroke were 4
times more likely to have had a stroke (95% confidence inter-
val, CI, 2.66.0) than people with moderate or low familial
risk. They were also 1.3 times (95% CI 1.11.6) more likely to
have high blood pressure and 1.5 times (95% CI 1.32.0) more
likely to have congestive heart failure. The sensitivity and
specificity of using family history alone, high blood pressure
alone or both risk factors to estimate stroke risk were 52 and
83%, 53 and 74%, and 29 and 95%, respectively. Conclu-
Received: August 7, 2008
Accepted after revision: January 20, 2009
Published online: March 23, 2009
Mercy Mvundura, PhD
National Office of Public Health Genomics
Centers for Disease Control and Prevention
4770 Buford Hwy, NE, Mailstop K 89, Atlanta, GA 30341 (USA)
Tel. +1 360 236 3511, Fax +1 360 236 2323, E-Mail MMvundura@cdc.gov
2009 S. Karger AG, Basel
16624246/10/01310013$26.00/0
Accessible online at:
www.karger.com/phg
The findings and conclusions in this report are those of the authors
and do not necessarily represent the official position of the CDC.
Mvundura /McGruder /Khoury /Valdez /
Yoon
Public Health Genomics 2010;13:1320 14
studies report an independent association between a per-
sons risk for stroke and the history of stroke among that
persons first-degree relatives [39] . Despite these find-
ings, family history of stroke has had limited use in as-
sessing stroke risk. A recent study found that people clas-
sified as having strong and moderate familial risks for
coronary heart disease (CHD) were 5 and 2 times more
likely, respectively, to have had early-onset CHD (at or
before age 60 years) than were those with a weak familial
risk [10] .
In this study we evaluated the performance of a 3-
tiered algorithm of family history of stroke in estimating
the risk for early-onset stroke (age ^ 60 years) in US
adults. We also examined the sensitivity and specificity
of this algorithm to detect stroke, alone or in combina-
tion with high blood pressure (HBP). We assessed wheth-
er knowledge of familial risk for stroke was associated
with the adoption of risk-reducing behaviors. Recent
public health initiatives promote awareness of family his-
tory as a means to assess health risk and influence early
detection and prevention [11] .
Subjects and Methods
Study Design
We analyzed cross-sectional data from the 2005 HealthStyles
survey. The HealthStyles survey is an annual mail-in survey con-
ducted by Synovate Inc. Households were invited to participate in
the consumer opinion panel through a recruitment survey. The
list of household was obtained from a large credit-reporting agen-
cy. From the approximately 450,000 households that agreed to be
in the 2005 household panel, 20,000 were selected to participate
in HealthStyles. The survey was performed in 2 phases: (1) the
ConsumerStyles questionnaire was mailed to households selected
according to region, income, population density, age of residents
and household size to match the US general population as report-
ed by the census; the first phase of the survey had a response rate
of approximately 63%; (2) the HealthStyles questionnaire was sent
to half of the households that responded to the ConsumerStyles
questionnaire; the response rate for this phase of the survey was
approximately 78% or 4,819 respondents.
The Centers for Disease Control and Prevention (CDC) influ-
ence the design and administration of the HealthStyles survey,
which is a proprietary database of Porter-Novelli (Washington,
D.C., USA). HealthStyles data are used in health communication
planning by the CDC. More information about the survey can be
obtained from the CDC National Center for Health Marketing.
Variable Definitions
During the survey design, a literature review was conducted
and the findings were that most of the literature defining early
onset of cardiovascular disease (heart disease and stroke) used an
age cutoff of 65 years for women and 55 years for men. For practi-
cal considerations during the survey design, it was decided to use
age 60 for both sexes in order to reduce the number of questions
that had to be asked in the family history module.
Personal history of stroke was assessed with the question:
Have you ever been diagnosed by your doctor as having [had] a
stroke/transient ischemic attack? The response options were yes,
at or before the age 60, yes, diagnosed after age 60, no and I
dont know. The survey also included questions about health
problems that the respondent had during the past year or was cur-
rently suffering from. The stroke-related conditions were diabe-
tes, atrial fibrillation, congestive heart failure and HBP (HBP di-
agnosed on at least 2 doctor visits or respondent answered that
he/she was currently on medication). Personal history of stroke
and the presence of stroke-related conditions were self-reported
and were not verified through medical records. The survey nei-
ther included questions about stroke subtypes nor about CHD or
cholesterol levels.
Respondents were asked about a diagnosis of stroke/TIA in
their mother or father at or before age 60 or after age 60, and how
many siblings, mothers relatives (sisters, brothers and parents)
and fathers relatives (sisters, brothers and parents) had received
such diagnoses. They were also asked about their current partici-
pation in 5 activities to reduce their risk of developing stroke or
heart disease: reducing their intake of food that is high in fat or
cholesterol, eating more fruits and vegetables, being more physi-
cally active, cutting down on salt or sodium, and (if they smoked)
trying to stop smoking.
Familial Risk Stratification for Stroke
We classified respondents into 3 familial risk categories: high,
moderate or low, according to a previously published algorithm
[10] . Early-onset stroke was defined as stroke occurring at or be-
fore the age of 60 and late-onset stroke as a stroke occurring after
that age. We defined high familial risk as (1) one or more first-de-
gree relatives (mother, father or sibling) had had an early-onset
stroke, (2) two or more second-degree relatives (aunts, uncles or
grandparents) from the same lineage had had an early-onset
stroke, or (3) at least 1 second-degree relative had had an early-
onset stroke and 2 or more second-degree relatives from the same
lineage had had a late-onset stroke. We defined moderate familial
risk as (1) first-degree relatives only had had a late-onset stroke,
(2) first-degree relatives only had had a late-onset stroke and only
1 second-degree relative from the same lineage had had an early-
onset stroke, (3) only 1 first-degree relative had had a late-onset
stroke and at least 1 second-degree relative from the same lineage
had had a late-onset stroke and no second-degree relatives from
the same lineage had had an early-onset stroke, (4) two or more
second-degree relatives from the same lineage had had a late-on-
set stroke, or (5) only 1 second-degree relative had had an early-
onset stroke and only 1 from the same lineage had had a late-on-
set stroke. We defined low familial risk as (1) no stroke-affected
family member at any age of onset or an unknown family history,
(2) only 1 second-degree relative with late-onset stroke from ei-
ther side of the lineage, or (3) only 1 second-degree relative with
early-onset stroke from either side of the lineage.
Statistical Analyses
We performed all statistical analyses using STATA version 9
[12] . We calculated the distribution of demographic variables and
health conditions related to stroke for the whole sample and by
stratum of familial risk. We defined early-onset stroke as stroke
Family History as a Risk Factor for Stroke Public Health Genomics 2010;13:1320 15
occurring at or before age 60. We used logistic regressions to es-
timate the association between family history of stroke and risk
for early-onset stroke, while controlling for demographic factors,
smoking status, HBP, atrial fibrillation, congestive heart failure
and diabetes. We calculated stroke risk using 2 logistic regression
models: one comparing stroke risk among respondents in the
high and moderate familial risk strata with those in the low fa-
milial risk stratum, and the other comparing stroke risk among
those in the high familial risk stratum with those in the moderate
and low risk strata combined. We decided to combine the moder-
ate and low risk categories because of the small number of people
with early-onset stroke in the moderate risk stratum.
We only explored the association between family history and
early-onset stroke for 2 reasons. First, previous studies suggest
that genetic factors have a greater role in determining stroke risk
at younger ages [3, 9, 13] ; second, the number of respondents who
reported having a late-onset stroke was small and the majority of
the respondents were young, and as a result we would not have
had enough statistical power to examine late-onset stroke.
We also used logistic regressions to examine family history of
stroke as a risk factor for HBP, atrial fibrillation, congestive heart
failure and diabetes. We calculated the sensitivity and specificity
(receiver operating characteristic curve) of family history as a pre-
dictor of stroke and the positive and negative predicted values.
Table 1. Distribution of selected characteristics of HealthStyles survey respondents: overall and by familial
risk for stroke/transient ischemic attack
Overall
(n = 4,819)
High risk
(n = 864)
Moderate risk
(n = 896)
Low risk
(n = 3,059)
Sex
Male 2,163 (44.9) 355 (41.1) 384 (42.9) 1,424 (46.6)
Female 2,656 (55.1) 509 (58.9) 512 (57.1) 1,635 (53.5)
Age group
1834 years 884 (18.3) 128 (14.8) 78 (8.7) 678 (22.2)
3544 years 1,341 (27.8) 226 (26.2) 201 (22.4) 914 (29.9)
4554 years 1,207 (25.1) 237 (27.4) 257 (28.7) 713 (23.3)
5564 years 684 (14.2) 142 (16.4) 176 (19.6) 366 (12.0)
65 years 703 (14.6) 131 (15.2) 184 (20.5) 388 (12.7)
Race
White 3,261 (67.7) 525 (60.8) 643 (71.8) 2,093 (68.4)
Black 609 (12.6) 154 (17.8) 92 (10.3) 363 (11.9)
Hispanic 644 (13.4) 125 (14.5) 113 (12.6) 406 (13.3)
Other 305 (6.3) 60 (6.9) 48 (5.4) 197 (6.4)
Education
1
High school or less 1,510 (32.5) 318 (37.9) 255 (29.3) 937 (31.9)
Some college 1,672 (36.0) 325 (38.7) 317 (36.4) 1,030 (35.1)
College graduate 1,915 (31.5) 196 (23.4) 298 (34.3) 970 (33.0)
Income, USD
<25,000 1,314 (27.3) 315 (36.5) 226 (25.2) 773 (25.3)
25,00059,000 1,590 (33.0) 264 (30.6) 306 (34.2) 1,020 (33.3)
60,000 1,915 (39.7) 285 (33.0) 364 (40.6) 1,266 (41.4)
Marital status
Ever married 4,127 (86.4) 733 (85.7) 800 (89.8) 2,594 (85.6)
Never married 648 (13.6) 122 (14.3) 91 (10.2) 435 (14.4)
Current smoker 841 (17.5) 193 (22.3) 139 (15.5) 509 (16.6)
Stroke
Early-onset stroke 103 (2.1) 54 (6.3) 13 (1.5) 36 (1.2)
Any history of stroke 171 (3.5) 69 (8.0) 32 (3.6) 70 (2.3)
Other health conditions
HBP 1,277 (26.5) 287 (33.2) 279 (31.1) 711 (23.2)
Atrial fibrillation 531 (11.0) 116 (13.4) 106 (11.8) 309 (10.1)
Congestive heart failure 386 (8.0) 101 (11.7) 62 (6.9) 223 (7.3)
Diabetes 520 (10.8) 129 (14.9) 92 (10.3) 299 (9.8)
Figures in parentheses are percentages.
1
Education level is missing for 173 respondents who did not specify their education level.
Mvundura /McGruder /Khoury /Valdez /
Yoon
Public Health Genomics 2010;13:1320 16
Sensitivity and specificity are the ability of family history to cor-
rectly identify respondents with and without stroke, respectively.
Positive and negative predicted values are the odds ratio that the
respondent has or does not have stroke given their family history.
We also tested the association between the strata of familial risk
and engagement in behaviors known to reduce stroke risk, using

2
tests.
Results
Table 1 shows that 18% of respondents had a high fa-
milial risk for stroke, 19% had a moderate familial risk
and 63% had a low familial risk. About 55% of respon-
dents were female; 46% were aged 45 or younger and 15%
were aged 65 or older; 68% were white; they were evenly
distributed across the 3 education categories; 86% were
married or had been married at some time in their lives.
About 27% had HBP, 11% had atrial fibrillation, 8% had
congestive heart failure and 11% had diabetes. The prev-
alence of early-onset stroke in the sample was 2%, and the
prevalence of stroke at any age of onset was 4%.
Table 2 shows that respondents in the high familial
risk category were approximately 4 times more likely to
have had an early-onset stroke than those in the low fa-
milial risk category. There was no statistical difference in
the occurrence of early-onset stroke between respondents
with moderate and low familial risk. These associations
changed little after controlling for other risk factors. Re-
spondents in the high familial risk category were still 4
times more likely to have a stroke (95% confidence inter-
val 2.66.0) than the moderate and low familiar risk
pooled.
In our familial risk stratification, we classified those
respondents who did not know their family history of
stroke (n = 66) as low familial risk. We redid the analysis
after excluding these respondents and found no change
in our results. We report only the results including these
respondents in the low risk strata, as it is most likely that
people who do not know their family history of stroke are
also most likely not to have any close relative with a med-
ical history of stroke.
Table 3 shows that HBP and congestive heart failure
were significantly and independently associated with fa-
milial risk for stroke, but diabetes and atrial fibrillation
were not. Depending on the variables we controlled for,
respondents with a high familial risk for stroke were 30
40% more likely to have HBP and 5060% more likely to
have congestive heart failure than those with a low or
moderate familial risk.
Table 4 shows that the prevalence of early-onset stroke
was 4.2% among respondents with high familial risk for
stroke, 2.5% among those with HBP and 10.5% among
those with both risk factors. The sensitivity and specific-
ity to detect stroke were 52 and 83%, respectively, for
high familial risk, 53 and 74%, respectively, for HBP, and
29 and 95%, respectively, for both risk factors. The pre-
dictive value of a negative test for these risk factors, alone
or in combination, was over 98%, implying that those
without a high familial risk or without HBP are unlikely
to have had an early-onset stroke. The rate of false nega-
tives was low. The predictive value of a positive test was
6% for high familial risk alone, 4% for HBP alone and
11% for both. Since this value depends on the prevalence
of early-onset stroke (2.1%), family history and HBP
combined can increase the detection of stroke by about
6 times.
To test the power of family history and HBP to dis-
criminate between cases and no cases of stroke, we used
the receiver operating characteristic curve analysis. In
this analysis, the area under the curve (AUC) represents
the probability that a test can correctly distinguish cases
from no cases. The AUC for HBP as a detector of early-
onset stroke was 64%. It was 68% for family history alone,
and 74% for family history and HBP combined. The AUC
reached 84% for family history and HBP combined with
demographics and related conditions.
Risk-Reducing Behaviors
Figure 1 a shows that, compared with those at a lower
familial risk, a greater proportion of those at high famil-
ial risk who reported having had a stroke were trying to
Table 2. Adjusted odds ratios for early-onset stroke (at or before
age 60) according to familial risk
Odds ratio
1
Model I
High familial risk 3.7 (2.35.8)
Moderate familial risk 0.8 (0.41.6)
Low familial risk 1.0
Model II
High familial risk 4.0 (2.66.0)
Moderate to low familial risk 1.0
Figures in parentheses are 95% confidence intervals.
1
Regression adjusted for sex, age, race, education, income,
marital status, current smoking habits, HBP, atrial fibrillation,
diabetes and congestive heart failure.
Family History as a Risk Factor for Stroke Public Health Genomics 2010;13:1320 17
reduce their salt intake (80 vs. 68%) and stop smoking (54
vs. 27%) and a significantly smaller proportion reported
trying to eat fewer high-fat foods (61 vs. 77%). There were
no differences on reported consumption of fruits and
vegetables (78 vs. 80%) and intention to be more physi-
cally active (61 vs. 62%).
Figure 1 b shows that, compared with those in a lower
familial risk, a greater proportion of those in the high
familial risk who reported not having had a stroke re-
ported trying to reduce their salt intake (63 vs. 57%), eat
more fruits and vegetables (78 vs. 75%), and to quit smok-
ing (38 vs. 33%). There were no significant differences
between these groups in the frequencies of the other be-
haviors.
Discussion
In this study, we used a 3-tiered familial risk algorithm
for stroke based on the self-reported stroke history of
both first- and second-degree relatives. We found that a
high familial risk for stroke was independently associated
with the likelihood of having had a stroke. Early-onset
strokes were 4 times more likely among people in the high
familial risk stratum than among those in the lower risk
strata, independently of demographic factors and other
health conditions. There was no significant difference in
risk for early-onset stroke between people in the low and
moderate risk strata, probably because of our small study
population.
In our study, the odds of having a stroke among those
with a high familial risk were slightly higher than the
odds reported in other studies [3, 9, 1316] . The most
Table 3. Adjusted odds ratios for HBP, congestive heart failure, atrial fibrillation and diabetes according to familial risk of stroke
High blood
pressure
odds ratio
Congestive
heart failure
odds ratio
Atrial
fibrillation
odds ratio
Diabetes
odds ratio
High familial risk
Adjusted for demographics 1.4 (1.11.6) 1.6 (1.22.1) 1.1 (0.91.4) 1.2 (1.01.6)
Adjusted for demographics, any history of stroke
and other health conditions 1.3 (1.11.6) 1.5 (1.32.0) 1.0 (0.71.2) 1.2 (0.91.4)
Moderate familial risk
Adjusted for demographics 1.2 (1.01.4) 1.1 (0.81.5) 0.9 (0.71.2) 0.8 (0.61.1)
Adjusted for demographics, any history of stroke
and other health conditions 1.2 (1.01.4) 1.1 (0.81.5) 0.9 (0.71.2) 0.8 (0.61.1)
Low familial risk 1.0 1.0 1.0 1.0
Figures in parentheses are 95% confidence intervals.
Table 4. Sensitivity, specificity as well as positive and negative predicted value of high familial risk and HBP to detect early-onset stroke
Early
stroke
No early
stroke
Total Prevalence
of early-
onset stroke
Sensitivity Specificity Positive
predictive
value
Negative
predictive
value
High familial risk 24 553 577 4.2 52.4% 82.8% 6.3% 98.8%
HBP 25 965 990 2.5 53.4% 74.1% 4.3% 98.6%
High familial risk and HBP 30 257 287 10.5 29.1% 94.6% 10.5% 98.4%
Neither 24 2,941 2,964 0.8 23.3% 37.6% 0.8% 95.7%
Total 103 4,716 4,819 2.1
Mvundura /McGruder /Khoury /Valdez /
Yoon
Public Health Genomics 2010;13:1320 18
likely explanation may be recall bias combined with our
risk stratification: respondents who had a stroke and were
at the highest risk stratum, according to our risk algo-
rithm, were probably more likely to be aware of their fam-
ily history of stroke than patients who have not had a
stroke. We could not account for other factors, such as
family size, because this information was not collected in
the survey. Actually, the influence of family history on
the odds of having a stroke should have been lower in our
study because we used a broad category of stroke. We
were not able to distinguish between stroke subtypes or
between stroke and TIA. Studies with a better classifica-
tion of stroke and a risk classification similar to ours
should clarify this finding.
HBP [2] , heart disease [17] and diabetes [2] are all risk
factors for stroke. In this study, we tested the association
between family history of stroke and these conditions. In
agreement with previous studies [57, 18] , we found an
independent association between family history of stroke
and personal history of HBP. We also found family his-
tory of stroke to be associated with congestive heart fail-
ure but not with atrial fibrillation, which is the most com-
mon risk factor for stroke after HBP [17] . Previous studies
also found family history of stroke positively associated
with ischemic heart disease [19] , congestive heart failure
and coronary artery disease, but not with atrial fibrilla-
tion [18] . We also found no association between family
history of stroke and personal history of diabetes, in
agreement with previous findings [7, 18] .
Our results suggested that neither family history
alone (52% sensitivity, 83% specificity) nor HBP alone
(53% sensitivity, 74% specificity) was very predictive of
stroke risk. The combined use of family history and
HBP was not very predictive either (29% sensitivity, 95%
specificity). A recent study indicates that individual risk
factors usually have limited ability to predict future dis-
ease when relative risks are low [20] . For a risk factor to
be a valid screening tool, the associated relative risk and
the prevalence of the risk factor in the population must
both be high. In this study, the prevalence of high famil-
ial risk for stroke was relatively high (18%), but the ad-
justed odds of stroke among those with a high familial
risk for stroke compared to those at lower risk were
about 4-fold, making high familial history for stroke a
poor screening tool for stroke, when used in isolation
[21, 22] . Multiple risk factors would increase the predic-
tive value of a screening tool. We have shown that fam-
ily history becomes an even better detector of early-
90
80
70
60
50
40
30
20
10
0
Cutting
down
on salt*
%
80
68
Trying to
stop
smoking*
Eating
fewer high
fat foods*
Eating more
fruits and
vegetables
Being more
physically
active
54
61
78
61
27
77
80
62
a Behavior
High familial risk Moderate to average familial risk
Fig. 1. a Engagement in stroke risk-reducing behavior among those with a history of stroke at any age of onset.
b Engagement in stroke risk-reducing behavior among those with no history of stroke at any age of onset. * Sig-
nificant difference in the proportions of the groups.
90
80
70
60
50
40
30
20
10
0
Cutting
down
on salt*
%
63
57
Trying to
stop
smoking*
Eating
fewer high
fat foods*
Eating more
fruits and
vegetables
Being more
physically
active
38
67
78
64
33
64
75
65
b Behavior
High familial risk Moderate to average familial risk
Family History as a Risk Factor for Stroke Public Health Genomics 2010;13:1320 19
onset stroke when used in combination with HBP and
demographic factors.
In addition to its potential as a screening tool, family
history of stroke may also be useful in the formulation of
risk-specific public health interventions and in motivat-
ing people with a family history of stroke to reduce their
risk for stroke through lifestyle modifications [23] . Re-
cent analyses from the Hypertension and Ambulatory
Recording Venetia Study indicate that people with a fam-
ily history of hypertension had a higher prevalence of un-
desirable lifestyle behaviors than those without such
family history at the beginning of the study. Moreover,
the lifestyle of those with a family history of hypertension
improved, while the behaviors of those with no family
history worsened [24] .
Behavioral changes can reduce the risk of a first stroke
as well as the risk of stroke recurrence. We found that a
greater proportion of those in the high familial risk stra-
tum than those in the other 2 strata were consuming a
low sodium diet and trying to quit smoking. However,
there were no differences in other beneficial behaviors,
such as a reduced cholesterol intake, a diet rich in fruits
and vegetables, and an increased physical activity [23] . It
could be that these recommendations may not be well
known by the general US population [2] .
This study has several limitations. First, our results
may be biased if the self-reports of personal history of
stroke or stroke-related medical conditions were inaccu-
rate. However, previous studies have shown that self-re-
ports of physician diagnoses of stroke are accurate [25, 26]
and so are those for hypertension, but not for cardiovas-
cular disease [27, 28] . We could not determine for this
study how self-reported medical conditions would affect
our risk estimations. Second, the use of unverified family
histories may have led to the underreporting of strokes in
the family, especially among second-degree relatives. In
addition, participants who had had an early-onset stroke
were probably more aware of any history of stroke in their
family than those who had not (recall bias) [8, 13, 15] .
These limitations are common in self-reported surveys.
Other specific limitations of this study are: first, the
survey did not ask respondents to report the type of stroke
they had and also that there was no distinction between
TIA and stroke; second, our dataset did not include any
information about cholesterol levels in blood or personal
histories of CHD, which are important risk factors for
stroke. The failure to control for the effect of CHD on risk
of stroke may have biased our results and may be another
factor explaining why our estimates are larger than those
found in previous studies; third, participation in the
HealthStyles survey is voluntary and participants were
thus not a random sample of the US adult population.
However, estimates of the prevalence of various chronic
conditions based on HealthStyles survey data have been
found comparable to corresponding estimates from the
Behavioral Risk Factor Surveillance System (BRFSS) data
and the similarities hold from year to year [29] . For ex-
ample, the estimated US prevalence of stroke in 2005 was
2.6% [30] based on BRFSS data, whereas the prevalence
we estimated was 2.1% based in HealthStyles data.
Because the HealthStyles survey is cross-sectional, we
were unable to assess causation or temporal associations
between key variables. For example, we could not deter-
mine whether a given lifestyle and health behavior oc-
curred before or after the occurrence of stroke. We were
also unable to assess stroke incidence because people oth-
erwise eligible for the study might have died before the
survey was conducted.
The survey does not include the number of people who
refused to be included in the household panel and this
may have affected the generalizability of the results. How-
ever, the resulting samples were poststratified and weight-
ed according to US census benchmarks on age, sex, race/
ethnicity, income and household size to reduce potential
bias due to under- or overresponse in categories within
these demographic variables.
The results of this study, although promising, need to
be taken cautiously, given the limitations of the dataset.
However, it is encouraging that despite the limitations dis-
cussed here we were still able to show a significant associa-
tion between a personal history of stroke and family his-
tory for the disease. Obviously, these results need verifica-
tion in larger and, if possible, prospective datasets (to avoid
recall bias). Given the level of risk detected in this study,
family history may not serve as a standalone tool to detect
stroke risk, but it could be a significant addition to cur-
rently used risk tools which include other well-known risk
factors for stroke. A probable step could be to refine the
familial risk stratification used here to achieve a better dis-
crimination of the levels of familial risk. Our study also
suggests that family history of stroke is associated with
some positive lifestyle behaviors, regardless of the person-
al history of stroke. Although behaviors are extremely dif-
ficult to modify, physician counseling about diet, smoking
cessation and hypertension control has been previously
shown to be effective in reducing stroke risk among pa-
tients [31] . The findings of our study suggest that a persons
family history of stroke may be an effective means of help-
ing to identify people at increased risk for stroke who might
readily benefit most from active lifestyle counseling.

Mvundura /McGruder /Khoury /Valdez /
Yoon
Public Health Genomics 2010;13:1320 20
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