By Nycole K. Joseph, M.D. – Stroke is the second-leading cause of death worldwide, according to the World Health Organization, and in the United States, about 800,000 strokes occur per year. Eighty-seven percent of strokes are “ischemic” and these occur when a clot blocks a blood vessel in the brain and stops blood flow. The remaining 13% are “hemorrhagic,” where a blood vessel ruptures causing bleeding into the brain tissue.
In the U.S., stroke has dropped to the fifth-leading cause of death due to improved systems of care, including earlier recognition and treatments, which have resulted in overall better outcomes. Despite these advances, there is a distinct disparity in stroke care and outcomes among Black people in America compared to the rest of the population. Stroke prevalence and mortality rates are consistently higher among Black patients than for any other racial group. Black stroke survivors also are more likely to be disabled and have difficulties with daily activities.
Many factors contribute to these unfortunate statistics, some of which are controllable, while others are not. Among the latter are risk factors that include age, gender, race, and family history.
Sickle cell anemia is a genetic disorder more common among Black people that increases the risk for stroke. But there are risk factors that can be modified and patients can take measures to change. It is imperative that Black people are made aware of these health risks, to adjust their lifestyle and prevent strokes.
Risk factors for stroke such as high blood pressure, high cholesterol, diabetes, tobacco use, alcohol use and obesity are prevalent in the Black community. Obstructive sleep apnea also is an independent risk factor for stroke, as is atrial fibrillation, an abnormal heart rhythm that can be detected using a rhythm strip (electrocardiogram/ECG) or prolonged heart monitor.
Black patients are inadequately treated by health care providers regarding primary and secondary stroke prevention strategies, compared with white patients1. I encourage patients to be proactive about their health and work with their primary care physicians to minimize their risk of stroke. Here are key factors to watch:
- Blood pressure should be maintained consistently less than 130/80mmHg and patients are encouraged to monitor their blood pressure at home.
- Regular aerobic exercise is important to lowering blood pressure and living a healthier life.
- Cholesterol levels should be checked and managed appropriately. The low density lipoprotein (LDL), known as the “bad cholesterol” should be maintained less than 70mg/dl.
- Blood sugars should be tightly controlled and a hemoglobin A1c can be measured to obtain an average blood sugar level over the last 3 months, with a goal of less than 7%.
- Patients should be screened for obstructive sleep apnea – a condition characterized by snoring and episodes where patients stop breathing in their sleep, affecting the oxygen supply to the brain.
- Smoking is a major risk factor and patients should be encouraged to stop smoking and avoid secondhand exposure to smoke.
- Alcohol consumption should not exceed 1 to 2 servings per day.
- A healthy diet is indispensable and the Mediterranean diet, rich in fresh fruits and vegetables, and favoring white meat and fish over red meat, is emphasized in stroke prevention.
- Taking prescribed medication correctly is key to ensure that each of these risk factors remains well-controlled.
There are disparities inherent to the health care system that impact the care Black people receive. Differences in socioeconomic status and insurance coverage may contribute to unequal access to care and poorer quality of care. Unmeasured factors such as implicit racial/ethnic biases and cultural incompetence among medical providers treating Black patients generates mistrust in the health care system and differences in compliance with recommendations. These, in turn, may impact the different rates of stroke morbidity and mortality1.
Black patients are more likely than white patients to delay going to the hospital after onset of stroke symptoms and receive fewer evidence-based treatments for strokes. To improve outcomes, it is important to recognize the symptoms of a stroke and call 911 as quickly as possible. Pay special attention to the time that symptoms started, which will help the medical team to determine treatments. If patients come to the hospital within 4 1/2 hours after their symptoms start and meet specific criteria, they may receive a medication to break up the clot that is blocking the blood vessel in the brain. Within 24 hours of first symptoms, doctors can perform procedures with new technology to remove the clots from blood vessels supplying the brain.
The acronym “FASTER” can help people remember the signs and symptoms of stroke:
F – FACE: an uneven smile; one side of the face is weak or numb
A – ARM: one arm drifts down when raising both; or one arm is weaker or more numb
S – STABILITY: loss of coordination, dizziness, hard time keeping balance, trouble walking
T – TALKING: slurred speech, unable to speak
E – EYES: difficulty seeing out of one or both eyes, double vision
R – REACT: check the time that symptoms began and call 911 immediately, even if the symptoms seem to go away.
Remember the phrase “time is brain” – the more quickly you recognize the symptoms of stroke, the more quickly a person can be treated and the more lives can be saved.
The disparities in health care affecting Black patients have been long-standing, driven by underlying social, economic and racial inequities. Addressing the disparities in stroke treatment is important to improve patient outcomes and reduce morbidity and mortality.
Nycole K. Joseph, M.D., is a vascular neurology fellow at Mayo Clinic in Jacksonville.
- Cruz-Flores S, Rabinstein A, Biller J et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Epidemiology and Prevention; Council on Quality of Care and Outcomes Research. Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Jul;42(7):2091-116. doi: 10.1161/STR.0b013e3182213e24. Epub 2011 May 26. PMID: 21617147.