Stroke Cerebrovascular Accident

Key Points

• Risk of stroke is six times greater in smokers (>1 pack/day).

• Smokers who are also hypertensive have a 20 times greater stroke risk.

• Risk of CVA declines rapidly after smoking cessation, and at 5 years is the same as for a nonsmoker.

Stroke (CVA) is the third most common cause of death in the United States. Although hypertension is the greatest risk factor for stroke, cigarette smoking is also significant. The incidence of stroke in smokers is two to four times higher than in nonsmokers. Among those screened in the Multiple Risk Factor Intervention Trial (MRFIT), smokers had twice the risk of a nonhemorrhagic stroke, and smoking was strongly associated with all forms of stroke (Neaton et al., 1993).

The risk of stroke increases in proportion to the amount of smoking. Those who smoke more than 40 cigarettes/ day have twice the stroke risk of those who smoke less than 10 cigarettes/day. Compared with women who have never smoked, the risk of stroke increases 2.2-fold in women smoking 1 to 14 cigarettes/day and 3.7-fold in women smoking 25 or more cigarettes/day (Colditz et al., 1988). Noting a clear dose-response relationship, Bonita and associates (1986) found a threefold increase in the risk of stroke in smokers versus nonsmokers (see eFig. 50-1 online). The risk is 5.6 times higher in persons smoking more than one pack daily. Cigarette smokers who are also hypertensive have a 20-fold increased risk of stroke (US Surgeon General, 2004).

Sclerosis of the carotid arteries is directly proportional to the amount of smoke exposure. Smoking increases the risk of ischemic heart disease and cerebrovascular disease regardless of the level of serum cholesterol. Low cholesterol level did not protect against smoking-related arteriosclerotic cardiovascular disease in patients in South Korea, where the prevalence of smoking is among the highest in the world (72% of men) (Jee et al., 1999). Smoking may increase the likelihood of thrombosis by increasing serum fibrinogen, enhancing platelet aggregation, and increasing blood viscosity.

The risk of stroke declines rapidly after cessation of smoking. After 5 years, risk of CVA is at the level of nonsmokers, which emphasizes that "it is never too late to quit," no matter how long the patient has been smoking.

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