Last Update: 10/26/20

Author: VDH Heart Disease Program

A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures. When that happens, part of the brain cannot get the blood and oxygen it needs, so area and its brain cells die.[1] There are two types of stroke: i) an ischemic stroke is caused by a clot obstructing the flow of blood to the brain; and ii) an hemorrhagic stroke occurs when a blood vessel ruptures and prevents blood flow to the brain. A TIA (transient ischemic attack), or "mini stroke", is caused by a temporary clot. The brain is an extremely complex organ that controls various body functions. If a stroke occurs and blood flow can't reach the region that controls a particular body function, that part of the body won't work as it should. If the stroke occurs toward the back of the brain, for instance, it's likely that some disability involving vision will result. The effects of a stroke depend primarily on the location of the obstruction and the extent of brain tissue affected. Visit the American Stroke Association’s Effect of Stroke webpage to learn more about the effects of stroke on the brain.

The table below, which uses Instant Atlas age adjusted Vital Statistics data, illustrates that the trend for this measure is moving in the right direction. Adult death rates for stroke have improved dramatically in the last ten years; stroke has fallen from being the 3^rd cause of death in 2002 to currently being the 6^th cause of death (COD) for men and women in Vermont. It is unclear why stroke has dropped from third to sixth cause of death. During that period the Department of Health has continued managing programs and activities that support the prevention of stroke risk factors. Between 2007 and 20010 the American Stroke Association and Health Department collaborated on several stroke awareness campaigns designed to increase peoples’ understandings about the signs and symptoms of a stroke. During that same period, a state level stroke system of care taskforce was implemented which included participation from all 14 Vermont hospitals and which focused on improving the quality of acute stroke care provided in Vermont. Although it is not possible to pinpoint the impact of each project on the stroke death rate, it appears that together, they have helped decrease deaths from stroke in Vermont over time.

See more information on stroke

This indicator is important because it is the sixth cause of death for men and women in Vermont (fifth in the nation)[1] and according to the American Stroke Association, stroke is linked to several risk factors that cannot be changed – these include age, heredity (family history), race, sex (gender), and prior stroke, heart attack, or TIA. There are also risk factors for stroke that are preventable with appropriate evidence based lifestyle changes, medicines, and medical procedures. These include:[2]

• High blood pressure — High blood pressure is the leading cause of stroke and the most important controllable risk factor for stroke. Many people believe the effective treatment of high blood pressure is a key reason for the accelerated decline in the death rates for stroke.
• Cigarette smoking — in recent years, studies have shown cigarette smoking to be an important risk factor for stroke. The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system in many ways. The use of oral contraceptives combined with cigarette smoking greatly increases stroke risk.
• Diabetes mellitus — Diabetes is an independent risk factor for stroke. Many people with diabetes also have high blood pressure, high blood cholesterol and are overweight. This increases their risk even more. While diabetes is treatable, the presence of the disease still increases your risk of stroke.
• Carotid or other artery disease — the carotid arteries in your neck supply blood to your brain. A carotid artery narrowed by fatty deposits from atherosclerosis (plaque buildups in artery walls) may become blocked by a blood clot. Carotid artery disease is also called carotid artery stenosis.
• Peripheral artery disease is the narrowing of blood vessels carrying blood to leg and arm muscles. It's caused by fatty buildups of plaque in artery walls. People with peripheral artery disease have a higher risk of carotid artery disease, which raises their risk of stroke.
• Atrial fibrillation — this heart rhythm disorder raises the risk for stroke. The heart's upper chambers quiver instead of beating effectively, which can let the blood pool and clot. If a clot breaks off, enters the bloodstream and lodges in an artery leading to the brain, a stroke results.
• Other heart disease — People with coronary heart disease or heart failure have a higher risk of stroke than those with hearts that work normally. Dilated cardiomyopathy (an enlarged heart), heart valve disease and some types of congenital heart defects also raise the risk of stroke.
• Sickle cell disease (also called sickle cell anemia) — this is a genetic disorder that mainly affects African-American and Hispanic children. "Sickled" red blood cells are less able to carry oxygen to the body's tissues and organs. These cells also tend to stick to blood vessel walls, which can block arteries to the brain and cause a stroke.
• High blood cholesterol — People with high blood cholesterol have an increased risk for stroke. Also, it appears that low HDL (“good”) cholesterol is a risk factor for stroke in men, but more data are needed to verify its effect in women.
• Poor diet — Diets high in saturated fat, trans fat and cholesterol can raise blood cholesterol levels. Diets high in sodium (salt) can contribute to increased blood pressure. Diets with excess calories can contribute to obesity. Also, a diet containing five or more servings of fruits and vegetables per day may reduce the risk of stroke.
• Physical inactivity and obesity — Being inactive, obese or both can increase your risk of high blood pressure, high blood cholesterol, diabetes, heart disease and stroke. So go on a brisk walk, take the stairs, and do whatever you can to make your life more active. Try to get a total of at least 30 minutes of activity on most or all days.

The measure for stroke death rate per 100,000 (the number, per 100,000 adults, who die of stroke each year) is a Healthy Vermonters 2020 performance indicator. The Department of Health receives grant funds from the CDC to coordinate activities and partnerships that support strategies to reduce risk factors for stroke across the state. These Health Department programs are managed in the Division of Health Promotion and Chronic Disease Prevention, and include the following programs: Tobacco Control Program, Physical Activity and Nutrition Program, heart health side of the Ladies First Program, and a coordinated chronic disease grant which focuses on school health, diabetes, obesity, and hypertension – all of which support strategies that play an important role in reduce risk factors that lead to stroke and educating Vermonters about the risk factors for stroke which cannot be changed.

See more information on high blood pressure

• Vermont Blueprint for Health and its statewide network of Community Health Teams
• AARP
• Primary Care Providers (no link available – these are individual practices)
• Community Health Centers
• Million Hearts ^®
• Association of State and Territorial Leaders (ASTHO)
• American Heart and Stroke Association of Vermont

Reducing risk factors for stroke (including those listed above), is directly tied to lowering a person’s risk for stroke. Evidence based strategies include maintaining a healthy weight, staying physically active, not smoking, limiting alcohol, and eating a healthy diet rich in fruits, vegetables and fiber and low in fats and sugars. Several programs housed within the Department of Health’s Division of Health Promotion and Chronic Disease Prevention and Division of Alcohol and Drug Prevention support activities that promote those strategies.

It is also critical to highlight the role that education and stroke systems of care can play in reducing the death rate associated with stroke. Early treatment of the most common type of stroke, ischemic stroke, can limit brain damage and vastly improve outcomes. Ischemic stroke is the kind caused by atherosclerosis, which causes blood clots that block the blood supply to a part of the brain. Yet some research suggests that fewer than 10% of ischemic stroke patients receive important clot-busting drugs, which are most effective when given within three hours after symptoms start. Patients often arrive at the hospital after that window of opportunity has closed or are sent to a hospital that is not equipped to properly diagnose and treat a stroke.[1]

Many Health Departments and community organizations have developed and/ or promote educational campaigns and materials that educate the public about the symptoms and signs of stroke. One widespread campaign, which is supported by the American Heart and Stroke Association is the F.A.S.T. campaign where the word F.A.S.T. stands for: Face drooping, Arm weakness, Speech difficulty, and Time to call 9-1-1. Evidence based stroke systems of care and stroke assessment tools for use communities and pre-hospital and hospital settings have also been developed to promote optimal outcomes for stroke patients. These tools and systems of care are designed to promote activities that support prevention of stroke risk factors, streamline identification of a stroke in community and clinical settings, and put clinical systems in place to appropriately treat a stroke.

National organizations including the Centers for Disease Control and Prevention (CDC), Million Hearts, American Diabetes Association, and the American Heart and Stroke Association recommend a number of evidence-based interventions to help adults with reduce risk factors associated with stroke. These include:

• Working with a health care team
• Making lifestyle changes (healthy diet, being active, not smoking and limiting alcohol).
• Using self-measured Blood Pressure techniques
• Using self-management programs such as the Stanford Healthier Living Workshop – Diabetes (HLWD), Chronic Disease Self-Management (CDSMP) and the National Diabetes Prevention Program
• Working to promote use of evidence based treatment protocols among Primary Care Providers
• Promoting evidence based resources such as the DASH Eating Plan and the Healthy Eating and Lifestyle Resource Center
• Recognizing the signs and symptoms of a stroke – and what to do

See more information on staying healthy

The Vermont Department of Health is funded by the CDC to work on prevention activities that reduce stroke risk factors heart disease through a grant called Improving the Health of Americans Through Prevention and Control of Diabetes and Heart Disease and Stroke. Our strategy is to work with providers, clinics, schools and community partners to create healthy environments, promote best practices, and support Vermonters to make healthy choices that will prevent or help reduce the likelihood of having a stroke.

Although a self-management program specifically focused on stroke is not currently available, programs such as the Chronic Disease Self-Management (CDSMP) and the National Diabetes Prevention Program help teach people with or at risk for stroke to manage lifestyle and behaviors that will lead to better blood pressure control, weight loss, lower cholesterol, and other lifestyle factors that lower the risk for stroke. These programs are available across the state to all Vermonters at no cost. The CDSMP is called “Healthier Living Workshop” in Vermont and is offered throughout the state. The program specifically addresses arthritis, diabetes, lung and heart disease, but teaches skills useful for managing a variety of chronic diseases. This program was developed at Stanford University and helps individuals develop skills to cope with their condition, improve energy levels, manage pain, and learn to make the best choices for their condition and lifestyle. It covers topic such as: techniques to deal with problems associated with chronic disease, appropriate exercise, appropriate use of medications, communicating effectively with family, friends, and health professionals, nutrition, and how to evaluate new treatments. Participants who took CDSMP demonstrated significant improvements in exercise, ability to do social and household activities, less depression, fear and frustration or worry about their health, reduction in symptoms like pain, and increased confidence in their ability to manage their condition.

An important first step is to make an appointment with your primary care provider to have your stroke risk assessed. Your provider can help identify ways to reduce stroke risk factors, or develop a plan that could include lifestyle changes and possibly medications, to help lower your risk factors. Recommendations from health care providers are among the most influential factors in convincing people to be physically active and join a self-management program. The American Heart and Stroke Association also has an online health assessment tool called My Life Check – Life’s Simple 7 where people can take the assessment online, see their heart health score, and receive a seven step list related to lifestyle behaviors that can help people stay healthy or take steps to reduce risk factors linked to heart disease and stroke.

By focusing on the health and well-being of all Vermonters through quality health systems, physical activity, nutrition and tobacco prevention and cessation intervention – the most effective ways to prevent or reduce the risk for stroke – we can help to address the most significant risk factors and ensure better quality of life for those at risk for having a stroke.

BRFSS

Vermont tracks the risk behaviors of its adult residents using a telephone survey, the Behavioral Risk Factor Surveillance System (BRFSS), for landlines and cellular phones leverage through funding from the Centers for Disease Control and Prevention (CDC). The inclusion of cellular phones began in 2009; this was done to ensure the survey contained an accurate representative sample of adult Vermonters as cell phone use as the primary household phone was increasing significantly. The sample of respondents is then weighted, using standardized methodology developed by the CDC, to achieve population level estimates. In 2011 this weighting methodology was changed due to the fact that cell phones became the predominant make-up of the entire sample. This new system of raking allows for the incorporation of other variables not traditionally used in the weighting process, most importantly, telephone source.

Behavioral Risk Factor Surveillance System -- BRFSS

Vermont tracks risk behaviors and chronic disease using a telephone survey of adults called the Behavioral Risk Factor Surveillance Survey (BRFSS). Since 1990, Vermont, along with the 49 other states, Washington D.C. and U.S. territories, has participated in the BRFSS with the Centers for Disease Control and Prevention. The CDC provides the Vermont Department of Health with funding each year to carry out the survey. Several thousand Vermonters are randomly and anonymously selected and called annually, on both landlines and cell phones. An adult (18 or older) is asked a uniform set of questions. The results are weighted to represent the adult population of the state.

Note that beginning in 2011 the CDC implemented changes to the BRFSS weighting methodology in order to more accurately represent the adult population.While this makes calculations more representative of the population, the changes in methodology also limit the ability to compare results from 2011 forward with those from previous years.The Vermont Department of Health recommends that comparisons between BRFSS data from 2011 forward and earlier years be made with caution.Statistical differences may be due to methodological changes, rather than changes in opinion or behavior.

YRBS

The Youth Risk Behavior Survey (YRBS) is a paper survey taken by Vermont middle and school students every other year as a collaboration between the Department of Health’s Division of Alcohol and Drug Abuse Program and the Agency of Education’s Coordinated School Health Programs. It measures the prevalence of behaviors that contribute to the leading causes of death, disease, and injury among Vermont Youth. Data is weighted so as to generate population level estimates for all Vermont Middle and High Schools.

Youth Risk Behavior Survey -- YRBS

The Youth Risk Behavior Survey (YRBS) is a paper survey administered in Vermont middle and high schools every two years since 1993. The survey is sponsored by the Department of Health's Division of Alcohol and Drug Abuse Programs, and the Department of Education's Coordinated School Health Programs and the CDC. The YRBS measures the prevalence of behaviors that contribute to the leading causes of death, disease, and injury among youth. Vermont surveys over 30,000 students at each administration. Weighted data is compiled to generate a representative state sample, and local data is used by schools, supervisory unions, health programs and other local organizations. The YRBS is completed in over 40 other states and there is a national weighted sample for comparison.

VITAL STASTICS

The Vermont vital statistics system monitors vital events (births, deaths, marriages and civil unions, divorces and dissolutions, etc.). Death certificates are often completed by the funeral directors who obtain all necessary information from the family. However, a physician is required to complete and certify the cause of death in the Electronic Death Registration System (EDRS).Mortality rates are calculated based on the ICD-10 code for the underlying cause of death listed on death records received by Vital Records. Only Vermont residents are included in these calculations.Rates were calculated by comparing the number of deaths in a given time period to the overall population of Vermont in the same time period.

WHEN A MEASURE IS AGE ADJUSTED

Age adjustment is used for comparison of regions with varying age breakdowns.In order to remain consistent with the methods of comparison at a national level, some statistics in Vermont are age adjusted.In cases where age adjustment was noted as being part of the statistical analysis, the estimates were adjusted based on the proportional age breakdowns of the U.S. population in 2000.

Se more information on age adjustment

Methods

Prevalence and percentages are calculated by using descriptive statistical procedures using software such as SPSS, SAS, and/or SUDAAN.These statistics describe the proportion of individuals with a given trait in the population during a specified period of time.

Discharge rates are calculated using the Vermont Uniform Hospital Discharge data set.We look at all hospital and ED discharge among Vermont residents who utilized services at regional hospitals (including hospitals in bordering states).We compared the number of discharges in a given time period to the Vermont population in the same time period to calculate discharge rates.