The Risk Factor of Recurrence Stroke Among Stroke and Transient Ischemic Attack Patients in Indonesia

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ICHT 2019

Selection and Peer-review under the responsibility of the ICHT Conference


Committee
Volume 2019

Conference Paper

The Risk Factor of Recurrence Stroke among


Stroke and Transient Ischemic Attack Patients
in Indonesia
Listian Prisilia Rahayu1 , Diwa Agus Sudrajat1 , Gina Nurdina1 , Elis Nurhayati
Agustina2 , and Tri Antika Rizki Kusuma Putri1
1
STIKep PPNI Jawa Barat,West Java-Indonesia
2
National Brain Center Hospital, Jakarta-Indonesia

Abstract
Background:Stroke described as a disruption of blood flow in the brain which can
lead to brain malfunction, neurological deficits, and even death. Although with good
managementin acute period, the incidence of recurrent stroke still increasing every
year. Objectives: This study aimed to determine the dominant risk factorof stroke
recurrence. Methods: This study was a cross sectional descriptive study with 274
strokes patients as samples. The samples were recruited from one of general hospital
Corresponding Author:
specialize in neurology disorders in Jakarta, Indonesia. Results: The result indicated
Listian Prisilia Rahayu a significant correlation betweencardiovascular disorders, cholesterol, and activity
prisilialistian97@gmail.com withincidence of stroke recurrent (p<0.05). The dominant risk factor in this study
wasobesity event (OR = 0.616). Conclusion: Besides the dominant factor, there
Received: 22 September 2019
were 3 factors that significantly affectstroke recurrence;cardiovascular disorders,
Accepted: 4 October 2019
Published: 10 October 2019
hypercholesterolemia, and physical activity.Nurses should be more aware that some
patients may still have risk factors of stroke recurrence even they have discharged
Publishing services provided by from hospital. With some efforts like health education and controlling the factors can
Knowledge E
help to reduce the risk of stroke recurrence.
Listian Prisilia Rahayu
Keywords: Stroke, Recurrence stroke
et al. This article is distributed
under the terms of the Creative
Commons Attribution License,
which permits unrestricted use
and redistribution provided that
the original author and source 1. Introduction
are credited.

Selection and Peer-review under


Stroke defined asa clinical syndrome caused by sudden brain blood vessel disorder
the responsibility of the ICHT which can occur in patients aged 45-80 years. Stroke also described as a neurological
2019 Conference Committee.
change caused by the disruptionof blood supply to the part of the brain [1]. Stroke divided
into two types; ischemicstroke (non-hemorrhagic) and hemorrhagic stroke. Ischemic
strokeoccurredbecause of an arteriosclerotic or blood clot in blood vessel leading to
decreasing the blood flow. While the hemorrhagic stroke happened when blood vessels
ruptured and make abnormal blood flow into the brain and cause damageto it [2]. It
concluded that stroke is an interruption of blood flow to the brain which can causebrain
malfunction.

How to cite this article: Listian Prisilia Rahayu, Diwa Agus Sudrajat, Gina Nurdina, Elis Nurhayati Agustina, and Tri Antika Rizki Kusuma Putri, (2019),
“The Risk Factor of Recurrence Stroke among Stroke and Transient Ischemic Attack Patients in Indonesia” in Selection and Peer-review under the Page 87
responsibility of the ICHT Conference Committee, KnE Life Sciences, pages 87–97. DOI 10.18502/kls.v4i13.5229
ICHT 2019

According to [3], stroke is the second leading cause of death in the world, whereas,
in big country like USA, stroke became one of the highest cause of death after cardio-
vascular disease and cancer with 795.000 people in the USA suffer a stroke every each
year and185.000 of which are recurrent stroke. While in Indonesia there are 500.000
people suffering from stroke each year and 2.5% of them suffered disabilities both mild
and moderate or even death [4]. Based on Indonesian Health Research in 2018 the
stroke prevalence nationallyhas increased compared to 2013 (7.0%). It is aligned with
the stroke prevalence in Jakarta-Indonesiain 2018 showed an increase (9.7%).
The datashows the incidence of stroke is increasing every year, especially in devel-
oping countries like Indonesia. Strokes can cause various symptoms and effects such
as facial or limbs paralysis, slurred speech, altered consciousness, impaired vision, and
any other neurological deficits symptom [5]. In severe case, strokes can cause death
or in better condition As for the impact in severe cases can result in death, while in the
better scenario dementia, depression, or even recurrent stroke can occur as a result.
Stroke Recurrence is one of the most happened complications after hospital dis-
charge [6]. According to [7], 25% of stroke patients had at least one episode of recurrent
strokes which 2-22% occurred in the first year and 10-53% at 5 years after the primary
stroke [8]. Stroke patients with risk factors can have a period of recurrent stroke in the
same or different place on the brain [9]. After primary stroke, the recurrence stroke can
occur with more fatal effects than the primary with extent damage of the brain [10]. It’s
also happened in patients with lack of self-control which can trigger period of stroke
recurrenceif bleeding or the problems wider than the primary attack. The problems
because of stroke can affect the physical condition like disability or pshycological defect
in the productive age or older which can lead to socio-economic problems [11].
According to the theories, a lot of recurrent stroke risk factors are well known.
Therefore, further analysis is needed to identify the dominant risk factors of recurrent
strokes in Indonesian Population. The purpose of this study was to determine the
dominant risk factor of recurrent strokes among Indonesia stroke and transient ischemic
stroke patients.

2. Methods
2.1. Study design

This study was a cross-sectional descriptive study with 274 stroke patients at National
Brain Hospital as respondents.

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2.2. Sample

This study conducted at National Barin Center hospital with 274 strokes patients as
samples.The inclusion criteria in this study were 1) strokepatients 2) didn’t have cognitive
disorder. Independent variables included age, sex, contraception, diagnosis, hyper-
tension, cardiovascular disorders, arrhythmia, hypercholesterolemia, obesity, smoking,
alcohol consumption, diabetes mellitus, physical activity, self-efficacy, NIHSS, and recur-
rent stroke as dependent variable.

2.3. Instrument

This study used questionnaires and checklist form to described the variables. The
questionnaires are Bharthel Index, NIHSS (National Institutes of Health Stroke Scale)
score sheet, the stroke self-efficacy scale, and another form to describe the character-
istics of respondents. This study starts with making doing paperwork for permission and
ethical clearance STIkep PPNI Jabar and National Brain Hospital. All of the variables got
analyzed independently, bivariate analysis used Chi Square, and multifactorial analysis
used binary regression test.

2.4. Data collection procedure

This study conducted in May-June 2019 at National Brain Center Hospital Jakarta-
Indonesia.

2.5. Data analysis

Data in this study analyzed for univariate, bivariate, and multivariate. The most dominant
factor in this study found by multi variance analysis using binomial regression.

3. Results

Table.1 showed the result of univariate analysis for all the variables in this research.
The results from univariate analysis based on the incidence of recurrent stroke showed
109 (39.8%) patients suffered a recurrence stroke, 227 (82.8%) patients have above 45
years old, 233 (85.0%) respondents did not have enough education, 123 (44.9%) still
working independently like being an employee at private agencies or businessman.

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Around 56.9% of respondents are male and more than a half respondents came from
Java tribe. The diagnosis of stroke, more than a half samples diagnosed with ischemic
stroke.
Table.2 showed the result of bivariate analysis. The results indicated that there is
no significant correlation between age, gender, contraception, family history of stroke,
hypertension, alcohol consumption, physical activity, self-efficacy, NIHSS score, and
education level with recurrence stroke (p value>0.005). While there was significant
correlation between cardiovascular disorders, arrhythmia, smoking history, diabetes
mellitus, and hypercholesterolemia with recurrence stroke (p value>0.005).
The multifactorial analysis was conducted to determine the dominant risk factors
independent. The results showed that the dominant risk factor on strokes recurrence
stroke was obesity (p = 0.015; OR 0.616).

4. Discussion

The prevalence of stroke in Indonesia is still increasing every year which get along with
increasing the risk factors of stroke recurrence. Recurrent stroke can occur if the risk
factors are not controlled both in the same and different part of the brain with the primary
attack.Sometimes, patients with recurrent stroke can have more dangerouscondition
than the primary stroke. It is because the extent of brain damage that occurs as a result
of a previous and current stroke [10]. Age is one of risk factor of stroke that can not be
changed, while someone gets older, the risk of recurrent stroke is increasing. According
to, that age is one of undeniable risk on stroke patient, due to bad elasticity of blood
vessels in older peoples. [3] also mentioned that the risk factors of stroke doubled each
decade of age after 55y.o. Prevalence of stroke in Indonesia highest obtained at the
age of 75 years [5].
This study showed that some have maintained a large proportion of respondents
aged over 45 years have 227 (82.8%) (Table.1). According to the research of [7] involved
140 stroke patients in Thailand obtained an average age of stroke patients was 65.5
years. The research by [12] in Panti Wilasa Citarum Semarang revealed that most
respondents age >45 y.o. The study [13] showed that the frequency distribution that the
highest age of respondents is 46-50 years (27.5%). While in this study found that there
was no significant correlation between age and the risk of stroke recurrence (Table 2).
This is in line with research conducted by WahyunahandSaefuloh (2016) said that age
does not significantly associate with the occurrence of recurrent stroke (p = 0.059, 95%
CI).

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Table 1: Risk Factors of Recurrence Stroke.

Variables Frequency Percentage (%)


Stroke Primary 165 60.9
Recurrent 109 39.8
Education High 41 15.0
Low 233 85.0
Work Government Employee 15 5.5
Private Employee 185 67.5
Does not work 74 27.0
Medical diagnosis Hemorrhagic stroke 79 28.8
Ischemic stroke 195 71.2
Age <15 47 17.2
> 15 227 82.8
Gender Woman 156 56.9
Man 118 43.1
Family History No 156 56.9
Yes 118 43.1
Hypertension History No 140 51.1
Yes 133 48.5
Cardiovascular disorders No 235 85.8
Yes 39 14.2
Arrythmia No 242 81.8
Yes 50 18.2
Hypercholesterolemia No 161 58.8
Yes 113 41.2
Obesity No 224 81.8
Yes 50 18.2
Smoking history No 224 81.8
Yes 50 18.2
Alcoholhistory No 270 98.5
Yes 4 1.5
Diabetes mellitus No 148 54.0
Yes 126 46.0
Activity No 217 79.2
Yes 57 20.8
Self-efficacy Low 186 67.9
Moderate 69 25.2
High 19 6.90
NIHSS <15 256 93.4
> 15 18 6.60

In Table 1 obtained more than half of the respondents are male 156 (56.9%). According
to Chih, Ying and Wu in March 2007 - August 2008 in Taiwan, found the incidence of

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Table 2: Results of the Bivariate analysis Stroke incidence recurring factors.

Variables OR 95% CI P-Value


Diagnosis .715 .421 to 1.213 .213
Age 1.345 .696 to 2.598 .377
Gender 1.456 .893 to 2.373 .131
Contraception 1.267 .756 to 2.124 .369
Family history .943 .578 to 1.538 .814
Hypertension .981 .605 to 1.592 .940
Cardiovascular .233 .940 to.577 .001
Disorders
Arrythmia 1.042 .491 to 2.205 .917
Hypercholesterolemia .402 .240 to 0.674 .000
Obesity 1.510 .815 to 2.789 .189
Smoking .739 .389 to 1.406 .356
Alcohol .500 .051 to 4.970 .543
Diabetes Mellitus 1.525 .937 to 2.481 .089
Physical Activity .290 .143 to.591 .000
Self Efficacy .871 .520 to 1.458 .598
Education Level 1.509 .744 to 3.063 .252
NIHSS 2.543 .950 to 6.754 .056

Table 3: Multivariate Analysis on Strokes Recurrence Among Strokes and Transient Ischemic Stroke *
Excluded from modeling.

Variable Step 1 Step 2 Step3 Step4 F (Z−𝑒 )


Gender 1.075 *
Type of Stroke .878 .881 *
NIHSS 2.416 2.448 2.436 *
Cardiovascuar Disorder .211 .205 .202 .207 .148
Hypercholesterolemia .533 .531 .542 .512 .302
Obesity 1.917 1.951 1.968 1.899 .616
Physical Activity .392 .392 .383 .377 .242
Diabetes mellitus 1.746 1.376 1.676 1.675 .586

stroke in men more than in women with the percentage of each 63.4% male and 36.6%
female. The study [13] showed that the respondent distribution dominated by male than
women. Male patient tends to be higher because of the smoking incidence higher in
male dan women which can lead to blood vessel damage and lead to stroke incidence.
Female has the estrogen as a hormone which can increase the HDL levels in the
blood, thus preventing atherosclerosis in women. However, when estrogen production
is reduced or even not been established yet, a woman’s risk of stroke would be greater
than men. The pattern of this attack is related to the protection of the female sex
hormones, so it will changed when female patients come into menopause period.

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Highprevalence of strokes in communities with low educational but there was no


significant correlation between education level and the risk of recurrent stroke (Table
2). Hypertension is one of the factors that not properly controlled which contribute to
the incidence of recurrent strokes. The higher the blood pressure also make the risk of
recurrent strokes increasing. [14] said that based on data analysis using Chi Square test
showed p <0.05 means there is a significant correlation between hypertension with
recurrent strokes. Controlling the blood pressure on stroke patients will reduce the risk
of recurrence stroke.
Hypercholesterolemiahas a very close relation to recurrent stroke, this case put
forward by the theory show that hypercholesterolemia can lead to atherosclerosis event
in the blood vessels of the brain and the formation of fat so that blood flow is slow.
Besides, hypercholesterolemia can cause coronary heart disease too. In these studies
showed that hypercholesterolemiahas a significant relationship with the incidence of
recurrent stroke (p = 0.000). The research in China conducted by [15] showed p-value
<0.05 which means that there was a significant correlation between dyslipidemia with
an incidence of recurrent strokes.
Respondents who suffer from cardiovascular disorders in this study were 39 peoples
or 14.2%. The results of the bivariate analysis using chi square indicated that there was a
significant correlation between history of heart problems with the incidence of recurrent
stroke (p = 0.001) (Table 2). Heart disease is the most powerful factors which can lead
to ischemic stroke. According to [12] that smoking is a risk factor for cardiovascular
disease and stroke. National Stroke Association (2014) described that The content of
cigarette such carbon monoxide can cause a lack of oxygen bound to hemoglobin in
the blood. It make the heart will work harder in order to fulfill the cardiac output for
the whole body parts. In addition, cigarettes substances will make it easier to blood
vessel formed a blood clot or thrombus which can block blood flow. The disturbance
in blood flow to the part of the brain will cause a stroke. However, the risk of stroke
can be reduced by quitting smoking. According to [16] cigarette contains 4000 different
chemical compounds who need to be absorbed into the bloodstream and distributed
throughout the body via the vascular system. Many of these compounds can work as
free radicals which initiate unwanted chemical reactions, some of these chemicals are
known to be directly toxic to the endothelium of blood vessels. Smoking will increase
the risk of stroke by 50% also subarachnoid hemorrhage by 100%.
This study found that there was no significant association between smoking history
and recurrent stroke with p-value of 0.356. [14] stated that there is no significant
relationship between smoking and the incidence of recurrent stroke with a p-value

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1.000 (p>α).the same result in getting from research found no significant correlation
between smoking and the incidence of stroke with p-value 0.527 (p> α). In this study,
smoking does not affect the possibility of recurrent stroke events as it relates to the
number of cigarettes smoked per day and is also related to how long the respondent
started smoking.
In addition to smoking, alcohol is also one factor that can contribute to the incidence
of recurrent stroke. Alcoholic consumption will affect the incidence of recurrent stroke
which totals 80 cc or 560 cc per day of the week [17]. Theoretically alcohol can induce
the increase of blood pressure which is the risk factor of stroke, but the levels of alcohol
consumed also affects the incidence of recurrent strokes. In this study, the proportion
of respondents with a history of alcohol less than respondents who did not have a
history of alcohol. Research conducted by Omori et al (2015) in Japan was found in
respondents recurrent stroke by 40% had the habit of drinking alcohol. According to
the research of [18] on the characteristics and the risk of recurrent stroke in China
obtained thatalcohol is a risk factor for stroke in the West, but for the population in
Indonesia has not been proven as one of the different cultural. Specifically reported
that alcohol consumption of more than 60 grams per day of 1.69 times risk of stroke
when compared with respondents who did not consume alcohol.
Respondents with a history of diabetes mellitus in this study were126 respondents
(46.0%) and there is no significant relationship between diabetes mellitus with an
incidence of recurrent stroke with a p-value of 0.089 (p> α). Research by Karuniawati
et al (2015) there wasn’t a significant relationship with the occurrence of diabetes
mellitus and recurrent stroke with the results of the statistical test Chi-Square p-value
= 0.409 (p> α). However this is not in line with research of [19] about diabetes as an
independent factor for recurrence stroke who obtained OR 1.45 (p-value <0.05) means
that the risk of recurrent stroke with diabetes was 1.45 times higher than those without
diabetes. Lambert mentioned that although diabetes is a risk factor for the occurrence
of stroke for the first time, not a lot of data showing that diabetes has a significant
effect on the incidence of recurrent stroke. Diabetes is estimated to affect only 9% in
the incidence of recurrent stroke lead [20].
Physical activities in this study viewed from everyday activities which include activities
in their daily activities. The results of this study noted that was a significant relationship
between physical activity with incidence of recurrent stroke (p<0.005). The research by
[7] in Thailand stated that stroke patients with a Barthel Index score ≤60 have a higher
risk for recurrent stroke than patients who can do the physical activity independently.
In this study, patients with stroke usually bear disabilities as a result of a neurological

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disorder and make them need assistance to do their activity daily living. Stroke also has
an impact on a person’s activity cause it can make paralysis, disability, communication
disorders, emotional disorders, pain, sleep disorders, depression, and dysphagia. NIHSS
score can also affect the occurrence of recurrent stroke, in this study, the majority of
respondents NIHSS score less than 15, the lower the value NIHSS then also increase
the risk of recurrent stroke events.
Dysfunction in stroke patients may impact psychologically and socially to the patient,
such as low self-esteem, hopelessness, sorrow, anxiety, and despair which it was
the signs of low self-efficacy [21]. Someone with low self-efficacy tendsto not have
confidence and doubt their own abilities. Meanwhile patients with high self-efficacy
have healthy behaviors that can increase the independence to fulfill their daily activity
so it can reduce depression, lowering concerns, increasing self-esteem, and improve
quality of life [22].
After controlling other variables on multifactorial analysis using binomial regression
found that cardiovascular disease, hypercholesterolemia, obesity, physical activity, and
diabetes mellitus affect the recurrence stroke with obesity as dominant factor (OR =
0.616) (Table.3). Obesity contributes to the occurrence of stroke. described that obesity
did not show a positive relationship with the incident of the stroke but it’s associated
with high blood pressure and blood sugar levels so the heart works harder to pump
blood throughout the body and lead to increase of blood pressure. [23] said that obesity
is a major risk factor for heart disease, type 2 diabetes mellitus, increased cholesterol
levels, and blood pressure which triggers the process of atherosclerosis.

5. Conclusion

The dominant risk factors for stroke recurrence in Indonesia is cardiovascular disease,
hypercholesterolemia, obesity, physical activity, and diabetes mellitus.Because of the
great impact of recurrence stroke, nurse practitioner and another health provider can
focus not only on acute treatment but also to control the risk factors of recurrence
stroke.

Acknowledgments

We would like to thank the Muhammadiyah Pekajangan Health Science Higher School
that has supported us to this scientific journal publication.

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Conflict of Interest

The authors have no conflict of interest to declare.

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