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Are Childhood Risk Factors Linked to Stroke in Young Adulthood?

  • Authors: News Author: Fran Lowry; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 10/14/2022
  • Valid for credit through: 10/14/2023
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Target Audience and Goal Statement

This activity is intended for primary care physicians, pediatricians, neurologists, cardiologists, nurses/nurse practitioners, pharmacists, physician assistants and other members of the healthcare team, who care for children and young adults at risk for stroke.

The goal of this activity is for learners to be better able to understand how members of the health care team can help to reduce the effects of atherosclerotic ischemic stroke among children and young adults.

Upon completion of this activity, participants will:

  • Analyze trends in the prevalence of ischemic stroke among young adults in the US
  • Assess the effect of atherosclerotic risk factors in promoting ischemic stroke among children and young adults
  • Outline implications for the healthcare team


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News Author

  • Fran Lowry

    Freelance writer, Medscape


    Fran Lowry has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

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  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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Are Childhood Risk Factors Linked to Stroke in Young Adulthood?

Authors: News Author: Fran Lowry; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 10/14/2022

Valid for credit through: 10/14/2023


Clinical Context

The prevalence of stroke has declined overall in the United States, and this difference has been led by a lower rate of stroke among older adults. However, the authors of the current study report that the prevalence of stroke is increasing among young adults. A previous study by George and colleagues, published in the June 1, 2017, issue of JAMA Neurology, examined this trend.[1]

Researchers compared data from national inpatient diagnostic codes for stroke during 2003 to 2004 and 2011 to 2012. There was a strong trend toward a higher rate of ischemic stroke in 2011 to 2012 among both men and women younger than 45 years. The risk for stroke increased over time among White adults between 18 and 34 years of age, but not among Black adults at the same age. Not surprisingly, the prevalence of all atherosclerotic risk factors (ARFs) for stroke increased in young adults between 2003 to 2004 and 2011 to 2012. Meanwhile, rates of hemorrhagic stroke remained stable among young adults from 2003 to 2004 to 2011 to 2012.

It is thought than many ARFs develop during childhood, and early atherosclerosis leads to a higher risk for stroke among young adults. The current study evaluates this issue.

Study Synopsis and Perspective

In a case-control study, atherosclerotic risk factors were uncommon in childhood and did not appear to be associated with the pathogenesis of arterial ischemic stroke in children or in early young adulthood. But by the fourth and fifth decades of life, these risk factors were strongly associated with a significant risk for stroke, heightening that risk almost 10-fold.

"While strokes in childhood and very early adulthood are not likely caused by atherosclerotic risk factors, it does look like these risk factors increase throughout early and young adulthood and become significant risk factors for stroke in the 30s and 40s," lead author Sharon N. Poisson, MD, MAS, associate professor of neurology at the University of Colorado, Aurora, Colorado, told | Medscape Cardiology.

The findings were published online August 1 in JAMA Neurology.[2]

In this study, the researchers focused on arterial ischemic stroke, not hemorrhagic stroke. "We know that high blood pressure, diabetes, smoking, obesity, all of these are risk factors for ischemic stroke, but what we didn't know is at what age do those atherosclerotic risk factors actually start to cause stroke," Dr Poisson said.

To find out more, she and her team did a case control study of data in the Kaiser Permanente Northern California system, which had been accumulating relevant data during a period of 14 years, from January 1, 2000, through December 31, 2014. The analysis included 141 children and 455 young adults with arterial ischemic stroke and 1382 age-matched controls.

The children were divided into 2 age categories: ages 29 days to 9 years and ages 10 to 19 years. In the younger group, there were 69 cases of arterial ischemic stroke. In the older age group, there were 72 cases. Young adults were divided into 3 age categories: 20 to 29 years (n = 71 cases), 30 to 39 years (144 cases), and 40 to 49 years (240 cases). 

Among pediatric controls, 168 children aged 29 days to 9 years (46.2%) and 196 children aged 10 to 19 years (53.8%) developed arterial ischemic stroke. There were 121 cases of ischemic stroke among young adult controls who were in the 20- to 29-year age group, 298 cases among controls in the 30- to 39-year age group, and 599 cases in the 40- to 49-year age group.

Both childhood cases and controls had a low prevalence of documented diagnoses of ARFs. The odds ratio (OR) of having any ARFs on arterial ischemic stroke was 1.87 for ages 0 to 9 years and 1.00 for ages 10 to 19 years.

However, cases rose with age.

The OR was 2.3 for age range 20 to 29 years, 3.57 for age range 30 to 39 years, and 4.91 for age range 40 to 49 years. The analysis also showed that the OR associated with multiple ARFs was 5.29 for age range 0 to 9 years, 2.75 for age range 10 to 19 years, 7.33 for age range 20 to 29 years, 9.86 for age range 30 to 39 years, and 9.35 for age range 40 to 49 years.

Multiple risk factors were rare in children but became more prevalent with each decade of young adult life.

The presumed cause of arterial ischemic stroke was atherosclerosis. Evidence of atherosclerosis was present in 1.4% of the 10- to 19-year age group, 8.5% of the 20- to 29-year age group, 21.5% of the 30- to 39-year age group, and 42.5% of the 40- to 49-year age group.

"This study tells us that, while stroke in adolescence and very early adulthood may not be caused by atherosclerotic risk factors, starting to accumulate those risk factors early in life clearly increases the risk of stroke in the 30s and 40s. I hope we can get this message across, because the sooner we can treat the risk factors, the better the outcome," Dr Poisson said.

Prevention Starts in Childhood

Prevention of cardiovascular disease begins in childhood, which is a paradigm shift from the way cardiovascular disease was thought of a couple of decades ago, noted pediatric cardiologist Guilherme Baptista de Faia, MD, from the Ann & Robert H. Lurie Children's Hospital in Chicago, Illinois.

"Our guidelines for risk factor reduction in children aim to address how or when do we screen for these risk factors, how or when do we intervene, and do these interventions impact cardiovascular outcomes later in life? This article is part of the mounting research that aims to understand the relationship between childhood cardiovascular risk factors and early cardiovascular disease," Dr Baptista de Faia said.

The knowledge that atherosclerotic risk factors in children can lead to acceleration of atherosclerosis in later life opens the door to preventive medicine, Dr Baptista de Faia, who was not part of the study, noted.

"This is where preventive medicine comes in. If we can identify the children at increased risk, can we intervene to improve outcomes later in life?" he said. Familial hypercholesterolemia is "a great example of this," he added. "We can screen children early in life, there is an effective treatment, and we know from population studies that early treatment significantly decreases the risk for cardiovascular disease later in life."

Dr Poisson reports that she received grants from the National Institutes of Health during the conduct of this study, which was supported by the National Institutes of Health.

JAMA Neurol. Published online August 1, 2022.

Study Highlights

  • The study was conducted as a retrospective cohort study using health records from a large managed care database in California. Patients between the ages of 29 days and 49 years who presented with symptoms of stroke along with radiological confirmation of stroke between 2000 and 2014 were compared with at least 2 controls who did not have stroke.
  • The main study analysis focused on rates of ARF among cases and controls and when these ARFs promoted a higher risk for stroke, if at all.
  • The health system contained data on 4.7 million children during the study period. Researchers confirmed 141 cases of acute ischemic stroke, 48.9% of which occurred from infancy through age 9 years; 51.1% of stroke cases occurred between ages 10 and 19 years.
  • Among 7.5 million young adults, there were 455 cases of acute ischemic stroke, with 15.6%, 31.6%, and 52.7% of cases occurring among age groups 20 to 29 years, 30 to 39 years, and 40 to 49 years, respectively.
  • There were no differences in sex between cases and controls. Asian race was a risk factor for stroke among children between 29 days and 9 years of age. Being Black became a risk factor for stroke in the 40- to 49-year-old age group.
  • The prevalence of ARFs was low during childhood and adolescence in the case and control groups. Single ARF became a significant risk factor for stroke only when patients passed into the age group of 20 to 29 years (odds ratio [OR], 1.17-4.51). The OR associated with ARFs increased in the case vs control groups as patients passed into their fourth and fifth decades of life.
  • The prevalence of ARF increased steadily with age among young adult cases, and it did the same with controls in the same age groups. However, rates of smoking declined among control patients between ages 20 and 39 years.
  • In the third decade, only hypertension was related to a higher risk for stroke. However, by the fourth decade, every individual ARF was associated with a higher risk for stroke.
  • The presence of multiple ARF became significant in promoting a higher OR for stroke in the 10- to 19-year-old cohort (7.33; 95% confidence interval, 1.92-27.9). The respective OR increased to 9.53 (95% CI, 6.31-13.8) for persons in the 40- to 49-year-old cohort.
  • Strokes were presumed to be atherosclerotic in 8.5% of patients in the 20- to 29-year-old group and 42.5% in the 40- to 49-year-old group.

Clinical Implications

  • A previous study found that the prevalence of ischemic stroke in the US was increasing among both women and men from 2003 to 2004 to 2011 to 2012, even while the overall prevalence of stroke was declining. The increased rate of stroke among persons aged 18 to 34 years was more prevalent among White vs Black adults.
  • In the current study, the presence of any ARF was associated with a higher risk for stroke beginning at age 20 years, whereas the presence of multiple ARF was associated with a higher risk for stroke as young as 10 years.
  • Implications for the healthcare team: The healthcare team should emphasize healthy habits during childhood as a means to reduce the risk for cardiovascular events during young adulthood.

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