DISCUSSION

The current study was conducted to identify different types and risk factors associated with recurrent stroke in Madinah Al-Munawarah city, Saudi Arabia in the year of 2014 commencing at January and ending at December. The incidence of ischemic recurrent stroke was 83.93%, which is relatively comparable with the reported rate in Egypt (80%)¹⁵⁾, but less markedly percentage was reported in a Saudi study¹⁶⁾ and a study from Bahrain¹⁷⁾ 77% and 59% respectively. However, these latter two studies did not show whether these percentages yielded from first time or recurrent stroke.

It was reported that the risk of recurrent stroke substantially rises following increased levels of blood pressure¹⁸⁾. Stroke possibility recurrence also increases 4-fold in hypertensive patients and about 60–75% of the strokes take place in these conditions¹⁹⁾. However, data that support this claim are limited.

Hypertension is the most highly notable risk factor in this study as it found in 90% of our patients, which is compatible with the findings of stroke recurrent studies in Turkey 89% and 88% respectively^{20, 21)}. Higher rate was reported from Egypt study 100%¹⁵⁾ and lower rate reported from study in Spain 80%²²⁾. In contrast, the findings of some other studies such as in Scotland²³⁾ and Thailand²⁴⁾ demonstrated that hypertension was not identified as a risk factor of stroke recurrence.

Another factor that is most commonly associated with stroke recurrence is diabetes^24,25,26). The findings of the current study also showed diabetes mellitus to be the second most common risk factor with a rate of 62.5%. Furthermore, a remarkable higher rate (95%) was found in the study of Egypt. These may be due to hyperglycemia which is associated with endothelial dysfunction and elevated platelet aggregation²⁷⁾.

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Hypertension and diabetes mellitus are major clinical and public health problem in Kingdom of Saudi Arabia and the Middle East^28,29,30). The findings of this study showed also a high proportion of recurrent stroke patients had both of them as coexistent risk factors. However, this may be due to undiagnosed hypertension and diabetes mellitus and lack of people awareness^{29, 30)}.

Evidence revealed that risk for stroke recurrence was somewhat higher in smokers compared to non-smokers²⁶⁾. It also showed in this study that smoking may be a contributing factor accounted 22.3% of recurrent stroke patients. Furthermore, higher percentages were found in Spain (29%)²²⁾ and Egypt (52.5%)¹⁵⁾. Interestingly, the current study showed ischaemic heart disease in 51.8% patients, atrial fibrillation in 12.8% patients, indicating that cardiac dysfunction may participate in the occurrence of recurrent stroke. This also was supported in studies of Turkey²¹⁾ and Egypt¹⁵⁾ where 36% and 31.25% of recurrent stroke patients found with ischaemic heart disease and 11% and 21.25% with atrial fibrillation respectively.

The current study had a limitation where the size of the study population with recurrent stroke was small. Inadequate research papers with various methodologies were also noted which may hinder the comparison. However, the findings of this study highlighted the importance of conducting further studies in screening for stroke recurrence risk factors and planning for secondary prevention. In conclusion hypertension, diabetes, and ischaemic heart disease in particular were found to be crucial risk factors for stroke recurrence, thus future prospective studies are required to assess whether effective treatment methods with close monitoring, and educational health strategies of these risk factors can prevent or minimize the risk of stroke recurrence.