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Stroke (Holistic)

Stroke (Holistic)

About This Condition

Several types of strokes can strike the brain with little warning—but you can cut your risk for future strokes. According to research or other evidence, the following self-care steps may be helpful.
  • Modify your diet

    Reduce stroke risk by eating lots of fruits, vegetables, whole grains, and fish

  • Steer clear of smoke

    Kick the habit and avoid secondhand smoke to lower your risk

  • Take a test

    Visit your doctor for a series of tests to determine if you have problems with high blood pressure or high blood levels of cholesterol, triglycerides, or glucose; all may increase your risk of stroke

About

About This Condition

Stroke is a condition caused by a lack of blood supply to the brain or by hemorrhage (bleeding) within the brain.

Stroke is the third leading cause of death in the United States, but most strokes are not fatal. Depending on the area of the brain that is damaged, a stroke can cause coma, reversible or irreversible paralysis, speech problems, visual disturbances, and dementia. Factors that increase the risk of certain types of stroke include hypertension , diabetes , elevated levels of high cholesterol or homocysteine , and atherosclerosis (hardening of the arteries) of the blood vessels that supply the brain.

Symptoms

Symptoms of stroke include weakness, numbness, or inability to move an arm or leg; sudden and intense headache; severe dizziness or loss of coordination and balance; difficulty with speaking or understanding; and blurred or decreased vision in one or both eyes. People with stroke may also have seizures, vomiting, drooling, and difficulty swallowing. Some people experience temporary warning episodes of neurologic symptoms called transient ischemic attacks (TIAs) before suffering a complete stroke. People experiencing symptoms suggestive of having suffered a stroke or a TIA require immediate (emergency room) medical attention.

Healthy Lifestyle Tips

Smoking is associated with a significantly increased risk of stroke.1 , 2 , 3 Even secondhand smoke puts nonsmokers at increased risk.4

Exercise reduces the risk of stroke according to most,5 , 6 , 7 , 8 though not all,9 studies. The benefits of exercise are probably due to its effects on body weight, blood pressure , and glucose tolerance.

Obesity has been associated with an increased risk of stroke in most studies.10 , 11 Excess abdominal fat appears to be more directly linked to increased risk of stroke, compared with fat accumulation in the thighs and buttocks.12 , 13 , 14 While losing weight and keeping it off is difficult for most people, normalizing weight with a healthful diet and exercise program is one of the best ways to reduce the risk of many diseases, including stroke.

Eating Right

The right diet is the key to managing many diseases and to improving general quality of life. For this condition, scientific research has found benefit in the following healthy eating tips.

Recommendation Why
Eat more fruits and veggies
Fruits and vegetables appear to protect against stroke and are a good source of potassium, which has been linked to a decreased stroke risk in some studies.

Researchers have found an association between diets low in potassium and increased risk of stroke.15 , 16 , 17 People who take potassium supplements have been reported to have a low risk of suffering a stroke.18 However, the association of increasing dietary potassium intake and decreasing stroke mortality only occurred in black men and hypertensive men in one study.19 Others have found an association between increased risk of stroke and the combination of low dietary potassium plus high salt intake.20 Increasing dietary potassium has lowered blood pressure in humans, which by itself should reduce the risk of stroke.21 However, some of the protective effect of potassium appears to extend beyond its ability to lower blood pressure .22 Maintaining a high potassium intake is best achieved by eating fruits and vegetables.

Diets high in fruit and/or vegetables are associated with a reduced risk of stroke, according to most studies.23 , 24 In a large preliminary study, cruciferous and green leafy vegetables, as well as citrus fruit and juice, conferred the highest degree of protection.25 Because it is not clear which components of fruits and vegetables are most responsible for the protective effect against stroke, people wishing to reduce their risk of stroke should rely primarily on eating more fruits and vegetables themselves, rather than taking supplements.

Feast on fish
Eating fish has been linked to reduced stroke risk in most studies.

Evidence is accumulating in favor of fish consumption, a rich source of omega-3 fatty acids , as a way to help prevent stroke. Eating fish has been linked to reduced stroke risk in most,26 , 27 , 28 but not all,29 , 30 studies.

Fill up on whole grains
In one study, women who ate higher amounts of whole grains were at lower risk of stroke.

A large study also found that women who eat higher amounts of whole grains are at lower risk of ischemic stroke.31 Those women who ate more than one whole-grain food on an average day (twice the amount of fiber eaten by the average American) had approximately a 35% lower risk of suffering an ischemic stroke compared with women who ate virtually no whole-grain products on an average day. This study fits with previous research showing that women who consume more whole grains are also at reduced risk for heart disease caused by atherosclerosis .

Sidestep salt
Too much salt can contribute to both stroke and hypertension, a major risk factor for stroke. Use less salt to reduce your risk.

High salt intake is associated with both stroke32 and hypertension , a major risk factor for stroke.33 Salt intake may increase stroke risk independent of its effect on blood pressure.34 Among overweight people, an increase in salt consumption of about 1/2 teaspoon (2.3 grams) per day was associated with a 32% increase in stroke incidence and an 89% increase in stroke mortality.35 Reducing salt intake is recommended as a way to reduce the risk of stroke.36

Don’t drink alcohol to excess
Having one or two alcoholic drinks per day may actually reduce stroke risk, but regular heavy drinking or binge drinking has consistently shown to increase it.

Having one or two drinks per day has lowered stroke risk in most studies,37 , 38 though some researchers report no protection39 and others find that even light drinking leads to an increased risk of stroke.40 Regular heavy drinking or binge drinking, however, has consistently raised the risk of suffering a stroke by increasing blood pressure and causing heart muscle abnormalities and other effects.41 , 42 , 43

Stay tuned about fat
More research is needed to clarify the relationship between dietary fat and stroke risk, as different kinds of fat appear to have varying effects on different types of stroke. In the meantime, it’s a good idea to stick with monounsaturated fats, which are known to be heart healthy, such as olive oil.

The influence of dietary fat on the risk of stroke is not as clear as it is for heart disease risk. Some recent reports suggest an association between increased fat intake, including saturated fat (primarily found in meat and dairy), and a decreased stroke risk.44 , 45 These unexpected findings may be due to unique dietary conditions in the country studied (Japan) or to flaws in study design.46 , 47 , 48 Other evidence suggests the opposite relationship—that people consuming more saturated fat are at higher risk of stroke.49

Evidence regarding the role of unsaturated fats (primarily found in vegetable oils, cooked and processed foods made with vegetable oils, nuts, and seeds) is equally unclear,50 , 51 , 52 suggesting that unsaturated fats may have varying effects on different types of stroke or that some unsaturated fats differ from others in their influence on stroke risk.

Supplements

What Are Star Ratings?

Our proprietary “Star-Rating” system was developed to help you easily understand the amount of scientific support behind each supplement in relation to a specific health condition. While there is no way to predict whether a vitamin, mineral, or herb will successfully treat or prevent associated health conditions, our unique ratings tell you how well these supplements are understood by some in the medical community, and whether studies have found them to be effective for other people.

For over a decade, our team has combed through thousands of research articles published in reputable journals. To help you make educated decisions, and to better understand controversial or confusing supplements, our medical experts have digested the science into these three easy-to-follow ratings. We hope this provides you with a helpful resource to make informed decisions towards your health and well-being.

3 Stars Reliable and relatively consistent scientific data showing a substantial health benefit.

2 Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.

1 Star For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support.

Supplement Why
2 Stars
Vinpocetine
30 to 60 mg per day taken with food
Learn More

Vinpocetine given by intravenous injection has been reported to improve some biochemical measures of brain function in stroke patients.61 , 62 A controlled trial found intravenous vinpocetine given within 72 hours of a stroke reduced some of the losses in brain function that typically follow a stroke.63 However, the reliability of human stroke research using vinpocetine has been questioned,64 , 65 and more double-blind trials are needed. No studies using oral vinpocetine for treating acute strokes have been published.

1 Star
Folic Acid (High Homocysteine)
Refer to label instructions
Learn More

Elevated blood levels of homocysteine , a toxic amino acid byproduct, have been linked to risk of stroke in most studies.66 , 67 , 68 Supplementation with folic acid , vitamin B6 , and vitamin B12 generally lowers homocysteine levels in humans.69 , 70 , 71 In a pooled analysis (meta-analysis) of eight randomized trials, folic acid supplementation in varying amounts (usually 0.5 mg to 5 mg per day) reduced stroke risk by 18%.72

1 Star
Magnesium
Refer to label instructions
Learn More

Researchers have found an association between diets low in magnesium and increased risk of stroke, an effect explained partially, but not completely, by the ability of magnesium to reduce high blood pressure .73 Protection from stroke associated with drinking water high in magnesium has also been reported.74 Intravenous magnesium given immediately after a stroke has been proposed as a treatment for reducing stroke deaths,75 but results so far have been inconclusive.76

1 Star
Tocotrienols
Refer to label instructions
Learn More

In a double-blind trial, people with atherosclerosis in the carotid arteries were given a palm oil extract containing 160–240 mg of tocotrienols (a vitamin E-like supplement) and approximately 100–150 IU vitamin E per day. After 18 months, they had significantly less atherosclerosis or less progression of atherosclerosis compared to a group receiving placebo.77 Vitamin E plus aspirin , has been more effective in reducing the risk of strokes and other related events than has aspirin, alone.78 However, most preliminary trials have shown no protective effects from antioxidant supplementation.79 , 80 , 81 , 82 , 83 , 84 A large Finnish trial concluded that supplementation with either vitamin E or beta-carotene conferred no protection against stroke in male smokers,85 although a later review of the study found that those smokers who have either hypertension (high blood pressure) or diabetes  do appear to have a reduced risk of stroke when taking vitamin E.86

People with high risk for stroke, such as those who have had TIAs or who have a heart condition known as atrial fibrillation,87 are often given aspirin or anticoagulant medication to reduce blood clotting tendencies. Some natural inhibitors of blood clotting such as garlic ,88 , 89 , 90 fish oil ,91 and vitamin E ,92 , 93 may have protective effects, but even large amounts of fish oil are known to be less potent than aspirin.94 Whether any of these substances is an adequate substitute to control risk of stroke in high-risk people is unknown, and anyone taking anticoagulant medication should advise their prescribing doctor before beginning use of these natural substances.

1 Star
Vitamin B12 (High Homocysteine)
Refer to label instructions
Learn More

Elevated blood levels of homocysteine , a toxic amino acid byproduct, have been linked to risk of stroke in most studies.95 , 96 , 97 Supplementation with folic acid , vitamin B6 , and vitamin B12 generally lowers homocysteine levels in humans.98 , 99 , 100 In a pooled analysis (meta-analysis) of eight randomized trials, folic acid supplementation in varying amounts (usually 0.5 mg to 5 mg per day) reduced stroke risk by 18%.101

1 Star
Vitamin B6 (High Homocysteine)
Refer to label instructions
Learn More

Elevated blood levels of homocysteine , a toxic amino acid byproduct, have been linked to risk of stroke in most studies.102 , 103 , 104 Supplementation with folic acid , vitamin B6 , and vitamin B12 generally lowers homocysteine levels in humans.105 , 106 , 107 In a pooled analysis (meta-analysis) of eight randomized trials, folic acid supplementation in varying amounts (usually 0.5 mg to 5 mg per day) reduced stroke risk by 18%.108

1 Star
Vitamin E
Refer to label instructions
Learn More

Narrowing of the neck arteries (carotid stenosis) caused by atherosclerosis is a risk factor for stroke. Preliminary diet studies have found that people who eat foods high in antioxidants such as vitamin C and vitamin E have less carotid stenosis.109 , 110

In a double-blind trial, people with atherosclerosis in the carotid arteries were given a palm oil extract containing 160–240 mg of tocotrienols (a vitamin E-like supplement) and approximately 100–150 IU vitamin E per day. After 18 months, they had significantly less atherosclerosis or less progression of atherosclerosis compared to a group receiving placebo.111 Vitamin E plus aspirin , has been more effective in reducing the risk of strokes and other related events than has aspirin, alone.112 However, most preliminary trials have shown no protective effects from antioxidant supplementation.113 , 114 , 115 , 116 , 117 , 118 A large Finnish trial concluded that supplementation with either vitamin E or beta-carotene conferred no protection against stroke in male smokers,119 although a later review of the study found that those smokers who have either hypertension (high blood pressure) or diabetes  do appear to have a reduced risk of stroke when taking vitamin E.120

People with high risk for stroke, such as those who have had TIAs or who have a heart condition known as atrial fibrillation,121 are often given aspirin or anticoagulant medication to reduce blood clotting tendencies. Some natural inhibitors of blood clotting such as garlic ,122 , 123 , 124 fish oil ,125 and vitamin E ,126 , 127 may have protective effects, but even large amounts of fish oil are known to be less potent than aspirin.128 Whether any of these substances is an adequate substitute to control risk of stroke in high-risk people is unknown, and anyone taking anticoagulant medication should advise their prescribing doctor before beginning use of these natural substances.

References

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2. Jacobs DR Jr, Adachi H, Mulder I, et al. Cigarette smoking and mortality risk: twenty-five-year follow-up of the Seven Countries Study. Arch Intern Med 1999;159:733–40.

3. Shinton R, Beevers G. Meta-analysis of relation between cigarette smoking and stroke. BMJ 1989;298:789–94.

4. You RX, Thrift AG, McNeil JJ, et al. Ischemic stroke risk and passive exposure to spouses’ cigarette smoking. Melbourne Stroke Risk Factor Study (MERFS) Group. Am J Public Health 1999;89:572–5.

5. Lee IM, Hennekens CH, Berger K, et al. Exercise and risk of stroke in male physicians. Stroke 1999;30:1–6.

6. Sacco RL, Gan R, Boden-Albala B, et al. Leisure-time physical activity and ischemic stroke risk: the Northern Manhattan Stroke Study. Stroke 1998;29:380–7.

7. Agnarsson U, Thorgeirsson G, Sigvaldason H, et al. Effects of leisure-time physical activity and ventilatory function on risk for stroke in men: the Reykjavik Study. Ann Intern Med 1999;130:987–90.

8. Bronner LL, Kanter DS, Manson JE. Primary prevention of stroke. N Engl J Med 1995;333:1392–400 [review].

9. Evenson KR, Rosamond WD, Cai J, et al. Physical activity and ischemic stroke risk : the atherosclerosis risk in communities study. Stroke 1999;30:1333–9.

10. Rexrode KM, Hennekens CH, Willett WC, et al. A prospective study of body mass index, weight change, and risk of stroke in women. JAMA 1997;277:1539–45.

11. Bronner LL, Kanter DS, Manson JE. Primary prevention of stroke. N Engl J Med 1995;333:1392–400 [review].

12. Megnien JL, Denarie N, Cocaul M, et al. Predictive value of waist-to-hip ratio on cardiovascular risk events. Int J Obes Relat Metab Disord 1999;23:90–7.

13. Walker SP, Rimm EB, Ascherio A, et al. Body size and fat distribution as predictors of stroke among US men. Am J Epidemiol 1996;144:1143–50.

14. Folsom AR, Prineas RJ, Kaye SA, et al. Incidence of hypertension and stroke in relation to body fat distribution and other risk factors in older women. Stroke 1990;21:701–6.

15. Ascherio A, Rimm EB, Hernan MA, et al. Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men. Circulation 1998;98:1198–204.

16. Sasaki S, Zhang XH, Kesteloot H. Dietary sodium, potassium, saturated fat, alcohol, and stroke mortality. Stroke 1995;26:783–9.

17. Khaw KT, Barrett-Connor E. Dietary potassium and stroke-associated mortality. A 12-year prospective population study. N Engl J Med 1987;316:235–40.

18. Ascherio A, Rimm EB, Hernan MA, et al. Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men. Circulation 1998;98:1198–204.

19. Fang J, Madhavan S, Alderman MH. Dietary Potassium Intake and Stroke Mortality. Stroke 2000;31:1532–7.

20. Yamori Y, Nara Y, Mizushima S, et al. Nutritional factors for stroke and major cardiovascular diseases: international epidemiological comparison of dietary prevention. Health Rep 1994;6:22–7.

21. Stamler J, Caggiula AW, Grandits GA. Relation of body mass and alcohol, nutrient, fiber, and caffeine intakes to blood pressure in the special intervention and usual care groups in the Multiple Risk Factor Intervention Trial. Am J Clin Nutr 1997;65:338S–65S.

22. Suter PM. The effects of potassium, magnesium, calcium, and fiber on risk of stroke. Nutr Rev 1999;57:84–8.

23. Rodriguez Artalejo F, Guallar-Castillon P, Banegas Banegas JR, et al. Consumption of fruit and wine and the decline in cerebrovascular disease mortality in Spain (1975–1993). Stroke 1998;29:1556–61.

24. Ness AR, Powles JW. Fruit and vegetables, and cardiovascular disease: a review. Int J Epidemiol 1997;26:1–13.

25. Joshipura KJ, Ascherio A, Manson JE, et al. Fruit and vegetable intake in relation to risk of ischemic stroke. JAMA 1999;282:1233–9.

26. Zhang J, Sasaki S, Amano K, et al. Fish consumption and mortality from all causes, ischemic heart disease, and stroke: an ecological study. Prev Med 1999;28:520–9.

27. Keli SO, Feskens EJ, Kromhout D. Fish consumption and risk of stroke. The Zutphen Study. Stroke 1994;25:328–32.

28. Iso H, Rexrode KM, Stampfer MJ, et al. Intake of fish and omega-3 fatty acids and risk of stroke in women. JAMA 2001;285:304–12.

29. Orencia AJ, Daviglus ML, Dyer AR, et al. Fish consumption and stroke in men. 30-year findings of the Chicago Western Electric Study. Stroke 1996;27:204–9.

30. Morris MC, Manson JE, Rosner B, et al. Fish consumption and cardiovascular disease in the physicians’ health study: a prospective study. Am J Epidemiol 1995;142:166–75.

31. Liu S, Manson JE, Stampfer MJ, et al. Whole grain consumption and risk of ischemic stroke in women. A prospective study. JAMA 2000;284:1534–40.

32. Sasaki S, Zhang XH, Kesteloot H. Dietary sodium, potassium, saturated fat, alcohol, and stroke mortality. Stroke 1995;26:783–9.

33. Tobian L. Dietary sodium chloride and potassium have effects on the pathophysiology of hypertension in humans and animals. Am J Clin Nutr 1997;65:606S–11S [review].

34. Perry IJ, Beevers DG. Salt intake and stroke: a possible direct effect. J Hum Hypertens 1992;6:23–5.

35. He J, Ogden LG, Vupputuri S, et al. Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults. JAMA 1999;282:2027–34.

36. Antonios TF, MacGregor GA. Salt intake: potential deleterious effects excluding blood pressure. J Hum Hypertens 1995;9:511–5 [review].

37. Hillbom M. Alcohol consumption and stroke: benefits and risks. Alcohol Clin Exp Res 1998;22:352S–8S [review].

38. Caicoya M, Rodriguez T, Corrales C, et al. Alcohol and stroke: a community case-control study in Asturias, Spain. J Clin Epidemiol 1999;52:677–84.

39. Donahue RP, Abbott RD, Reed DM, Yano K. Alcohol and hemorrhagic stroke. JAMA 1986;255:2311–4.

40. Romelsjö A, Leifman A. Association between alcohol consumption and mortality, myocardial infarction, and stroke in 25 year follow up of 49,618 young Swedish men. BMJ 1999;319:821–2.

41. Thrift AG, Donnan GA, McNeil JJ. Heavy drinking, but not moderate or intermediate drinking, increases the risk of intracerebral hemorrhage. Epidemiology 1999;10:307–12.

42. Caicoya M, Rodriguez T, Corrales C, et al. Alcohol and stroke: a community case-control study in Asturias, Spain. J Clin Epidemiol 1999;52:677–84.

43. Hillbom M. Alcohol consumption and stroke: benefits and risks. Alcohol Clin Exp Res 1998;22:352S–8S [review].

44. Gillman MW, Cupples LA, Millen BE, et al. Inverse association of dietary fat with development of ischemic stroke in men. JAMA 1997;278:2145–50.

45. Seino F, Date C, Nakayama T, et al. Dietary lipids and incidence of cerebral infarction in a Japanese rural community. J Nutr Sci Vitaminol (Tokyo) 1997;43:83–99.

46. Brunner R. Dietary fat and ischemic stroke. JAMA 1998;279:1171–2 [letter].

47. Ornish D. Dietary fat and ischemic stroke. JAMA 1998;279:1172 [letter].

48. Stein HD. Dietary fat and ischemic stroke. JAMA 1998;279:1172 [letter].

49. Sasaki S, Zhang XH, Kesteloot H. Dietary sodium, potassium, saturated fat, alcohol, and stroke mortality. Stroke 1995;26:783–9.

50. Ricci S, Celani MG, Righetti E, et al. Fatty acid dietary intake and the risk of ischaemic stroke: a multicentre case-control study. UFA Study Group. J Neurol 1997;244:360–4.

51. Gillman MW, Cupples LA, Millen BE, et al. Inverse association of dietary fat with development of ischemic stroke in men. JAMA 1997;278:2145–50.

52. Seino F, Date C, Nakayama T, et al. Dietary lipids and incidence of cerebral infarction in a Japanese rural community. J Nutr Sci Vitaminol (Tokyo) 1997;43:83–99.

53. Ascherio A, Rimm EB, Hernan MA, et al. Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men. Circulation 1998;98:1198–204.

54. Sasaki S, Zhang XH, Kesteloot H. Dietary sodium, potassium, saturated fat, alcohol, and stroke mortality. Stroke 1995;26:783–9.

55. Khaw KT, Barrett-Connor E. Dietary potassium and stroke-associated mortality. A 12-year prospective population study. N Engl J Med 1987;316:235–40.

56. Ascherio A, Rimm EB, Hernan MA, et al. Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men. Circulation 1998;98:1198–204.

57. Fang J, Madhavan S, Alderman MH. Dietary Potassium Intake and Stroke Mortality. Stroke 2000;31:1532–7.

58. Yamori Y, Nara Y, Mizushima S, et al. Nutritional factors for stroke and major cardiovascular diseases: international epidemiological comparison of dietary prevention. Health Rep 1994;6:22–7.

59. Stamler J, Caggiula AW, Grandits GA. Relation of body mass and alcohol, nutrient, fiber, and caffeine intakes to blood pressure in the special intervention and usual care groups in the Multiple Risk Factor Intervention Trial. Am J Clin Nutr 1997;65:338S–65S.

60. Suter PM. The effects of potassium, magnesium, calcium, and fiber on risk of stroke. Nutr Rev 1999;57:84– 8.

61. Gulyas B, Bonoczk P, Vas A, et al. [The effect of a single-dose intravenous vinpocetine on brain metabolism in patients with ischemic stroke.] Orv Hetil2001;142:443–9 [in Hungarian].

62. Szakall S, Boros I, Balkay L, et al. Cerebral effects of a single dose of intravenous vinpocetine in chronic stroke patients: a PET study. J Neuroimaging1998;8:197–204.

63. Feigin VL, Doronin BM, Popova TF, et al. Vinpocetine treatment in acute ischaemic stroke: a pilot single-blind randomized clinical trial. Eur J Neurol2001;8:81–5.

64. Bereczki D, Fekete I. A systematic review of vinpocetine therapy in acute ischaemic stroke. Eur J Clin Pharmacol 1999;55:349-52 [review].

65. Bereczki D, Fekete I. Vinpocetine for acute ischaemic stroke. Cochrane Database Sys Rev2000;2:CD000480.

66. Lalouschek W, Aull S, Serles W, et al. Genetic and nongenetic factors influencing plasma homocysteine levels in patients with ischemic cerebrovascular disease and in healthy control subjects. J Lab Clin Med 1999;133:575–82.

67. Ridker PM, Manson JE, Buring JE, et al. Homocysteine and risk of cardiovascular disease among postmenopausal women. JAMA 1999;281:1817–21.

68. Perry IJ. Homocysteine, hypertension and stroke. J Hum Hypertens 1999;13:289–93 [review].

69. Genest J Jr. Hyperhomocyst(e)inemia—determining factors and treatment. Can J Cardiol 1999;15:35B–38B [review].

70. Ubbink JB, Hayward WJ, van der Merwe A, et al. Vitamin requirements for the treatment of hyperhomocysteinemia in humans. J Nutr 1994;124:1927–33.

71. Manson JB, Miller JW. The effects of vitamin B12, B6, and folate on blood homocysteine levels. Ann NY Acad Sci 1992;669:197–204 [review].

72. Wang X, Qin X, Demirtas H, et al. Efficacy of folic acid supplementation in stroke prevention: a meta-analysis. Lancet 2007;369:1876–82.

73. Ascherio A, Rimm EB, Hernan MA, et al. Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men. Circulation 1998;98:1198–204.

74. Yang CY. Calcium and magnesium in drinking water and risk of death from cerebrovascular disease. Stroke 1998;29:411–4.

75. Muir KW. New experimental and clinical data on the efficacy of pharmacological magnesium infusions in cerebral infarcts. Magnes Res 1998;11:43–56.

76. Muir KW, Lees KR. A randomized, double-blind, placebo-controlled pilot trial of intravenous magnesium sulfate in acute stroke. Stroke 1995;26:1183–8.

77. Tomeo AC, Geller M, Watkins TR, et al. Antioxidant effects of tocotrienols in patients with hyperlipidemia and carotid stenosis. Lipids 1995;30:1179–83.

78. Steiner M, Glantz M, Lekos A. Vitamin E plus aspirin compared with aspirin alone in patients with transient ischemic attacks. Am J Clin Nutr 1995;62(6 Suppl):1381–4S.

79. Blot WJ, Li JY, Taylor PR, et al. Nutrition intervention trials in Linxian, China: supplementation with specific vitamin/mineral combinations, cancer incidence, and disease-specific mortality in the general population. J Natl Cancer Inst 1993;85:1483–92.

80. Gaziano JM, Manson JE, Ridker PM, et al. Beta-carotene therapy for chronic stable angina. Circulation 1990;82(Suppl III):III–201 [abstract].

81. Ascherio A, Rimm EB, Hernan MA, et al. Relation of consumption of vitamin E, vitamin C, and carotenoids to risk for stroke among men in the United States. Ann Intern Med 1999;130:963–70.

82. Mark SD, Wang W, Fraumeni JF Jr, et al. Do nutritional supplements lower the risk of stroke or hypertension? Epidemiology 1998;9:9–15.

83. Hennekens CH, Buring JE, Manson JE, et al. Lack of effect of long-term supplementation with beta carotene on the incidence of malignant neoplasms and cardiovascular disease. N Engl J Med 1996;334:1145–9.

84. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med 1994;330:1029–35.

85. Leppala JM, Virtamo J, Fogelholm R, et al. Controlled trial of alpha-tocopherol and beta-carotene supplements on stroke incidence and mortality in male smokers. Arterioscler Thromb Vasc Biol 2000;20:230–5.

86. Leppala JM, Virtamo J, Fogelholm R, et al. Vitamin E and beta carotene supplementation in high risk for stroke: a subgroup analysis of the alpha-tocopherol, beta-carotene cancer prevention study. Arch Neurol 2000;57:1503–9.

87. Kopecky SL, Gersh BJ, McGoon MD, et al. Lone atrial fibrillation in elderly persons: a marker for cardiovascular risk. Arch Intern Med 1999;159:1118–22.

88. Bordia A, Verma SK, Srivastava KC. Effect of garlic (Allium sativum) on blood lipids, blood sugar, fibrinogen and fibrinolytic activity in patients with coronary artery disease. Prostaglandins Leukot Essent Fatty Acids 1998;58:257–63.

89. Berthold HK, Sudhop T. Garlic preparations for prevention of atherosclerosis. Curr Opin Lipidol 1998;9:565–9 [review].

90. Kiesewetter H, Jung F, Pindur G, et al. Effect of garlic on thrombocyte aggregation, microcirculation and other risk factors. Int J Pharm Ther Toxicol 1991;29:151–4.

91. Leaf A, Weber PC. Cardiovascular effects of n-3 fatty acids. N Engl J Med 1988;318:549–57 [review].

92. Calzada C, Bruckdorfer KR, Rice-Evans CA. The influence of antioxidant nutrients on platelet function in healthy volunteers. Atherosclerosis 1997;128:97–105.

93. Steiner M. Vitamin E: more than an antioxidant. Clin Cardiol 1993;16:I16–8 [review].

94. Heemskerk JW, Vossen RC, van Dam-Mieras MC. Polyunsaturated fatty acids and function of platelets and endothelial cells. Curr Opin Lipidol 1996;7:24–9 [review].

95. Lalouschek W, Aull S, Serles W, et al. Genetic and nongenetic factors influencing plasma homocysteine levels in patients with ischemic cerebrovascular disease and in healthy control subjects. J Lab Clin Med 1999;133:575–82.

96. Ridker PM, Manson JE, Buring JE, et al. Homocysteine and risk of cardiovascular disease among postmenopausal women. JAMA 1999;281:1817–21.

97. Perry IJ. Homocysteine, hypertension and stroke. J Hum Hypertens 1999;13:289–93 [review].

98. Genest J Jr. Hyperhomocyst(e)inemia—determining factors and treatment. Can J Cardiol 1999;15:35B–38B [review].

99. Ubbink JB, Hayward WJ, van der Merwe A, et al. Vitamin requirements for the treatment of hyperhomocysteinemia in humans. J Nutr 1994;124:1927–33.

100. Manson JB, Miller JW. The effects of vitamin B12, B6, and folate on blood homocysteine levels. Ann NY Acad Sci 1992;669:197–204 [review].

101. Wang X, Qin X, Demirtas H, et al. Efficacy of folic acid supplementation in stroke prevention: a meta-analysis. Lancet 2007;369:1876–82.

102. Lalouschek W, Aull S, Serles W, et al. Genetic and nongenetic factors influencing plasma homocysteine levels in patients with ischemic cerebrovascular disease and in healthy control subjects. J Lab Clin Med 1999;133:575–82.

103. Ridker PM, Manson JE, Buring JE, et al. Homocysteine and risk of cardiovascular disease among postmenopausal women. JAMA 1999;281:1817–21.

104. Perry IJ. Homocysteine, hypertension and stroke. J Hum Hypertens 1999;13:289–93 [review].

105. Genest J Jr. Hyperhomocyst(e)inemia—determining factors and treatment. Can J Cardiol 1999;15:35B–38B [review].

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