Risk Factors Analysis in Recurrent Stroke Events: Literature Review

: After the first stroke, according to epidemiological data, there is a 30% risk of recurrent stroke. That events are the population who had suffered stroke and the recurrence rate is 9 times compared to the normal population. Results of research from the Stroke Association stated that the possibility of recurrence stroke was 3.1% in 30 days, 11.1% within one year, 26.4% within five years, and 39.2% within 10 years. This literature review is intended to analyze the risk factors of recurrent stroke events. The literature review was carried out by searching for articles in 2011-2021 in Indonesian and English. There were four databases for providing electronic journal articles, namely Garuda, Google Scholar, Science Direct, and PubMed. The quality of the articles carried out using JBI's Critical Appraisal Tools. Narrative synthesized was used to analyze the data of the review. There were 6 articles synthesized in this review. The review result showed that diabetes mellitus, hypertension, cardiovascular disorders, anemia, obesity, lack of physical activity, high serum of LDL/HDL, non-adherence to treatment, lack of confidence in treatment, lack of knowledge about the disease, and gender can encourage the occurrence of recurrent stroke. Many factors cause recurrent stroke events but diabetes mellitus, hypertension and non-adherence to treatment are most widely discussed in the six articles.


Introduction
Riskesdas in 2007 showed data of 8.3 per 1000 Indonesians had a stroke.Then in 2013, that number increased by 12.1%. 1 After the first stroke, according to epidemiological data, there is a 30% risk of recurrent stroke, with the population who had suffered a stroke having a recurrence rate of 9 times compared to the normal population. 1,2The results of research from the Stroke Association stated that the possibility of recurrent stroke was 3.1% within 30 days, 11.1% within one year, 26.4% within five years and 39.2% within 10 years. 3n order to reduce the number of patients with recurrent stroke, patients need not only to understand the importance of the post-stroke rehabilitation process, but also to understand the importance of controlling risk factors.Stroke risk factors are factors that increase a person's likelihood of suffering a stroke. 2,4nowing the importance of controlling action against risk factors for recurrent stroke.It is necessary to strengthen the role of nurses as educators and researchers.Therefore, research on risk factors associated with recurrent stroke needs to be done.There are many risk factors in various articles for reccurent stroke.However, the exact risk factors are the main thing to prevent the secondary stroke event.This is to add accurate information about risk factors for recurrent stroke, so that nurses can provide correct and effective health education to patients and families related to control risk factors for recurrent stroke. 5

Research Method
This research was conducted through a literature review.The literature review was carried out by searching for articles in 2011-2021.There are four databases for providing electronic journal articles, namely Garuda, Google Scholar, Science Direct, and PubMed.The keywords during the literature search were adjusted to the Medical Subject Heading (MeSH) and Indonesian thesaurus.The keywords were "Recurrent Stroke" OR "Recurrent Stroke" OR "Secondary Stroke" AND "Risk Factors" OR "Risk Factors".Furthermore, the articles used in the study met the inclusion criteria set by the researcher, namely articles in the form of quantitative research with a cross-sectional study design, research articles that used the entire population of recurrent stroke patients or had experienced recurrent strokes, and the results of the research from the article were defined as the risk factors that are related or touched the occurrence of recurrent stroke.The research articles in this study were given a quality assessment foremostly by two reviewers using the Joanna Briggs Institute (JBI) cross sectional checklist sheet, then the data synthesized in narrative.

Results
The Figure 1 describes the steps of researchers in finding, selecting, and analyzing articles in research.

Cross Sectional
Risk factors for recurrent ischemic stroke were cardiovascular disorders, hypercholesterolemia, obesity, physical activity, and DM with p<0.05.The prominent factor was obesity (OR=0.616).

Cross Sectional Study
There was a significant relationship or intercourse between anemia as an independent risk factor for recurrent ischemic stroke with p value = 0.0015.
There is an intercourse between gender and the occurence of recurrent ischemic stroke p<0.001.

Discussion
The relationship of uncertainty and nonadherence to therapy with the case of recurrent stroke Non-adherence to therapy is associated with recurrent stroke.Patients who are unsure of their treatment have a low level of adherence to their therapy.This is driven by patient concerns about the long-term side effects of the drugs.They think and feel that they take too many drugs.So, those patients stop the treatment or reduce their drug consumption without discussing it with their doctor 3 Uncertainty about treatment which results in low adherence to treatment after a stroke is a risk factor of recurrent stroke.Another risk factor for recurrent stroke is diabetes mellitus.

The intercourse between diabetes mellitus and the occurrence of recurrent stroke
Diabetes mellitus is also associated with recurrent stroke.

Relationship of hypertension with the occurrence of recurrent stroke
Apart from diabetes mellitus, hypertension is also an incident factor for recurrent stroke. 3,4This is because of hypertension is able to accelerate the accumulation of fat in and under the lining of the artery walls that clog blood vessels and cause a stroke to occur. 6he relationship of lack of knowledge with the occurrence of recurrent stroke Lack of knowledge about stroke can encourage the continuation of an unhealthy lifestyle and low adherence to the treatment process.So, the risk of recurrent stroke is even greater.Hence, it is necessary to conduct health education that emphasizes stroke risk factors owned by patients to improve patient compliance with treatment and recommended lifestyle modifications. 7Relationship of obesity, hypercholesterolemia, lack of physical activity, and high levels of oxidized HDL/LDL serum with the occurrence of recurrent stroke Obesity, hypercholesterolemia, and lack of physical liveliness are related with the occurrencee of recurrent stroke because they can trigger atherosclerosis. 5In addition to these factors, high levels of oxidized HDL/LDL serum also take a place in the occurrence of atherosclerosis because it can cause oxidative stress.So, that high levels of oxidized HDL/LDL serum are also a risk factor for recurrent stroke. 8 The intercourse between sex and the occurrence of recurrent stroke Shanghani et al's research found that men with anemia were more prone to recurrent strokes than women. 9This is in line with Suiraoka's opinion which states that the risk of men having a stroke is 20% higher than women. 6he intercourse between anemia and the occurrence of recurrent stroke Anemia which is a condition of low hemoglobin levels than normal is said to be a sign of a poor prognosis for several cardiovascular disorders, including stroke.Decreased oxygen-carrying capacity of blood in anemic patients plays a primary mission in the pathophysiology of ischemic stroke.Anemia plays a role in exacerbating the ischemic state of the brain in patients after an acute ischemic event. 9

Conclusions
The results of a review of six articles showed that diabetes mellitus, hypertension, cardiovascular disorders, anemia, obesity, lack of physical activity, high serum oxLDL/HDL, non-adherence to treatment, lack of confidence in treatment, lack of knowledge about the disease, and gender can encourage the occurrence of recurrent stroke.Then DM, hypertension, and nonadherence to treatment were mentioned in two of the six articles, respectively, as risk factors for recurrence stroke.
There are no more articles which are discussed about risk factors for the case of recurrent stroke in haemorrhagic, so, the next researchers are expected to be able to review the risk factors which are relate with recurrent hemorrhagic stroke such as old age and hypertension (Schmidt, 2016) .Then, for educational institutions, it is hoped that they can add subject matter related to risk factors for recurrent stroke into teaching materials for medicalsurgical nursing courses or other appropriate fields.Furthermore, health professionals, especially nurses, are expected to be able to use the results of this study as a basis for conducting health education related to risk factors for recurrent stroke to patients and their families.

Table 1
Data Extraction of Recurrent Stroke Risk Factors Hypertension and DM were involved with recurrent ischemic stroke either concurrently or alone with a relative risk of 2.47 and 2.12.The risk of rrecurrence stroke in patients who do not adhere to therapy is 2.5 times greater than patients who adhere to therapy.