What are the signs of a stroke in an adult with a history of cardiovascular disease or risk factors?

Signs of Stroke in Adults with Cardiovascular Risk Factors

Recognize stroke immediately using sudden onset of facial droop, arm weakness, or speech difficulty—these three cardinal symptoms should trigger immediate 911 activation. 1

Primary Warning Signs

The American Heart Association identifies the following sudden-onset symptoms as stroke warning signs: 1

• Facial asymmetry or droop (unilateral weakness of the face) 1, 2
• Arm or leg weakness, especially on one side of the body (likelihood ratio ≥5.5 for stroke) 1, 2
• Speech disturbances including trouble speaking or understanding language 1, 3
• Sudden confusion or difficulty understanding speech 1
• Visual disturbances including sudden trouble seeing in one or both eyes, double vision, or visual field loss 1, 2
• Sudden trouble walking, dizziness, loss of balance or coordination 1
• Sudden severe headache with no known cause 1
• Numbness or tingling, particularly unilateral (likelihood ratio ≥5.5) 1, 2

FAST Assessment Method

The FAST mnemonic provides a structured approach with 59% sensitivity and 89% specificity when used by prehospital providers: 2

• Face: Check for facial drooping or asymmetry 2, 4
• Arms: Test for arm weakness or drift 2, 4
• Speech: Assess for speech difficulties 2, 4
• Time: Note the exact time symptoms began (critical for treatment eligibility) 2, 4, 3

A single abnormality on stroke recognition scales indicates a 72% probability of stroke. 2

Posterior Circulation (Vertebrobasilar) Stroke Signs

These symptoms suggest brainstem or cerebellar involvement and require immediate recognition: 2

• Dizziness and vertigo (high probability in vertebrobasilar strokes) 2
• Ataxia or unsteady gait/coordination problems 2
• Cranial nerve deficits, particularly affecting facial movement 2
• Crossed findings (ipsilateral facial weakness with contralateral body weakness suggests brainstem stroke) 3

Critical Action Steps

Call 911 immediately when stroke is suspected—do not wait to see if symptoms resolve. 1, 4

• Document the exact time of symptom onset as this determines eligibility for thrombolytic therapy (effective within 3-4.5 hours) 1, 4, 3
• Provide supplementary oxygen if oxygen saturation is <94% 2, 4
• Transport to a stroke center or facility with immediate brain imaging capability 4, 3
• Do not give the patient anything to eat or drink 1

Common Pitfalls

Many patients do not recognize their own stroke symptoms—39% of stroke patients admitted to emergency departments did not know a single stroke sign or symptom at the time of presentation. 5

• Elderly patients (≥65 years) are significantly less likely to recognize stroke symptoms (47% versus 28% in younger patients) 5
• Symptoms that spontaneously improve may still represent stroke or TIA and require immediate evaluation 1
• Stroke knowledge remains poor even among stroke survivors, with only 14% able to recall all three cardinal symptoms (face, arm, speech) 6

High-Risk Patient Context

For adults with cardiovascular disease or risk factors, additional considerations include: 7, 8

• Hypertension is the most important modifiable risk factor for stroke 3, 7, 8
• Atrial fibrillation significantly increases cardioembolic stroke risk 1
• Prior stroke or TIA places patients at substantially elevated risk for recurrent events 1
• Diabetes and smoking are major modifiable risk factors 3, 8