Primary Stroke Prevention
Key Points
Key Points
Stroke ranks as the fourth-leading cause of death in the United States.
Globally, over the past 4 decades, stroke incidence rates have fallen by 42% in high-income countries and increased by 100% in low- and middle-income countries. Stroke incidence rates in low- and middle-income countries now exceed those in high-income countries.
Stroke is a leading cause of functional impairment. For patients who are ≥65 years of age, 6 months after stroke, 26% are dependent in their activities of daily living, and 46% have cognitive deficits.
There are enormous opportunities for preventing stroke. An international case-control study of 6000 individuals found that 10 potentially modifiable risk factors explained 90% of the risk of stroke.
Primary prevention is particularly important because 76% of strokes are first events.
Diagnosis
...iagnosi...
...sing the Risk of First Stroke...
...use of a risk assessment tool such as the A...
...Genetic Factors...
...ng a family history can be useful in identifying...
...l for genetic counseling may be considere...
...reatment of Fabry disease with enzyme repla...
...nvasive screening for unruptured intrac...
...ening may be considered for unruptured intr...
...oninvasive screening for unruptured intracranial...
...netic dosing of vitamin K antagonists may...
...eening for unruptured intracranial aneurysms in...
...or intracranial aneurysms in every...
...ng of the general population for the pre...
...etic screening to determine risk for myopathy is...
Treatment
...atment...
.... Physical Inactivit...
...ical activity is recommended because it is...
...should perform at least moderate to vigoro...
...le 4. Dyslipidemia...
...ddition to therapeutic lifestyle ch...
...iacin may be considered for patients w...
...cid derivatives may be considered fo...
...onstatin lipid-lowering therapies such a...
...ble 5. Diet and Nu...
...duced intake of sodium and increased inta...
...le diet, which emphasizes fruits, vegeta...
...rich in fruits and vegetables and thereb...
...diet supplemented with nuts may be...
.... Hypertension...
...ar BP screening and appropriate treatment of...
...ng for high BP and health-promoting life...
...atients who have hypertension should be treated...
...uccessful reduction of BP is more impor...
...ured BP monitoring is recommended to improve BP c...
...7. Obesity and Body Fat Distribution
...erweight (BMI2=25-29 kg/m) and obese (BMI2 >...
...(BMI2=25-29 kg/m) and obese (BMI2 >3...
...e 8. Diabetes
...trol of BP in accordance with an AHA/ACC/...
...ults with diabetes mellitus with a st...
...ulness of aspirin for primary strok...
...ate to a statin in people with diabetes mel...
...9. Cigarette Smoking...
...unseling, in combination with drug therapy...
...rom cigarette smoking is recommended for patien...
...unity-wide or statewide bans on smoking in publi...
...e 10. AF
...r patients with valvular AF at high risk for st...
...ents with nonvalvular AF, a CHA2DS2-VASc sc...
...aban, and rivaroxaban. ( B , I )701...
...ctive screening for AF in the primary care settin...
...h nonvalvular AF and CHA2DS2-VASc score of 0, i...
...tients with nonvalvular AF, a CHA2...
...the LAA may be considered for high-risk p...
...Other Cardiac Conditions...
...on is indicated in patients with mitra...
...nticoagulation is indicated in patients with mi...
...in (target INRa, 2.0-3.0) and low-do...
...excision is recommended for the treatment of atr...
...ervention is recommended for sympto...
...reasonable after aortic or mitral...
...reasonable to give warfarin to achiev...
...ulants or antiplatelet agents are reasonable fo...
...tagonist therapy is reasonable for patients w...
...lation may be considered for asymptoma...
...gulation may be considered for patients...
...herapy may be considered for patients with STEMI...
...rombotic treatment and catheter-based...
...le 12. Asymptomatic Carotid Stenosis
...nts with asymptomatic carotid stenosis shou...
...n patients who are to undergo CEA, a...
...sonable to consider performing CEA in asympt...
...ble to repeat duplex ultrasonograp...
...ophylactic CAS might be considered in highly sele...
...patients at high risk of complications for caro...
...ow-risk populations for asymptomatic...
...able 13. SCD...
...screening for children with SCD is indicated...
...apy (target reduction of hemoglobin S,...
...hough the optimal screening interval has not be...
...rther studies, continued transfusi...
...igh risk for stroke who are unable or unw...
...A criteria for selection of children for primar...
...able 14. Migra...
...ion should be strongly recommended in women with...
...to OCs, especially those containing estrogen...
...reatments to reduce migraine frequency might be...
...ure of PFO is NOT indicated for prev...
...le 15. Metabolic Syndr...
...Management of individual components o...
...e 16. Alcohol Consumption
...ction or elimination of alcohol consumption in he...
...s who choose to drink alcohol, consumption of...
...17. Drug Abuse...
...ral to an appropriate therapeutic program is r...
...8. Sleep-Disordered Breathing...
Because of its association with stroke risk...
...sleep apnea to reduce the risk of...
...le 19. Hyperhomocysteinemia
...the B complex vitamins, cobalamin (B12),...
...e 20. Elevated Lp(a)
...cin, which lowers Lp(a), might be reasonable...
...nical benefit of using Lp(a) in stroke risk pr...
...Hypercoagulability...
...of genetic screening to detect inherited...
...ss of specific treatments for primary stroke preve...
...ow-dose aspirin (81 mg/d) is NOT indica...
...ble 22. Inflammation and Infect...
...with chronic inflammatory disease such as...
...nza vaccination can be useful in lo...
...ent of inflammatory markers such as h...
...tients with hs-CRP >2.0 mg/dL with a stati...
...ent with antibiotics for chronic infections as a...
...e 23. Antiplatelet Agents and Aspir...
...e of aspirin for cardiovascular (including but not...
...mg daily or 100 mg every other da...
...rin might be considered for the preventio...
...e reasonable for the prevention of a first stroke...
...in is NOT useful for preventing a first st...
...is NOT useful for preventing a first stroke in...
...seful for preventing a first stroke...
...irin for other specific situations (eg...
...s a result of a lack of relevant clinical tria...
Table 24. Primary Prevention in...
...d smoking cessation programs and interventio...
Identification of AF and evaluation for anticoag...
...on screening for hypertension is reaso...
...s identified as having a drug or alcohol abu...
...effectiveness of screening, brief...
...ble 25. Preventive Health Servi...
...ble to implement programs to systemati...