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
...iagnosis...
...Assessing the Risk of First Stroke...
...se of a risk assessment tool such as the AHA/...
...e 2. Genetic Fact...
...ing a family history can be useful in identifyi...
...genetic counseling may be considered for pa...
...f Fabry disease with enzyme replacement thera...
Noninvasive screening for unruptured intr...
...ive screening may be considered for unruptured...
...invasive screening for unruptured intracrani...
...tic dosing of vitamin K antagonists may be...
...creening for unruptured intracranial aneu...
...g for intracranial aneurysms in every ca...
Genetic screening of the general popula...
...ic screening to determine risk for...
Treatment
...atment...
...3. Physical Inactivity...
...ity is recommended because it is associate...
...lthy adults should perform at least moderate t...
...ble 4. Dyslipi...
...therapeutic lifestyle changes, tr...
...y be considered for patients with low HDL...
...vatives may be considered for patien...
...nonstatin lipid-lowering therapies such...
.... Diet and Nutritio...
...intake of sodium and increased intake of pota...
...iet, which emphasizes fruits, vegetables,...
...t is rich in fruits and vegetables and thereby hig...
...terranean diet supplemented with nuts may be co...
Table 6. Hyperten...
...creening and appropriate treatment of pati...
...al screening for high BP and health-promoting life...
...have hypertension should be treated with...
...cessful reduction of BP is more important in redu...
...easured BP monitoring is recommended...
...ty and Body Fat Distribution...
...ng overweight (BMI2=25-29 kg/m) and obese (...
...ght (BMI2=25-29 kg/m) and obese (BMI2 >30 kg/m)...
Table 8. Diabetes
...of BP in accordance with an AHA/ACC/CDC Advis...
...dults with diabetes mellitus with a stat...
The usefulness of aspirin for primary stroke...
Adding a fibrate to a statin in people w...
...9. Cigarette Smoking
...in combination with drug therapy using...
...om cigarette smoking is recommended for patien...
...munity-wide or statewide bans on smoking i...
...e 10. AF
...patients with valvular AF at high risk for stro...
...tients with nonvalvular AF, a CHA2DS2-VASc scor...
...ixaban, and rivaroxaban. ( B , I )701...
...creening for AF in the primary care setting...
...atients with nonvalvular AF and CHA2DS2-VA...
...r patients with nonvalvular AF, a CHA2...
...of the LAA may be considered for high-ri...
...le 11. Other Cardiac Condit...
...coagulation is indicated in patients with...
...agulation is indicated in patients wi...
...arfarin (target INRa, 2.0-3.0) and low-dose aspir...
...l excision is recommended for the treatmen...
...ntervention is recommended for symp...
...n is reasonable after aortic or mitral valve...
...ble to give warfarin to achieve an INR o...
...ants or antiplatelet agents are reaso...
...n K antagonist therapy is reasonable for...
...coagulation may be considered for asym...
...nticoagulation may be considered for pat...
...herapy may be considered for patie...
...hrombotic treatment and catheter-based closure...
...12. Asymptomatic Carotid S...
...nts with asymptomatic carotid stenos...
...who are to undergo CEA, aspirin is r...
...s reasonable to consider performing CEA in asymp...
...sonable to repeat duplex ultrasonography an...
...ic CAS might be considered in highly selected pa...
...tomatic patients at high risk of co...
...sk populations for asymptomatic carotid artery s...
...able 13. SCD
...screening for children with SCD is indicated st...
...apy (target reduction of hemoglobin S,...
...ough the optimal screening interval has not been...
...ending further studies, continued transfusi...
...igh risk for stroke who are unable o...
...iteria for selection of children for primary s...
Table 14. Migr...
...ng cessation should be strongly recommend...
...natives to OCs, especially those c...
...atments to reduce migraine frequency might be...
...FO is NOT indicated for preventing stroke in pati...
Table 15. Metabolic Syndr...
...of individual components of the m...
...able 16. Alcohol Consum...
...ction or elimination of alcohol consumption in h...
...r individuals who choose to drink alcohol,...
...17. Drug Abuse...
...ferral to an appropriate therapeutic prog...
...18. Sleep-Disordered Breathing...
...its association with stroke risk, screening fo...
...of sleep apnea to reduce the risk of stro...
...able 19. Hyperhomocystei...
...use of the B complex vitamins, cobalamin (B12), py...
...ble 20. Elevated Lp(a)...
...acin, which lowers Lp(a), might be reasona...
...l benefit of using Lp(a) in stroke ri...
Table 21. Hypercoagulabili...
...f genetic screening to detect inher...
...efulness of specific treatments for primary...
...in (81 mg/d) is NOT indicated for p...
...flammation and Infection...
Patients with chronic inflammatory...
...ual influenza vaccination can be useful...
...rement of inflammatory markers such as hs-CRP or...
...atment of patients with hs-CRP >2.0 mg/dL wit...
...antibiotics for chronic infection...
...iplatelet Agents and Aspirin...
...spirin for cardiovascular (including b...
...irin (81 mg daily or 100 mg every other day) can...
...considered for the prevention of a first strok...
...e reasonable for the prevention of a first...
...NOT useful for preventing a first...
...seful for preventing a first stroke in people wi...
...NOT useful for preventing a first strok...
...aspirin for other specific situations (eg, AF, ca...
...of a lack of relevant clinical trials, ant...
...rimary Prevention in the ED...
...-based smoking cessation programs and inter...
...n of AF and evaluation for anticoagulation in th...
...screening for hypertension is reasonable....
...en a patient is identified as having a...
...iveness of screening, brief intervent...
...25. Preventive Health Services
...ble to implement programs to systematically...