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
...Table...
...e use of a risk assessment tool such as the A...
...Table 2. Genetic Fact...
...btaining a family history can be useful in ide...
...genetic counseling may be considered for pat...
...ent of Fabry disease with enzyme replacement...
...invasive screening for unruptured i...
...e screening may be considered for unruptured...
...ive screening for unruptured intracrani...
...dosing of vitamin K antagonists ma...
...oninvasive screening for unruptured int...
...intracranial aneurysms in every carrie...
...etic screening of the general population fo...
...ening to determine risk for myopathy...
Treatment
Treatm...
...Table 3. Physical...
...al activity is recommended because...
...ealthy adults should perform at least moder...
...Table...
In addition to therapeutic lifestyle c...
...be considered for patients with low HDL c...
Fibric acid derivatives may be considere...
...nonstatin lipid-lowering therapies such a...
...Tabl...
...duced intake of sodium and increased...
A DASH-style diet, which emphasizes...
...hat is rich in fruits and vegetable...
...diterranean diet supplemented with nuts may be...
...Table 6. Hypertensi...
...egular BP screening and appropriat...
...screening for high BP and health-promoti...
...ients who have hypertension should be treate...
...duction of BP is more important in red...
...red BP monitoring is recommended t...
...Table 7. O...
...ong overweight (BMI2=25-29 kg/m) and obes...
...g overweight (BMI2=25-29 kg/m) and obese (B...
...Table 8....
...P in accordance with an AHA/ACC/CDC Advisory to a...
...ults with diabetes mellitus with a sta...
...ulness of aspirin for primary stroke preven...
...ding a fibrate to a statin in people with dia...
...Tab...
...n combination with drug therapy us...
...stention from cigarette smoking is reco...
...y-wide or statewide bans on smoking in...
...Table 10. AF...
...h valvular AF at high risk for stroke,...
...ts with nonvalvular AF, a CHA2DS2-VASc scor...
...igatran, apixaban, and rivaroxaban....
...for AF in the primary care setting in...
...ents with nonvalvular AF and CHA2DS2-VASc score o...
...tients with nonvalvular AF, a CHA2...
...sure of the LAA may be considered f...
...Table 11. Other C...
...oagulation is indicated in patients with mitral...
...is indicated in patients with mitral stenosis an...
...arfarin (target INRa, 2.0-3.0) and lo...
...excision is recommended for the treatm...
...cal intervention is recommended for symptom...
...rin is reasonable after aortic or mitral valve r...
...t is reasonable to give warfarin to achiev...
...ts or antiplatelet agents are reasonable for pat...
...onist therapy is reasonable for patients...
...may be considered for asymptomatic patien...
...may be considered for patients with se...
...ticoagulant therapy may be considered...
...ic treatment and catheter-based clos...
...Table 12. Asymptomati...
...ts with asymptomatic carotid steno...
...ients who are to undergo CEA, aspirin is...
...ble to consider performing CEA in...
...asonable to repeat duplex ultrasonography a...
...ic CAS might be considered in highly selected p...
...tomatic patients at high risk of complications f...
...ow-risk populations for asymptomatic...
...Table 1...
...screening for children with SCD is ind...
...ansfusion therapy (target reduction of hem...
...he optimal screening interval has no...
...further studies, continued transfusion, e...
...n at high risk for stroke who are unable or unw...
...nd MRA criteria for selection of c...
...Table 14. Migr...
...cessation should be strongly recommende...
...tives to OCs, especially those containing es...
...o reduce migraine frequency might be reasonable to...
...losure of PFO is NOT indicated for preventing...
...T...
...individual components of the metabolic s...
...Table 16. Alc...
...duction or elimination of alcohol consumption i...
For individuals who choose to drink...
...Tab...
...o an appropriate therapeutic program is reason...
...Table 18. Sleep-D...
...s association with stroke risk, screening f...
...ent of sleep apnea to reduce the r...
...Table 19. Hyperhomo...
...e B complex vitamins, cobalamin (B12...
...Table 20...
The use of niacin, which lowers Lp(a),...
...clinical benefit of using Lp(a) in str...
...usefulness of genetic screening to det...
...efulness of specific treatments for primary str...
...n (81 mg/d) is NOT indicated for prim...
...Table 22. In...
Patients with chronic inflammatory disease suc...
...a vaccination can be useful in lowering stroke ri...
...ement of inflammatory markers such as hs-CRP or li...
...tment of patients with hs-CRP >2.0 mg/dL wit...
...antibiotics for chronic infections as...
...Table 23. Antip...
...se of aspirin for cardiovascular (including...
...daily or 100 mg every other day) can be useful f...
...considered for the prevention of...
...stazol may be reasonable for the preve...
...useful for preventing a first stroke in...
...spirin is NOT useful for preventing a first strok...
...pirin is NOT useful for preventing a first...
...f aspirin for other specific situations (eg, AF,...
...lack of relevant clinical trials, a...
...Table 24. Prim...
...ased smoking cessation programs and...
...cation of AF and evaluation for anticoagulati...
...pulation screening for hypertension is reasonabl...
...is identified as having a drug or alc...
...eness of screening, brief intervention, and referr...
...Table 25. Preventi...
...easonable to implement programs to sys...