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
...gnosis...
Table 1. Assessing the Risk of First Stroke
...sk assessment tool such as the AHA/ ACC CV...
...ble 2. Genetic Fac...
...a family history can be useful in ident...
...genetic counseling may be considered for patient...
...eatment of Fabry disease with enzyme rep...
...screening for unruptured intracranial...
...ening may be considered for unruptured intracrania...
...e screening for unruptured intracranial aneurysms...
Pharmacogenetic dosing of vitamin K antago...
...e screening for unruptured intracranial aneurysm...
...ng for intracranial aneurysms in every...
...ing of the general population for the preven...
...ic screening to determine risk for myo...
Treatment
...eatment
...Physical Inactivit...
...vity is recommended because it is associated wi...
...ts should perform at least moderate to vigorous-i...
...ble 4. Dyslipidemia...
...n to therapeutic lifestyle changes, treatment wi...
...ay be considered for patients with l...
...d derivatives may be considered for...
...with nonstatin lipid-lowering ther...
...e 5. Diet and Nutritio...
...educed intake of sodium and increased intake...
...yle diet, which emphasizes fruits, vegetables,...
...hat is rich in fruits and vegetables and th...
...nean diet supplemented with nuts may be conside...
...able 6. Hypert...
...gular BP screening and appropriate...
...ng for high BP and health-promoting lifesty...
...ave hypertension should be treated w...
...ful reduction of BP is more important in...
...ured BP monitoring is recommended to improve BP c...
.... Obesity and Body Fat Distr...
...erweight (BMI2=25-29 kg/m) and obese (...
...overweight (BMI2=25-29 kg/m) and obese (BMI2 >...
...le 8. Diabete...
...in accordance with an AHA/ACC/CDC A...
...of adults with diabetes mellitus wit...
...ss of aspirin for primary stroke preven...
...e to a statin in people with diabetes mellitus is...
...9. Cigarette Smoking...
Counseling, in combination with drug th...
...om cigarette smoking is recommended for patie...
...ity-wide or statewide bans on smoking i...
...ble 10....
...ith valvular AF at high risk for s...
...with nonvalvular AF, a CHA2DS2-VASc score...
...pixaban, and rivaroxaban. ( B , I )701...
Active screening for AF in the pri...
...r patients with nonvalvular AF and...
For patients with nonvalvular AF, a C...
...he LAA may be considered for high-r...
...e 11. Other Cardiac Condi...
...icoagulation is indicated in patients wi...
...oagulation is indicated in patients wit...
...rin (target INRa, 2.0-3.0) and low-...
...on is recommended for the treatment of atrial my...
...vention is recommended for symptomatic fibroelas...
...easonable after aortic or mitral valve rep...
...easonable to give warfarin to achieve an...
...ts or antiplatelet agents are reasonable for pati...
...K antagonist therapy is reasonable for patien...
...agulation may be considered for asymp...
...ticoagulation may be considered for patie...
...therapy may be considered for patients with...
...treatment and catheter-based closure are NOT reco...
...mptomatic Carotid Stenosis...
...tients with asymptomatic carotid stenosis shoul...
...who are to undergo CEA, aspirin is recommen...
...s reasonable to consider performing CEA in asy...
...t is reasonable to repeat duplex ultrasonography...
...rophylactic CAS might be considered...
In asymptomatic patients at high risk of complic...
...eening low-risk populations for asympt...
...able 13. SC...
...screening for children with SCD is i...
...herapy (target reduction of hemoglobin S,...
...the optimal screening interval has not bee...
...urther studies, continued transfusion, even in...
...high risk for stroke who are unable or...
...riteria for selection of children for primary stro...
...14. Migraine...
...ssation should be strongly recommende...
...s to OCs, especially those containing estro...
...to reduce migraine frequency might be...
...PFO is NOT indicated for preventi...
...15. Metabolic Syndrome...
...ent of individual components of the metabolic...
...6. Alcohol Consumption
...ction or elimination of alcohol consumption in...
...individuals who choose to drink alcohol, consum...
...17. Drug Abuse
...an appropriate therapeutic program is reasonab...
...le 18. Sleep-Disordered B...
...f its association with stroke risk, screening...
...sleep apnea to reduce the risk of stroke may...
...19. Hyperhomocysteinemia
...the B complex vitamins, cobalamin (B12)...
...0. Elevated Lp(a...
...se of niacin, which lowers Lp(a), might be reaso...
The clinical benefit of using Lp(a) in str...
...ble 21. Hypercoagulabili...
...ess of genetic screening to detect in...
...sefulness of specific treatments for primary...
...(81 mg/d) is NOT indicated for primary stroke pre...
...2. Inflammation and Infection...
...s with chronic inflammatory disease such as...
...ual influenza vaccination can be us...
...inflammatory markers such as hs-CR...
...ment of patients with hs-CRP >2.0 m...
...h antibiotics for chronic infections as a means...
...iplatelet Agents and Aspirin...
...pirin for cardiovascular (including...
...1 mg daily or 100 mg every other day) can be us...
...e considered for the prevention of a...
...may be reasonable for the prevention of a fi...
...NOT useful for preventing a first strok...
...useful for preventing a first stroke in people w...
...useful for preventing a first stroke in...
...of aspirin for other specific situations (eg,...
...result of a lack of relevant clinical trials...
Table 24. Primary Prevention in the...
...ased smoking cessation programs and interventions...
...dentification of AF and evaluation for antic...
ED population screening for hyperte...
...ient is identified as having a drug o...
...tiveness of screening, brief interv...
...Preventive Health Services...
...easonable to implement programs to...