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 1. Assessing th...
...of a risk assessment tool such as th...
...btaining a family history can be useful in i...
...genetic counseling may be considered for patie...
...atment of Fabry disease with enzyme replacement...
...ninvasive screening for unruptured intracrani...
...asive screening may be considered for...
...e screening for unruptured intracranial aneu...
...ic dosing of vitamin K antagonists may be co...
...asive screening for unruptured intracra...
...r intracranial aneurysms in every carrie...
...ening of the general population for the pr...
...screening to determine risk for myopathy is N...
Treatment
...Treatment...
...Table 3. Physical...
...sical activity is recommended because it is...
...dults should perform at least moderate to vig...
...Table 4. Dysli...
...therapeutic lifestyle changes, tr...
...onsidered for patients with low HDL chole...
...acid derivatives may be considered fo...
...ith nonstatin lipid-lowering therap...
...Table 5. Diet and N...
Reduced intake of sodium and increased i...
...tyle diet, which emphasizes fruits, vegeta...
...rich in fruits and vegetables and ther...
...diet supplemented with nuts may be...
...Table 6. Hyperten...
...BP screening and appropriate treatment of...
...ng for high BP and health-promotin...
...ave hypertension should be treated with antih...
...essful reduction of BP is more important i...
...BP monitoring is recommended to impro...
...Table 7. Obesit...
...t (BMI2=25-29 kg/m) and obese (BMI2 >30 kg/m) in...
...ght (BMI2=25-29 kg/m) and obese (BMI2 >30 kg/m)...
...Table 8. Di...
...f BP in accordance with an AHA/ACC/CDC Advisory to...
...f adults with diabetes mellitus wi...
...of aspirin for primary stroke prevention...
...a fibrate to a statin in people with diabe...
...Table 9. Cigarette Smok...
...seling, in combination with drug therapy...
...cigarette smoking is recommended for p...
...r statewide bans on smoking in public spac...
...Table 10. AF...
...with valvular AF at high risk for s...
...or patients with nonvalvular AF, a CHA2DS2-VA...
...bigatran, apixaban, and rivaroxaban. ( B...
...ctive screening for AF in the primary care set...
...ts with nonvalvular AF and CHA2DS2-...
For patients with nonvalvular AF,...
...re of the LAA may be considered for hig...
...Table 11. Other Card...
...oagulation is indicated in patients with mitra...
...ticoagulation is indicated in patients with m...
...arin (target INRa, 2.0-3.0) and low-do...
...l excision is recommended for the treatmen...
...vention is recommended for symptomatic fibro...
...spirin is reasonable after aortic or mitr...
...reasonable to give warfarin to achieve an...
...r antiplatelet agents are reasonable for...
...itamin K antagonist therapy is reasonable f...
...coagulation may be considered for asympto...
...gulation may be considered for patients with...
...ant therapy may be considered for pati...
Antithrombotic treatment and catheter-...
...Table 12...
...atients with asymptomatic carotid stenosis sho...
...atients who are to undergo CEA, asp...
...nable to consider performing CEA in asymptomat...
...asonable to repeat duplex ultrasonography annua...
...rophylactic CAS might be considered in...
...ic patients at high risk of complications for...
...creening low-risk populations for as...
...Table 13. SCD...
...ing for children with SCD is indicat...
...herapy (target reduction of hemoglobin S,...
...optimal screening interval has not bee...
Pending further studies, continued tran...
...children at high risk for stroke who a...
...criteria for selection of children for primary s...
...Table 14. Migraine...
...on should be strongly recommended i...
...natives to OCs, especially those conta...
...nts to reduce migraine frequency might be...
...O is NOT indicated for preventing str...
...Table 15. Meta...
...Management of individual compone...
...Table 16. Alcohol...
...or elimination of alcohol consumption in h...
...dividuals who choose to drink alcohol, con...
...Table...
...l to an appropriate therapeutic program is rea...
...of its association with stroke risk, scree...
...eatment of sleep apnea to reduce the risk of strok...
...Table 19. Hyperhomocyst...
...use of the B complex vitamins, cobalamin (B1...
...Table 20. Elev...
...se of niacin, which lowers Lp(a), might be reason...
...nical benefit of using Lp(a) in str...
...s of genetic screening to detect i...
...of specific treatments for primary st...
...(81 mg/d) is NOT indicated for primary s...
...Table 2...
...ith chronic inflammatory disease su...
...l influenza vaccination can be useful...
...ent of inflammatory markers such as hs-...
...of patients with hs-CRP >2.0 mg/dL with...
...with antibiotics for chronic infections as...
...Table 23. Ant...
...use of aspirin for cardiovascular...
...pirin (81 mg daily or 100 mg every ot...
...be considered for the prevention of a first stroke...
...ay be reasonable for the prevention of a fi...
...useful for preventing a first stroke in l...
...pirin is NOT useful for preventing a first stro...
Aspirin is NOT useful for preventing a first s...
...pirin for other specific situations (eg, A...
...a result of a lack of relevant clinical t...
...Table 24. Pri...
...ing cessation programs and interventions are rec...
Identification of AF and evaluation for...
...population screening for hyperten...
...s identified as having a drug or alcohol abuse pro...
...veness of screening, brief interven...
...Table 25....
...t is reasonable to implement programs to systemat...