Primary Stroke Prevention

Publication Date: October 27, 2014

Key Points

Key Points

Approximately 795,000 people in the United States have a stroke each year, ~610,000 of whom have had first attacks, resulting in 6.8 million stroke survivors >19 years of age.

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

Diagnosis

...1. Assessing the Risk of First Stroke

...a risk assessment tool such as the AHA/ ACC CV R...


Table 2. Genetic Fact...

...amily history can be useful in iden...

...etic counseling may be considered for patient...

...bry disease with enzyme replacemen...

...asive screening for unruptured intracranial an...

...e screening may be considered for unruptured intra...

...screening for unruptured intracrani...

Pharmacogenetic dosing of vitamin K antagonists m...

...e screening for unruptured intracranial ane...

...ning for intracranial aneurysms in e...

...ening of the general population for the preve...

...ic screening to determine risk for myopa...


Treatment

...reatmen...

...Physical Inactivity...

...l activity is recommended because it is associ...

...thy adults should perform at least moderate to vig...


...4. Dyslipidemia

...herapeutic lifestyle changes, treatment with a...

...be considered for patients with low HDL cholester...

...derivatives may be considered for patien...

...with nonstatin lipid-lowering therapies...


...5. Diet and Nutritio...

...e of sodium and increased intake of potassiu...

...-style diet, which emphasizes fruits, veget...

...t is rich in fruits and vegetables...

...ean diet supplemented with nuts may...


...6. Hypertension...

...egular BP screening and appropriate treatm...

...reening for high BP and health-promoting...

...ents who have hypertension should be treated wit...

...ccessful reduction of BP is more im...

...red BP monitoring is recommended to impr...


...le 7. Obesity and Body Fat Distributi...

...mong overweight (BMI2=25-29 kg/m) and...

...ght (BMI2=25-29 kg/m) and obese (BM...


Table 8. Dia...

...n accordance with an AHA/ACC/CDC Advisory to a ta...

...atment of adults with diabetes mellitus with a st...

...lness of aspirin for primary stroke prevention f...

...ng a fibrate to a statin in people with diabete...


...9. Cigarette Smoking...

...g, in combination with drug therapy...

...on from cigarette smoking is recommended for...

...de or statewide bans on smoking in...


Table 10...

...ents with valvular AF at high risk f...

...s with nonvalvular AF, a CHA2DS2-VA...

...bigatran, apixaban, and rivaroxaban. ( B ,...

...ctive screening for AF in the primary car...

...with nonvalvular AF and CHA2DS2-VASc score o...

...s with nonvalvular AF, a CHA2DS2-VA...

...LAA may be considered for high-risk patients...


Table 11. Other Cardiac Conditions

...lation is indicated in patients with mitr...

...on is indicated in patients with mitral steno...

...farin (target INRa, 2.0-3.0) and low-dose...

...ision is recommended for the treatment of at...

...tervention is recommended for symptomatic...

...n is reasonable after aortic or mitral valve repla...

...nable to give warfarin to achieve an INR of 2.0...

...ulants or antiplatelet agents are reasonable f...

...itamin K antagonist therapy is reasonable for...

...on may be considered for asymptomatic patients...

...oagulation may be considered for pat...

...ulant therapy may be considered for patien...

...treatment and catheter-based closure ar...


...12. Asymptomatic Carotid St...

...ents with asymptomatic carotid stenosis...

...n patients who are to undergo CEA, aspirin is r...

It is reasonable to consider performi...

...e to repeat duplex ultrasonography annuall...

...ic CAS might be considered in highly selected pati...

...ymptomatic patients at high risk of compl...

Screening low-risk populations for asy...


Table 13. S...

...screening for children with SCD is ind...

...nsfusion therapy (target reduction of hemog...

...he optimal screening interval has not...

...ding further studies, continued transfusion...

...ildren at high risk for stroke who are unable...

MRI and MRA criteria for selection of...


...able 14. Migraine

...ing cessation should be strongly recommend...

...OCs, especially those containing estrogen, might...

...s to reduce migraine frequency might...

...of PFO is NOT indicated for preventing s...


...le 15. Metabolic Syndrome...

...gement of individual components of the meta...


...le 16. Alcohol Consu...

...uction or elimination of alcohol consumpt...

...who choose to drink alcohol, consumption...


...le 17. Drug Abuse...

...erral to an appropriate therapeutic...


...18. Sleep-Disordered Breat...

...ts association with stroke risk, s...

Treatment of sleep apnea to reduce the ri...


...le 19. Hyperhomocysteinemia...

...f the B complex vitamins, cobalamin (B12), pyri...


...le 20. Elevated Lp(a...

...cin, which lowers Lp(a), might be...

...nefit of using Lp(a) in stroke risk predictio...


...21. Hypercoagulability...

...fulness of genetic screening to detect inher...

...s of specific treatments for primary stroke prev...

...ow-dose aspirin (81 mg/d) is NOT indi...


...Inflammation and Infection...

...hronic inflammatory disease such as RA or SLE s...

...influenza vaccination can be useful...

...rement of inflammatory markers such a...

...patients with hs-CRP >2.0 mg/dL with a statin to...

...tment with antibiotics for chronic infections as...


...3. Antiplatelet Agents and Asp...

...pirin for cardiovascular (including...

...mg daily or 100 mg every other day) can b...

...n might be considered for the prevention of a fi...

...stazol may be reasonable for the prevention...

...useful for preventing a first str...

...NOT useful for preventing a first...

...n is NOT useful for preventing a first s...

...of aspirin for other specific situations (eg, A...

As a result of a lack of relevant clinical trial...


...4. Primary Prevention in the ED...

...D-based smoking cessation programs and interventi...

...of AF and evaluation for anticoagulati...

...n screening for hypertension is reasonable....

...ent is identified as having a drug or alcohol ab...

...ss of screening, brief intervention, and referra...


...Preventive Health Services...

...to implement programs to systematically...