Primary Stroke Prevention
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
Diagnos...
...Assessing the Risk of First Stroke...
...risk assessment tool such as the AH...
...le 2. Genetic Fact...
Obtaining a family history can be use...
...genetic counseling may be considered...
...abry disease with enzyme replacement therapy m...
...nvasive screening for unruptured intracr...
Noninvasive screening may be considered for unr...
...reening for unruptured intracranial aneurysms in p...
...rmacogenetic dosing of vitamin K antag...
...reening for unruptured intracranial aneurysms i...
...for intracranial aneurysms in every carri...
...c screening of the general population fo...
Genetic screening to determine risk for myopathy...
Treatment
...atment...
...able 3. Physical Inactivity
...vity is recommended because it is associat...
Healthy adults should perform at least m...
...e 4. Dyslipidemia
...addition to therapeutic lifestyle changes, treatm...
...be considered for patients with low HDL cho...
...d derivatives may be considered for patie...
...atment with nonstatin lipid-lowering ther...
...5. Diet and Nutrit...
...ed intake of sodium and increased...
...style diet, which emphasizes fruits,...
...t that is rich in fruits and vegetables and...
...diet supplemented with nuts may be consi...
...e 6. Hypertension
...r BP screening and appropriate treatment of patien...
...al screening for high BP and healt...
...nts who have hypertension should b...
...ction of BP is more important in reducing st...
...monitoring is recommended to impr...
...7. Obesity and Body Fat Dis...
...ht (BMI2=25-29 kg/m) and obese (BMI2 >30 kg/m) i...
...ng overweight (BMI2=25-29 kg/m) and obese (BM...
...e 8. Diabete...
...rol of BP in accordance with an AHA/ACC...
Treatment of adults with diabetes mellitus with a...
...usefulness of aspirin for primary stroke...
...e to a statin in people with diabetes mellitu...
...9. Cigarette Smoking...
...ling, in combination with drug therapy...
...tention from cigarette smoking is recommended...
...unity-wide or statewide bans on smoking in publi...
...ble 10. A...
...with valvular AF at high risk for st...
...nts with nonvalvular AF, a CHA2DS2-VASc scor...
...xaban, and rivaroxaban. ( B , I )573...
...creening for AF in the primary car...
...ients with nonvalvular AF and CHA2D...
...with nonvalvular AF, a CHA2DS2-VASc score of 1,...
...sure of the LAA may be considered for...
...e 11. Other Cardiac Conditions...
...ticoagulation is indicated in patients with mi...
...nticoagulation is indicated in patient...
...rin (target INRa, 2.0-3.0) and low-dose...
...cal excision is recommended for the treatmen...
...urgical intervention is recommended for symptomati...
...asonable after aortic or mitral valve replacement...
...le to give warfarin to achieve an INR o...
Anticoagulants or antiplatelet agents are reason...
...in K antagonist therapy is reasonable for...
...ion may be considered for asymptom...
...coagulation may be considered for...
...gulant therapy may be considered for patients with...
...rombotic treatment and catheter-ba...
...12. Asymptomatic Carotid Steno...
...tients with asymptomatic carotid stenosis should...
...ho are to undergo CEA, aspirin is recomm...
...onable to consider performing CEA in...
...e to repeat duplex ultrasonography annu...
...S might be considered in highly selected patient...
...matic patients at high risk of complicat...
...g low-risk populations for asymptomat...
...e 13. SCD
...reening for children with SCD is i...
...apy (target reduction of hemoglobin S,...
...optimal screening interval has not been estab...
...r studies, continued transfusion, e...
...n at high risk for stroke who are unable or u...
...teria for selection of children for pri...
...le 14. Migrain...
...ssation should be strongly recommended in women...
...OCs, especially those containing estrogen, migh...
...ents to reduce migraine frequency might be reaso...
...re of PFO is NOT indicated for preventing...
...5. Metabolic Syndro...
...t of individual components of the...
...6. Alcohol Consumption...
...elimination of alcohol consumption in...
...dividuals who choose to drink alcohol, consumptio...
...ble 17. Drug Abuse
Referral to an appropriate therapeutic program is...
...leep-Disordered Breathing...
...cause of its association with stro...
...tment of sleep apnea to reduce the risk...
...le 19. Hyperhomocyst...
...e use of the B complex vitamins, cobalamin (B12),...
...20. Elevated Lp(...
...use of niacin, which lowers Lp(a), might be re...
...inical benefit of using Lp(a) in stroke r...
...21. Hypercoagulabi...
...usefulness of genetic screening to d...
...usefulness of specific treatments for primary st...
...pirin (81 mg/d) is NOT indicated for primar...
...able 22. Inflammation and Infect...
...h chronic inflammatory disease such as RA or SLE s...
...nnual influenza vaccination can be usef...
...t of inflammatory markers such as hs-CRP or lip...
...of patients with hs-CRP >2.0 mg/dL with a...
Treatment with antibiotics for chronic inf...
...able 23. Antiplatelet Agents...
...rin for cardiovascular (including...
...aily or 100 mg every other day) can be useful for...
...be considered for the prevention of a first strok...
...ol may be reasonable for the prevention of a f...
...spirin is NOT useful for preventing a...
...OT useful for preventing a first str...
...n is NOT useful for preventing a first stroke...
...aspirin for other specific situations (eg...
...a result of a lack of relevant clinica...
...ble 24. Primary Prevention in...
...sed smoking cessation programs and interv...
...ification of AF and evaluation for anticoagulat...
...population screening for hypertension...
...tient is identified as having a dru...
The effectiveness of screening, brief inte...
...25. Preventive Health Ser...
...able to implement programs to systematically ide...