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
...agnosi...
...1. Assessing the Risk of First Stroke...
...use of a risk assessment tool such as...
...ble 2. Genetic Fac...
...amily history can be useful in identif...
...eferral for genetic counseling may be conside...
...of Fabry disease with enzyme replac...
...eening for unruptured intracranial aneury...
...ve screening may be considered for un...
...oninvasive screening for unruptured i...
...cogenetic dosing of vitamin K antagonists may...
...ive screening for unruptured intracranial...
...or intracranial aneurysms in every carrier of...
...reening of the general population for...
...eening to determine risk for myopathy is NOT reco...
Treatment
...eatment...
...e 3. Physical Inactivity...
...ivity is recommended because it is associated...
...dults should perform at least moderate to vigorous...
...able 4. Dyslipide...
...herapeutic lifestyle changes, treatment...
...may be considered for patients with low HD...
...rivatives may be considered for patients...
...th nonstatin lipid-lowering therapies suc...
...5. Diet and Nutrition...
Reduced intake of sodium and increased...
...SH-style diet, which emphasizes fru...
...that is rich in fruits and vegetables and t...
A Mediterranean diet supplemented with n...
...le 6. Hypertension...
...gular BP screening and appropriate treatment...
...reening for high BP and health-promoting l...
...ve hypertension should be treated wi...
...reduction of BP is more important in reducing...
...measured BP monitoring is recommen...
...Obesity and Body Fat Distribu...
...rweight (BMI2=25-29 kg/m) and obese...
...ng overweight (BMI2=25-29 kg/m) and...
...le 8. Diabetes...
...trol of BP in accordance with an AHA/...
...atment of adults with diabetes mel...
...efulness of aspirin for primary stroke pr...
...te to a statin in people with diabetes mellitu...
.... Cigarette Smoking...
...ng, in combination with drug therapy...
...bstention from cigarette smoking is...
...unity-wide or statewide bans on smoking in public...
...le 10. AF...
...ents with valvular AF at high risk for str...
...h nonvalvular AF, a CHA2DS2-VASc sco...
...n, apixaban, and rivaroxaban. ( B , I )...
...for AF in the primary care setting in pa...
...s with nonvalvular AF and CHA2DS2-VASc...
...with nonvalvular AF, a CHA2DS2-VASc score of 1,...
...e LAA may be considered for high-risk patients wi...
...11. Other Cardiac Conditi...
...nticoagulation is indicated in patients with mi...
...nticoagulation is indicated in patien...
...t INRa, 2.0-3.0) and low-dose aspirin...
...ical excision is recommended for t...
...l intervention is recommended for symptomati...
...pirin is reasonable after aortic or mit...
...easonable to give warfarin to achieve...
...nts or antiplatelet agents are reason...
...tagonist therapy is reasonable for p...
...may be considered for asymptomatic patie...
...ulation may be considered for patients wit...
...coagulant therapy may be considered for...
...c treatment and catheter-based clo...
...12. Asymptomatic Carotid Steno...
...tients with asymptomatic carotid stenosi...
...who are to undergo CEA, aspirin is recommend...
...reasonable to consider performing...
...reasonable to repeat duplex ultrasonog...
...ophylactic CAS might be considered in h...
...ymptomatic patients at high risk of...
...low-risk populations for asymptoma...
...e 13. SCD...
...screening for children with SCD i...
...on therapy (target reduction of hemoglo...
...the optimal screening interval has not...
...ther studies, continued transfusion, even in those...
...n children at high risk for stroke who are una...
...RA criteria for selection of children for prim...
...14. Migraine...
...ion should be strongly recommended in women with...
Alternatives to OCs, especially thos...
...tments to reduce migraine frequency might be...
...s NOT indicated for preventing stroke...
.... Metabolic Syndrom...
...anagement of individual components of the...
.... Alcohol Consumption
...on or elimination of alcohol consum...
...s who choose to drink alcohol, consumption of ≤...
...17. Drug Abuse...
...n appropriate therapeutic program is reasonable fo...
...e 18. Sleep-Disordered Breathing
...ts association with stroke risk, s...
...nt of sleep apnea to reduce the risk of stroke may...
...9. Hyperhomocysteinemia...
...the B complex vitamins, cobalamin (B12), pyri...
.... Elevated Lp(a)...
The use of niacin, which lowers Lp(a...
...al benefit of using Lp(a) in stroke risk pre...
...21. Hypercoagulability...
...f genetic screening to detect inherited h...
...efulness of specific treatments for primar...
...aspirin (81 mg/d) is NOT indicated for...
...flammation and Infection...
...s with chronic inflammatory disease su...
...nfluenza vaccination can be useful in...
...ement of inflammatory markers such...
...ients with hs-CRP >2.0 mg/dL with a stat...
...with antibiotics for chronic infections as a means...
...e 23. Antiplatelet Agents and Asp...
...aspirin for cardiovascular (including but...
...(81 mg daily or 100 mg every other day) can...
...be considered for the prevention of a firs...
Cilostazol may be reasonable for the p...
...is NOT useful for preventing a firs...
...seful for preventing a first strok...
...spirin is NOT useful for preventing a...
...irin for other specific situations (eg,...
...f a lack of relevant clinical trials,...
Table 24. Primary Prevention...
...moking cessation programs and interventions are re...
...n of AF and evaluation for anticoa...
...pulation screening for hypertension...
...t is identified as having a drug o...
...effectiveness of screening, brief interventi...
...25. Preventive Health Services...
It is reasonable to implement progr...