Primary Prevention of Stroke
Publication Date: October 20, 2024
Last Updated: October 21, 2024
Patient Assessment
In individuals 40–79 years of age, estimation of risk for atherosclerotic CVD (ie, nonfatal MI, nonfatal stroke, and fatal CVD) every 1 to 5 years is beneficial to guide decisions on treatments and lifestyle recommendations that may reduce risk for stroke. (I, B-NR)
573
In individuals with AF, calculation of the CHA2DS2-VASc score is recommended to guide decisions on prescription of oral anticoagulation to reduce risk for stroke. (I, B-NR)
573
In individuals ≥18 years of age, periodic screening for modifiable behaviors and medical conditions that increase stroke risk is recommended to reduce risk for stroke. (I, C-EO)
573
In individuals ≥18 years of age, periodic screening for SDOH (eg, food insecurity, lack of transportation) is beneficial to identify additional factors that contribute to stroke risk. (I, C-EO)
573
Management of Health Behaviors and Health Factors
Diet Quality
In adults without prior CVD and who are at high or intermediate CVD risk, a Mediterranean diet is recommended to reduce the risk of incident stroke. (I, B-R)
573
In adults who are ≥60 years of age and have uncontrolled BP (systolic BP [SBP] ≥140 mm Hg if taking antihypertensive medication or ≥160 mm Hg if not), compared with using 100% sodium chloride, salt substitution (75% sodium chloride and 25% potassium chloride) is reasonable to reduce the risk of incident stroke. (IIa, B-R)
573
In adults, folic acid supplementation and Bcomplex (folic acid, B12, B6) vitamins supplementation for reducing the risk of stroke are not well established. (IIb, B-NR)
573
In adults without prior CVD, long-chain fatty acids are not effective for reducing the risk of stroke. (III - No Benefit, B-R)
573
In adults, vitamin C, vitamin E, selenium, antioxidants, calcium, calcium with vitamin D, and multivitamin supplementation are not effective for reducing the risk of stroke. (III - No Benefit, B-R)
573
Physical Activity
In adults, screening for physical activity is recommended as part of a comprehensive effort to estimate stroke risk. (I, C-EO)
573
In adults, counseling patients to engage in at least 150 minutes of moderate-intensity physical activity, 75 minutes of vigorous-intensity physical activity, or an equivalent combination per week is recommended to reduce the risk of stroke. (I, C-LD)
573
In adults, counseling to avoid excessive time spent in sedentary behavior (characterized by low energy expenditure while sitting, reclining, or lying while awake) is recommended to reduce the risk of stroke. (I, C-LD)
573
Weight and Obesity
In adults >18 years of age, screening for overweight and obesity is recommended to inform the risk of stroke. (I, B-NR)
573
In patients with class II obesity (35–39.9 kg/m2) or greater, bariatric surgical procedures to promote weight loss may be considered to reduce the risk of stroke. (IIb, C-LD)
573
Sleep
The effectiveness of screening adults for OSA to prevent stroke is unclear. (IIb, B-R)
573
In patients with OSA, continuous positive airway pressure (CPAP) might be reasonable to reduce the risk of stroke. (IIb, C-LD)
573
Blood Sugar
In asymptomatic adults ≥18 years of age who have overweight, obesity, or atherosclerotic CVD, screening for prediabetes and diabetes is recommended to inform stroke risk. (I, C-LD)
573
In patients with diabetes and high cardiovascular risk or established CVD and hemoglobin A1c ≥7%, treatment with a GLP-1 receptor agonist is effective to reduce the risk of stroke. (I, A)
573
In patients with type 1 diabetes or diabetes, intensive glycemic control (targeting a hemoglobin A1c ≤6.5%) is not beneficial for stroke prevention. (III - No Benefit, B-R)
573
Blood Pressure
In adults ≥18 years of age, screening for hypertension is recommended to identify individuals at increased risk for stroke and eligible for antihypertensive treatment. (I, C-LD)
573
In adults with stage 2 hypertension or stage 1 hypertension with a higher risk for atherosclerotic CVD, lifestyle improvement and antihypertensive drug treatment to a SBP/diastolic BP (DBP) <130/80 mm Hg are recommended to prevent stroke. (I, A)
573
In adults with hypertension, thiazide and thiazidelike diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers are recommended as initial antihypertensive drug therapies to prevent stroke. (I, A)
573
In most adults with hypertension, antihypertensive drug treatment incorporating ≥2 antihypertensive medications is indicated to achieve the BP control necessary to prevent stroke. (I, A)
573
Lipids
In adults who qualify for treatment with lipidlowering therapy according to the 2019 ACC/AHA guideline on the primary prevention of CVD (eg, 20–75 years of age with LDL cholesterol [LDL-C] level >190 mg/dL [>4.9 mmol/L], 10-year ASCVD risk ≥20%, or 10-year ASCVD risk ≥7.5%–<20% plus ≥1 risk enhancers), treatment with a statin is recommended to reduce the risk of a first stroke. (I, A)
573
In adults without CVD who qualify for treatment with lipid-lowering therapy, according to the 2019 ACC/AHA guideline on the primary prevention of CVD (eg, 20–75 years of age with LDL-C level >190 mg/dL [>4.9 mmol/L], 10-year ASCVD risk ≥20%, or 10-year ASCVD risk ≥7.5%–<20% plus ≥1 risk enhancers), who cannot reach goals or cannot tolerate other therapies such as statins, the benefit of treatment with alirocumab or evolocumab compared with other active lipid-lowering therapy for the reduction of the risk of a first stroke is uncertain. (IIb, A)
573
In adults who do not tolerate statin therapy and who have LDL-C >100 mg/dL and elevated cardiovascular risk, treatment with bempedoic acid to reduce the risk of a first stroke is not well established. (IIb, B-R)
573
In adults with moderate or low intake of long-chain omega-3 fatty acid, supplementation is not recommended to reduce the risk of a first stroke. (III - No Benefit, A)
573
Tobacco Use
In all patients, screening for cigarette smoking, use of other forms of tobacco, use of electronic nicotine delivery systems such as electronic cigarettes (e-cigarettes) and vapes, and environmental tobacco smoke exposure (secondhand smoke exposure) is effective to inform stroke risk and target cessation interventions. (I, B-NR)
573
For patients who are nonusers of tobacco products, continued complete abstention from cigarette smoking, in addition to other tobacco products and electronic nicotine delivery systems, and avoidance of exposure to environmental tobacco smoke (secondhand smoke exposure) are recommended to avoid the associated increased risk of stroke. (I, B-NR)
573
For patients who are active cigarette smokers, smoking cessation pharmacotherapy delivered along with behavioral counseling is recommended, in preference to behavioral counseling alone, to facilitate smoking cessation. (I, A)
573
For patients who are active cigarette smokers and users of other tobacco products (eg, electronic nicotine delivery systems), assistance with cessation is recommended to reduce the risk of stroke. (I, C-LD)
573
For patients who are active cigarette smokers encountered in the hospital setting, providing smoking cessation pharmacotherapy along with behavioral counseling as the default treatment (“opt-out”), in preference to providing such treatment only for patients expressing a willingness to quit smoking (“opt-in”), can be beneficial to facilitate short-term smoking cessation and to increase engagement in smoking cessation treatment. (IIa, B-R)
573
For patients who are active cigarette smokers, the long-term health benefits of using e-cigarettes in place of nicotine replacement therapy to facilitate cigarette smoking cessation are not well established. (IIb, B-R)
573
Atherosclerotic and Nonatherosclerotic Risk Factors
Asymptomatic Carotid Artery Stenosis
In the asymptomatic population, routine screening for carotid artery stenosis is not recommended to reduce the risk of stroke. (III - No Benefit, B-NR)
573
In patients with asymptomatic carotid artery stenosis (ACS) >70%, shared decision-making between the patient and the health care team to decide between the 2 courses of treatment (carotid revascularization or medical management) is recommended to determine the best method of reducing stroke risk. (I, C-EO)
573
In patients with asymptomatic atherosclerotic carotid artery stenosis, medical treatment with statin can be beneficial to reduce the risk of stroke. (IIa, B-NR)
573
In patients with asymptomatic atherosclerotic carotid artery stenosis >70% and low perioperative risk, the use of carotid revascularization, in addition to intensive medical therapy, may be reasonable to reduce the risk of stroke. (IIb, B-R)
573
In patients with ACS >50%, annual carotid duplex ultrasound every 6 to 12 months might be reasonable to assess progression of disease and subsequent increased risk of stroke. (IIb, B-NR)
573
In patients with asymptomatic atherosclerotic carotid artery stenosis and high perioperative risk, the effectiveness of carotid revascularization to reduce risk of stroke is not established. (IIb, B-NR)
573
Asymptomatic Cerebral SVD, Including Silent Cerebral Infarcts
In adults with asymptomatic cerebral SVD (CSVD), including silent infarcts, assessment and management of risk factors (eg, hypertension, dyslipidemia, tobacco use, and diabetes) are recommended to reduce stroke risk. (I, C-LD)
573
In adults with silent cerebral infarcts (SCIs) who do not have an indication for statin therapy according to the 2019 ACC/AHA guideline (eg, 20–75 years of age with LDL-C level >190 mg/dL [>4.9 mmol/L], 10-year ASCVD risk ≥20%, or 10-year ASCVD risk ≥7.5%–<20% plus ≥1 more risk enhancers), use of low-dose statin therapy might be considered to reduce the risk of ischemic stroke. (IIa, B-NR)
573
In adults with SCI, the benefit of antiplatelet therapy to reduce the risk of ischemic stroke is uncertain. (IIb, C-LD)
573
Migraine
In adults 18 to 64 years of age with migraine with or without aura, evaluation and modification of vascular risk factors are recommended to address the elevated risk of stroke in this patient population. (I, C-LD)
573
In adults with migraine with aura who desire contraception, progestin-only or nonhormonal forms are recommended to avoid the increased risk of ischemic stroke associated with combined hormonal contraception. (I, C-LD)
573
Specific Populations
Sickle Cell Disease
In children 2 to 16 years of age with SCD (Hb SS or Hb S-beta0-thalassemia), transcranial Doppler (TCD) screening at a frequency based on the highest mean flow velocity in the terminal portion of the internal carotid or the proximal portion of the middle cerebral artery is recommended. (I, B-R)
573
In children 2 to 16 years of age with SCD at elevated risk per TCD measurements, regularly scheduled transfusion therapy (target reduction of hemoglobin S <30%) is effective for reducing stroke risk. (I, B-R)
573
In children 2 to 16 years of age and young adults with Hb SS or Hb S-beta0-thalassemia, an MRI of the brain without sedation should be performed as soon as possible to evaluate for SCI and to determine the need for chronic red cell transfusions (CRCTs) for stroke prevention. (IIa, B-R)
573
In children 2 to 16 years of age with SCD whose TCD velocities revert to normal, continued transfusion therapy can be beneficial to reduce the risk of stroke. (IIa, B-R)
573
In children 2 to 16 years of age with SCD and normalized mean flow velocities and no intracranial stenosis, transition from transfusion to hydroxyurea therapy can be considered to prevent stroke. (IIa, B-NR)
573
In children 2 to 16 years of age with SCD at high risk for stroke (TCD mean flow velocities ≥200 cm/s) but without intracranial stenosis who are unable to continue or cannot be treated with periodic red cell transfusion, hydroxyurea or bone marrow transplantation may be reasonable to prevent stroke. (IIb, B-NR)
573
Genetic Stroke Syndromes
In patients with CADASIL, counseling on smoking cessation and treatment of hypertension and other vascular risk factors are beneficial to reduce the risk of incident stroke. (I, C-LD)
573
In adults with hereditary hemorrhagic telangiectasia (HHT), screening for pulmonary arteriovenous malformations (PAVMs) is reasonable to identify the need for multidisciplinary evaluation to manage stroke risk. (IIa, B-NR)
573
In patients with Fabry disease, the effectiveness of enzyme replacement therapy (ERT) to reduce the risk of stroke is not well established. (IIb, C-LD)
573
Coagulation and Inflammatory Disorders
Inflammation in Atherosclerosis
In adults with a recent MI, the addition of lowdose colchicine to intensive statin therapy might be reasonable to decrease the risk of ischemic stroke. (IIb, B-R)
573
Autoimmune Conditions
In patients without a history of stroke and no clinical indication for anticoagulation, with a high-risk aPL profile (ie, triple-positive antiphospholipid testing [lupus anticoagulant, anticardiolipin antibody, anti–β2 glycoprotein 1] or double-positive [any combination] or isolated lupus anticoagulant or isolated persistently positive anticardiolipin antibody at medium to high titers), prophylactic treatment with aspirin (75–100 mg daily) is recommended to reduce the risk of stroke. (I, B-NR)
573
In patients with systemic lupus erythematosus (SLE) and no history of thrombosis or pregnancy complications and with a high-risk antiphospholipid profile (ie, lupus anticoagulant, anticardiolipin antibody, anti–β2-glycoprotein 1, or double-positive [any combination] or isolated lupus anticoagulant or isolated persistently positive anticardiolipin antibody at medium to high titers), prophylactic treatment with aspirin (75–100 mg daily) is recommended to reduce the risk of stroke. (I, B-NR)
573
In patients with antiphospholipid syndrome (APS) with prior unprovoked venous thrombosis, it is reasonable to choose vitamin K antagonist (VKA) therapy with a target international normalized ratio of 2 to 3 in preference to aspirin or direct oral anticoagulants for prevention of recurrent thrombotic events, including stroke. (IIa, B-R)
573
In patients with rheumatoid arthritis, statin treatment may be reasonable to reduce major adverse cardiovascular events, including stroke. (IIb, B-R)
573
In nonpregnant adults with a history of obstetric APS only, prophylactic treatment with aspirin (75–100 mg daily) after adequate risk/benefit evaluation (ie, aPL profile, coexistent traditional cardiovascular risk factors, intolerance, or contraindication to aspirin) may be considered to reduce the risk of stroke. (IIb, B-NR)
573
In patients with SLE and no history of thrombosis or pregnancy complications and with a low-risk antiphospholipid profile (ie, isolated anticardiolipin antibody or anti–β2-glycoprotein 1 antibodies at low to medium titers, particularly if transiently positive), prophylactic treatment with aspirin (75–100 mg daily) may be considered to reduce the risk of stroke. (IIb, C-LD)
573
Infection
In patients with periodontal disease (PD), good oral hygiene and regular dental care can be beneficial to lower stroke risk. (IIa, B-NR)
573
In patients hospitalized with COVID-19, treatment with full-dose anticoagulation (eg, enoxaparin, apixaban) is not recommended to prevent stroke. (III - No Benefit, B-R)
573
Substance Use and Substance Disorders
In all adults, screening for substance misuse and substance use disorders (eg, alcohol, cannabis, cocaine, opioids, amphetamines) is recommended to inform stroke risk. (I, B-NR)
573
In patients who use recreational drugs (eg, cannabis, synthetic cannabinoids, cocaine, heroin, methamphetamine), misuse alcohol or prescription medications (eg, stimulants and opioids), or have a substance use disorder, counseling to stop or appropriate substance use disorder treatments (eg, pharmacological, behavioral, or multimodal) as appropriate are reasonable to reduce stroke risk. (IIa, C-LD)
573
Sex- and Gender-Specific Factors
Prevention of Pregnancy-Associated Stroke
In pregnant or early postpartum (within 6 weeks of delivery), patients with severe hypertension (2 measurements of SBP ≥160 mm Hg or DBP ≥110 mm Hg, 15 minutes apart), BP-lowering treatment to a target <160/110 mm Hg as soon as possible is recommended to reduce the risk of fatal maternal ICH. (I, B-NR)
573
In patients with HDP, including chronic hypertension in pregnancy, treatment with antihypertensive medication to a goal BP of <140/90 mm Hg is reasonable to reduce the risk of pregnancyassociated stroke. (IIa, C-LD)
573
Pregnancy and Long-Term Stroke Risk
In adults, screening for a history of certain adverse pregnancy outcomes (APOs), including HDP, preterm birth, gestational diabetes, and placental disorders, followed by subsequent evaluation and management of vascular risk factors, is recommended to reduce the risk of stroke. (I, C-EO)
573
In patients with a history of HDP or other APOs, early evaluation and management of chronic hypertension are recommended to reduce the risk of stroke. (I, C-LD)
573
Endometriosis
In adults, screening for a history of endometriosis is reasonable to inform the risk of stroke. (IIa, B-NR)
573
In individuals with endometriosis, vascular risk factor evaluation and modification of vascular risk factors are reasonable to reduce the risk of stroke. (IIa, C-LD)
573
Hormonal Contraception
In individuals considering CHC, lower doses of ethinyl estradiol are recommended to minimize potential increased stroke risk. (I, B-NR)
573
In individuals with specific stroke risk factors (ie, age >35 years, tobacco use, hypertension, or migraine with aura) who are considering contraception, shared decision-making is recommended to determine the best contraceptive choice to balance the risk of stroke from contraception and the risk of stroke with pregnancy. (I, C-EO)
573
In individuals with specific stroke risk factors (ie, age >35 years, tobacco use, hypertension, or migraine with aura) who are considering contraception, progestin-only contraception or nonhormonal contraception is reasonable to prevent the increased stroke risk associated with estrogencontaining contraception. (IIa, C-LD)
573
Menopause
Screening for a history of premature ovarian failure (before 40 years of age) and early menopause (before 45 years of age) can be beneficial to inform the risk of stroke. (I, B-NR)
573
In patients with premature ovarian failure (menopause before 40 years of age) or early menopause (before 45 years of age), evaluation and modification of vascular risk factors are recommended to reduce the elevated stroke risk in this population. (I, C-LD)
573
In women ≥60 years of age, more than 10 years after natural menopause, or at elevated risk for CVD or stroke, oral estrogen-containing menopausal HT is associated with an excess risk of stroke and must be weighed against clinical benefits. (III - Harm, A)
573
Transgender Health
In transgender women and gender-diverse individuals taking estrogens for gender affirmation, evaluation and modification of risk factors can be beneficial to reduce the risk of stroke. (IIa, C-LD)
573
Testosterone
In men 45 to 80 years of age with confirmed hypogonadism who are considering testosterone therapy, initiation or continuation of testosterone replacement therapy is reasonable and does not increase the risk of stroke. (IIa, B-R)
573
Heart Disease
Cardiomyopathy
In patients with left ventricular systolic dysfunction (ejection fraction ≤35%–40%) and no evidence of AF or left ventricular thrombus, anticoagulation is not indicated to prevent stroke and is associated with a higher bleeding risk. (III - No Benefit, B-R)
573
Antiplatelet Use for Primary Prevention
In patients with diabetes or other common vascular risk factors and no prior stroke, the use of aspirin to prevent a first stroke is not well established. (IIb, A)
573
In patients with established, stable coronary artery disease and a low bleeding risk, the addition of ticagrelor to aspirin beyond 12 months for a period up to 3 years may be beneficial to reduce the rate of ischemic stroke. (IIb, B-R)
573
In individuals ≥70 years of age with at least 1 additional cardiovascular risk factor, the use of aspirin is not beneficial to prevent a first stroke. (III - No Benefit, A)
573
In patients with chronic kidney disease, the use of aspirin is not effective to prevent a first stroke. (III - No Benefit, B-NR)
573
Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Primary Prevention of Stroke
Authoring Organization
American Heart Association
Publication Month/Year
October 20, 2024
Last Updated Month/Year
November 5, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
The “2024 Guideline for the Primary Prevention of Stroke” replaces the 2014 “Guidelines for the Primary Prevention of Stroke.” This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke. The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.
Target Patient Population
Individuals who have not previously experienced a stroke or transient ischemic attack
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Long term care
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Prevention
Diseases/Conditions (MeSH)
D020521 - Stroke, D011322 - Primary Prevention
Keywords
primary prevention, stroke, Stroke Prevention, Ischemic Attack
Source Citation
Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, Creager MA, Eckel RH, Elkind MSV, Fornage M, Goldstein LB, Greenberg SM, Horvath SE, Iadecola C, Jauch EC, Moore WS, Wilson JA; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Functional Genomics and Translational Biology, and Council on Hypertension. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(12):3754-3832.
Supplemental Methodology Resources
Methodology
Number of Source Documents
735
Literature Search Start Date
April 1, 2023
Literature Search End Date
March 1, 2024