The American Heart Association and American Stroke Association (AHA/ASA) have updated guidelines on primary stroke prevention based on comprehensive and timely evidence from clinical investigations and research trials. Recommendations are included for controlling risk factors, using interventional approaches to atherosclerotic disease, and antithrombotic treatments for preventing stroke. The guidelines were published in Stroke and are available for free online at http://stroke.ahajournals.org.
“One of the most important changes in the AHA/ASA guidelines is that newer anticoagulants can be used as alternatives to warfarin to prevent stroke in patients with atrial fibrillation (AF),” says James F. Meschia, MD, FAHA, who chaired the AHA/ASA committee that developed the recommendations. The guidelines note that although some of the new AF drugs are more expensive, they require less ongoing monitoring and therefore represent reasonable options for patients.
Another key recommendation from the guidelines is that clinicians are urged to use of statins, along with diet and exercise, to help lower the stroke risk in patients at high risk for experiencing a stroke within the next 10 years. “In addition, the CHA2DS2-VASc is recommended for stratifying the risk for stroke,” says Dr. Meschia. “Patients with a score of 0 on the CHA2DS2-VASc do not require anticoagulants, but those with a score of 2 or higher should receive these therapies.” He adds that patients with a score of 1 on CHA2DS2-VASc can be considered for anticoagulants.
Women & Stroke
According to the AHA/ASA, women have higher stroke risks if they are pregnant, use oral contraceptives, use hormone replacement therapy, have migraines, and/or have depression. The guidelines recognize the different risk factors women face throughout their life. The update summarizes data behind these risk factors and treatments for them into an easy-to-use reference for clinicians. The AHA/ASA notes that efforts are needed to develop a female-specific stroke risk calculator to better provide accurate stroke risk assessment for women.
Controlling Blood Pressure
Elevated blood pressure (BP) continues to be one the most important modifiable risk factors for stroke. The guidelines emphasize the importance of lowering BP to reduce stroke risk. Reducing sodium intake and consuming a diet rich in potassium are strongly recommended to help control BP. Clinicians should to be vigilant about diagnosing hypertension as early as possible. Strategies for lowering risks for prehypertension (systolic BP between 120 and 140 mm Hg) are also discussed. Lifestyle changes are paramount for treating prehypertension and include consuming a diet rich in fruits, vegetables, nuts, and low-fat dairy products while keeping sodium intake low. Patients with prehypertension are also recommended to combine a healthy diet with vigorous aerobic activity 40 minutes per day, at least 3 to 4 days per week.
More to Come
The AHA/ASA guidelines for primary stroke prevention will continue to be updated as new data materializes. “The guidelines continue to stress the importance of informing patients about lifestyle interventions to reduce their stroke risk,” Dr. Meschia says. “In addition, it’s critical to treat conditions like AF and carotid artery disease, regardless of whether or not surgery is required. As new therapies and surgical procedures emerge, the guidelines will be updated to further assist clinicians in their efforts to prevent stroke in the future.”
Meschia JF, Bushnell C, Boden-Albala B, et al; 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. Stroke. 2014;45: 3754-3832. Available at: http://stroke.ahajournals.org/content/45/12/3754.
Jauch EC, Saver JL, Adams HP Jr, et al; on behalf of the American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2013;44:870–947.
Goldstein LB, Bushnell CD, Adams RJ, et al; on behalf of the American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Epidemiology and Prevention; Council for High Blood Pressure Research; Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:517-584.
Sacco RL. The new American Heart Association 2020 goal: achieving ideal cardiovascular health. J Cardiovasc Med (Hagerstown). 2011;12:255–257.