Top Things to Know: 2024 Guideline for the Primary Prevention of Stroke

Published: October 21, 2024

  1. From birth to old age, every person should have access to and regular visits with a primary care health professional to identify and achieve opportunities to promote brain health.
  2. Screening for and addressing adverse Social Determinants of Health (SDoH) is important in the approach to prevention of incident stroke. This updated guideline includes an orientation to SDoH, acknowledging its impact on access to care and treatment of stroke risk factors. Therefore, screening for SDoH is recommended in care settings where at-risk stroke patients may be evaluated, with the acknowledgment that evidence-based interventions to address adverse SDoH are evolving.
  3. The Mediterranean Diet is a dietary pattern that has been shown to reduce the risk of stroke, especially when supplemented with nuts and olive oil. However, low-fat diets have had very little impact on reducing the risk. This guideline recommends that adults with no prior cardiovascular disease (CVD), as well as those with high or intermediate risk, adhere to the Mediterranean diet.
  4. Physical activity is essential for cardiovascular (CV) health and stroke risk reduction. This guideline includes a summary of high-quality data showing that prolonged sedentary behavior during waking hours is associated with an increased risk of stroke. Therefore, we provide a new recommendation for screening for sedentary behavior, and counseling patients to avoid being sedentary, as well as a call for new studies of interventions to disrupt sedentary behavior. This is in addition to the recommendation to engage in regular moderate-to-vigorous physical activity.
  5. Glucagon-like protein-1 (GLP-1) receptor agonists have been shown to be effective not only for improving management of Type 2 diabetes mellitus, but also for weight loss and lowering the risk of CVD and stroke. Based on this robust data, we provide a new recommendation for the use of these drugs in patients with diabetes and high CV risk or established CVD.
  6. Blood pressure (BP) management is critical for stroke prevention. RCTs have demonstrated that treatment with one antihypertensive medication is effective for reaching the BP goal in only about 30% of participants, and that the majority of participants achieved the goal with 2 or 3 medications. Therefore, two or more antihypertensive medications are recommended for primary stroke prevention in most patients who require pharmacologic treatment of hypertension.
  7. Antiplatelet therapy is recommended for patients with antiphospholipid syndrome (APS) or systemic lupus erythematosus without a history of stroke or unprovoked venous thromboembolism to prevent stroke. Patients with APS who have had a prior unprovoked venous thrombosis likely benefit from vitamin K antagonist therapy (target INR 2-3) over direct oral anticoagulants.
  8. Prevention of pregnancy-related stroke can be achieved primarily through management of hypertension. Treatment of verified systolic BP of ≥160 mm Hg or diastolic BP of ≥110 mm Hg during pregnancy and within 6 weeks post-partum is recommended to reduce the risk of fatal maternal intracerebral hemorrhage (ICH). In addition, adverse pregnancy outcomes are common and are associated with chronic hypertension and an elevated stroke risk later in life. Therefore, screening for these pregnancy outcomes is recommended to evaluate for and manage vascular risk factors, and a screening tool is included to assist with screening in clinical practice.
  9. Endometriosis, premature ovarian failure (before age 40), and early onset menopause (before age 45) are all associated with an increased risk for stroke. Therefore, screening for all three of these conditions are reasonable steps in the evaluation and management of vascular risk factors in these individuals to reduce stroke risk.
  10. Understanding transgender health is essential to truly inclusive clinical practice. Transgender women taking estrogens for gender affirmation have been identified as having an increased risk of stroke. Therefore, evaluation and modification of risk factors could be beneficial for stroke risk reduction in this population.

Citation


Bushnell C, Kernan WN, Sharrief AZ, Chaturvedi S, Cole JW, Cornwell WK 3rd, Cosby-Gaither C, Doyle S, Goldstein LB, Lennon O, Levine DA, Love M, Miller E, Nguyen-Huynh M, Rasmussen-Winkler J, Rexrode KM, Rosendale N, Sarma S, Shimbo D, Simpkins AN, Spatz ES, Sun LR, Tangpricha V, Turnage D; Velazquez G, Whelton P. 2024 Guideline for the primary prevention of stroke: a guideline from the American HeartAssociation/American Stroke Association. Stroke. Published online October 21, 2024. doi: 10.1161/STR.0000000000000475