Stroke prevention guidelines

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  • Risk calculators, such as that endorsed by the American Heart Association (AHA) and the American College of Cardiology (ACC), can be useful in assessing patients’ risk for stroke in a holistic context. However, these tools should not absolutely dictate treatment decisions for each individual patient.
  • Not all strokes are ischemic. Clinicians should consider noninvasive screening of the cerebral vasculature for patients with at least two first-degree relatives with a history of subarachnoid hemorrhage or intracranial aneurysms.
  • The minimal amount of exercise recommended to prevent stroke is 40 min/day at 3 to 4 days/week.
  • Statins should be first-line agents for stroke prevention among patients who meet the 10-year risk criteria for use of these drugs.
  • Niacin can raise high-density lipoprotein cholesterol levels, but it is unproven in preventing stroke. Similarly, fibric acid derivatives may not actually prevent stroke.
  • Hypertension should be treated to a goal blood pressure (BP) of less than 140/90 mm Hg to prevent stroke. Achieving target blood pressure is, in itself, more important than the types of medications used to treat hypertension.
  • However, evidence exists that reducing systolic BP to a target of less than 130 mm Hg may prevent more strokes.
  • Self-measured BP monitoring helps to reduce overall BP values and is recommended.
  • A graded positive relationship appears to exist between the degree of obesity and the risk for stroke, regardless of other cardiovascular risk factors. Weight loss reduces BP and blood glucose levels and has been demonstrated to reduce the risk for stroke in long-term research protocols.
  • Comorbid diabetes should not alter BP targets to prevent stroke, but these patients should preferentially receive a statin. The 10-year overall cardiovascular risk profile should be used to decide on aspirin prophylaxis for these patients; the presence of diabetes alone is less appropriate as an indication for aspirin therapy.
  • Dabigatran has been associated with lower risks for stroke and embolic events compared with warfarin, as well as a lower risk for intracranial hemorrhage, among patients with AF. However, dabigatran was associated with a higher risk of gastrointestinal bleeding vs warfarin. Dabigatran may also slightly increase the risk for myocardial infarction.
  • Rivaroxaban is more similar to warfarin in risk reduction for stroke or embolism among patients with AF, with a lower risk of serious bleeding.
  • Similarly, the benefit of apixaban vs warfarin in cases of AF is more marked for intracranial hemorrhage vs stroke prevention.
  • Economic analyses of the three new oral anticoagulants have generally been favorable.
  • The three new anticoagulants and warfarin can be considered for patients with AF and a CHA2DS2-VASc score of 2 or more. Treatment choice should be individualized based on patients’ risks of bleeding, tolerability, cost, and patient preference.
  • Patients with AF and a CHA2DS2-VASc score of 0 should not receive anticoagulant or aspirin therapy, and treatment may also be withheld among patients with a score of 1.
  • Patients with mitral stenosis and a previous embolic event should receive anticoagulant therapy. Even severe mitral stenosis with left atrial enlargement might serve as an indication for anticoagulants.
  • For patients who receive an aortic or mitral bioprosthesis, aspirin is sufficient in stroke prevention.
  • Patients with asymptomatic carotid stenosis should receive aspirin and a statin. Carotid endarterectomy may be considered if the level of stenosis exceeds 70% and the risk for serious perioperative morbidity and mortality is less than 3%, but the efficacy of endarterectomy vs modern medical therapy is not well established.
  • Risk stratification using transcranial Doppler ultrasound screening should be initiated at age 2 years for patients with sickle cell disease, and these patients should receive annual screening through age 16 years.
  • Migraine with aura has been associated with a higher risk for stroke among women. Women with migraine should be urged not to smoke and should consider other methods of contraception besides oral contraceptives.
  • Chronic inflammatory diseases, such as rheumatoid arthritis, should be considered risk factors for stroke.
  • Annual influenza vaccination may reduce the risk for stroke among high-risk adults.
  • Aspirin at a dose of 81 mg per day or 100 mg every other day remains recommended for patients at high risk for stroke, including those with chronic kidney disease. Aspirin should not be used to prevent stroke among patients whose sole risk factor is diabetes or asymptomatic peripheral artery disease.
  • According to the new guidelines on primary stroke prevention, aspirin at a dose of 81 mg per day or 100 mg every other day remains recommended for patients at high risk for stroke, including those with chronic kidney disease. Aspirin should not be used to prevent stroke among patients whose sole risk factor is diabetes or asymptomatic peripheral artery disease.
  • The new guidelines on primary stroke prevention state that warfarin, dabigatran, rivaroxaban, and apixaban may be recommended to prevent stroke among high-risk patients with AF. The main benefit of newer agents compared with warfarin is a reduction in the risk for intracranial hemorrhage.