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Health See other Health Articles Title: New Stroke Prevention Guidelines: A Quick and Easy Guide Medscape...Introduction On October 28, 2014, new guidelines [1] for the primary prevention of stroke were released by the American Heart Association (AHA)/American Stroke Association (ASA), updating the previous guidelines from 2011. The report points out that "76% of stroke are first events"—emphasizing the importance of primary prevention—and also that in a 6000-person case/control study, "10 potentially modifiable risk factors explained 90% of the risk of stroke." With this in mind, writing group members performed a thorough review of relevant literature, guidelines, personal files, and expert opinion to formulate the new document. What follows is a quick reference guide to the new guidelines. Assessing the Risk for First Stroke The Basics • Risk assessment tools are useful, but have limitations... • ...however, a treatment plan based on their results should consider the patient's overall risk profile. The Bottom Line: As the authors point out, stroke risk assessment tools aren't perfect; no one of them considers all possible factors potentially contributing to stroke. But they are useful at quantifying stroke risk. As mentioned in the guidelines, the AHA/ACC CV Risk Calculator is reasonable to consider. In patients who have had strokes or have multiple stroke risk factors, risk assessment tools might not be necessary, because this population often falls into the most aggressive medical management category. If the patient has atrial fibrillation (AF), the CHADS2 or CHA2DS2-VASc risk calculators can be helpful. • Family history is useful. • Rare genetic causes of stroke: consider genetic counseling. • Fabry disease: consider enzyme replacement therapy; note that effectiveness is unknown. • ≥2 first-degree relatives with subarachnoid hemorrhage (SAH) or intracranial aneurysms: consider noninvasive screening for unruptured intracranial aneurysms. • Autosomal dominant polycystic kidney disease (ADPKD) and ≥1 relatives with ADPKD and SAH, ≥1 relatives with ADPKD and intracranial aneurysm: consider noninvasive screening for unruptured intracranial aneurysms. • Cervical fibromuscular dysplasia: consider noninvasive screening for unruptured intracranial aneurysms. • Consider pharmacogenetic dosing of vitamin K antagonists when therapy is initiated. • Noninvasive screening for unruptured intracranial aneurysms is not recommended in patients with no more than 1 relative with SAH or intracranial aneurysm. • Screening for intracranial aneurysms in every carrier of autosomal dominant polycystic kidney disease or Ehlers-Danlos type IV mutations is not recommended. • Genetic screening of the general population is not recommended. • Genetic screening to determine myopathy risk is not recommended when considering statin therapy. The Bottom Line: Although genetic causes of stroke—including those, for example, related to age and race—are still generally nonmodifiable risks because gene therapy is not yet available, providing counseling for such diseases as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukencephalopathy (CADASIL) can be helpful to families with that disorder. Enzyme replacement therapy is available for Fabry disease, in which lipid metabolism is impaired, potentially increasing cardiovascular risk. Finally, identification of potential stroke risks, such as unruptured aneurysms, can be sought in selected instances. Physical Inactivity The Basics • Physical activity is recommended • Healthy adults: moderate- to vigorous-intensity aerobic activity at least 40 minutes per day, 3-4 days per week The Bottom Line: Many observational studies have shown the benefit of exercise in the reduction of stroke risk. People should seek out activities they enjoy; even walking, for example, has been shown to reduce the risk for stroke. The time spent exercising can be broken up for those who find it difficult to exercise for the full recommended times. Dyslipidemia The Basics • Lifestyle interventions High 10-year cardiovascular risk: Initiate statin therapy • Low high-density lipoprotein cholesterol or high lipoprotein (Lp) (a): Consider niacin, although efficacy in stroke prevention not established • Hypertriglyceridemia: Consider fibric acid derivatives, although efficacy in stroke prevention not established • If statin-intolerant: Consider other lipid-lowering therapies, although efficacy in stroke prevention not established The Bottom Line: Statin therapy is indicated in patients with higher 10-year cardiovascular risks, as determined by a cardiovascular risk calculator, to reduce the chance of atherosclerotic stroke. Since the current guidelines were published, additional data have also emerged for ezetimibe, an agent that prevents reabsorption of cholesterol in the intestine, in the prevention of heart disease and stroke. In the IMPROVE-IT trial,[2] a combination of ezetimibe and simvastatin prevented more heart- and stroke-related events than simvastatin alone. Ezetimibe may provide an option for statin-intolerant patients. Diet and Nutrition The Basics • Reduced sodium and increased potassium intake • DASH-style diet rich in fruits and vegetables • Consider Mediterranean diet supplemented with nuts The Bottom Line: Both the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean-style diets are associated with a reduced stroke risk. The DASH diet emphasizes fruits, vegetables, whole grains, low-fat dairy, fish, poultry, and vegetable oils, but limits sodium and saturated fats. The Mediterranean diet is similar, emphasizing primarily plant-based foods and healthy fats (eg, olive oil), but with allowances for occasional fish and poultry consumption and less frequent red meat consumption. Red wine in moderation can also be considered. Hypertension The Basics • Regular blood pressure (BP) screening • Appropriate hypertension treatment • Prehypertension (systolic BP of 120-139 mm Hg or diastolic BP of 80-89 mm Hg): Perform annual BP screening and lifestyle modifications • Hypertension: Treat to target < 140/90 mm Hg • BP reduction is more important in lowering stroke risk than choice of agent; individualize therapy • Self-monitoring is recommended The Bottom Line: As the new guidelines point out, "hypertension remains the most important, well-documented modifiable stroke risk factor," before going on to emphasize that treating hypertension is one of the most effective strategies for preventing both ischemic and hemorrhagic stroke. Although some studies have suggested that aggressive blood pressure treatment may be associated with worse outcomes in the frail elderly population, most support treating blood pressures that are over 140/90 mm Hg. If a patient presents with a systolic blood pressure greater than 160 mm Hg, consideration should be given to starting two antihypertensive agents at once, such as a diuretic and an angiotensin-converting enzyme (ACE) inhibitor. Obesity and Body Fat Distribution The Basics • Weight reduction in overweight and obese individuals The Bottom Line: Although it is difficult to prove that weight reduction directly lowers stroke risk, a large body of evidence supports an association between increased weight and a greater incidence of stroke. The guidelines recommend weight loss in overweight (body mass index, 25-29 kg/m2) and obese (body mass index > 30 kg/m2) individuals, in an effort to lower BP and reduce stroke risk. Diabetes The Basics • Type 1 or type 2 diabetes: Control BP, per AHA/ACC/CDC Advisory to target < 140/90 mm Hg • Treat adults with diabetes with a statin, especially in case of additional risk factors • Usefulness of aspirin for primary stroke prevention in those with diabetes but a low 10-year risk for cardiovascular disease is unclear • Add-on fibrate in those with diabetes is not useful in reducing stroke risk The Bottom Line: In people with diabetes, tight control of hypertension with an ACE inhibitor or angiotensin receptor blocker reduces stroke risk. Although it's unclear whether glycemic control reduces stroke risk in this population, data do suggest that statin therapy decreases the risk for a first stroke in patients with diabetes mellitus. Smoking The Basics • Counseling plus drug therapy • Abstinence in those who have never smoked The Bottom Line: There is a clear link between cigarette smoking and an increased risk for ischemic stroke and SAH. Data showing that smoking cessation programs reduce the incidence of stroke are lacking; however, epidemiologic findings suggest that quitting smoking is associated with a reduced risk for stroke. The new guidelines comment that community- or state-wide bans on smoking in public spaces are a reasonable means of reducing risk for stroke and myocardial infarction. Atrial Fibrillation The Basics • Valvular AF and high stroke risk (CHA2DS2-VASc score ≥ 2): Initiate long-term warfarin therapy; target international normalized ratio (INR), 2.0-3.0 • Nonvalvular AF, CHA2DS2-VASc score ≥ 2, and low risk for hemorrhagic complications: Individualize care and consider warfarin, dabigatran, apixaban, or rivaroxaban • AF screening in the primary care setting in those older than 65 years • Nonvalvular AF and CHA2DS2-VASc score of 0: reasonable to omit antithrombotic therapy • Nonvalvular AF, CHA2DS2-VASc score 1, and low risk for hemorrhagic complications: No antithrombotic therapy, anticoagulant therapy, or aspirin therapy can be considered; selection of antithrombotic agent should be individualized on the basis of patient risk factors • High-risk patients with AF who are unsuitable for anticoagulation: Consider left atrial appendage closure, if performed at a center with a low complication rate The Bottom Line: Selecting a stroke prevention strategy in patients with AFcan be challenging, given that the data are ever-changing and numerous therapies are available. However, risk stratification with CHA2DS2-VASc scores is helpful in determining stroke risk and selecting a course of action. The novel anticoagulants, including dabigatran, rivaroxaban and apixaban, should be considered in patients who may have a higher risk for intracerebral hemorrhage (ICH), because each of them has been associated with a lower risk for ICH than warfarin. Apixaban is the only one with a trend toward lower gastrointestinal bleeding than warfarin. Dosing needs to be selected carefully on the basis of the patient's renal function. Other Cardiac Conditions The Basics • Mitral stenosis and prior embolic event: anticoagulation • Mitral stenosis and left atrial thrombus: anticoagulation • Aortic valve replacement with bileaflet mechanical or current-generation, single-tilting-disk prostheses plus no risk factors: warfarin (INR 2.0-3.0) and low-dose aspirin • Mechanical aortic valve replacement and risk factors: warfarin (INR 2.5-3.5) and low-dose aspirin • Mitral valve replacement with any mechanical valve: warfarin (INR 2.5-3.5) and low-dose aspirin • Risk factors include AF, previous thromboembolism, left ventricular dysfunction, and hypercoagulable state • Atrial myxomas: Surgical excision recommended • Symptomatic fibroelastomas and those > 1 cm or that appear mobile: surgical intervention • Aortic or mitral valve replacement with a bioprosthesis: Aspirin is reasonable • Aortic or mitral valve replacement with a bioprosthesis: Warfarin is reasonable (INR 2.0-3.0) • Heart failure but no AF or previous thromboembolic event: Anticoagulants or antiplatelets are reasonable • ST-segment elevation myocardial infarction (STEMI) and asymptomatic left ventricular mural thrombi: Vitamin K antagonist therapy is reasonable • Asymptomatic patients with severe mitral stenosis and left atrial dimension ≥ 55 mm by echo: Consider anticoagulation • Severe mitral stenosis, an enlarged left atrium, and spontaneous contrast on echo: Consider anticoagulation • STEMI and anterior apical akinesis or dyskinesis: Consider anticoagulation • Patent foramen ovale (PFO): Antithrombotic therapy and catheter-based closure are not recommended for primary stroke prevention The Bottom Line: Certain cardiac conditions predispose patients to a high risk for embolism, and anticoagulation should be used for stroke prevention if possible. Such patients include those with mitral valve stenosis and thrombus or embolism, mechanical valves (sometimes with added aspirin), high-risk AF, and mural thrombi. Atrial myxomas and certain fibroelastomas merit consideration of surgical therapies, whereas for cardiac conditions other than infective endocarditis, either anticoagulation or antiplatelet therapy might be reasonable. Asymptomatic Carotid Stenosis The Basics • Asymptomatic carotid stenosis: statin plus daily aspirin; screen for and manage other stroke risk factors • Carotid endarterectomy (CEA): peri- and postoperative aspirin, unless contraindicated • Asymptomatic with > 70% stenosis of internal carotid artery: Consider CEA if perioperative risk for stroke, MI, and death is low (<3%) • > 50% stenosis: Repeat duplex ultrasonography annually to assess progression, regression, and treatment response • Consider prophylactic stenting in highly selected patients with asymptomatic stenosis (≥ 60% by angiography; ≥70% by validated Doppler ultrasonography) • Asymptomatic, but high risk for CEA or carotid artery stenting complications: Effectiveness of revascularization vs medical therapy is not well established • Screening low-risk populations for asymptomatic stenosis is not recommended The Bottom Line: Although such trials as ACAS[3] and ACST[4] have shown the benefit of endarterectomy compared with medical treatment for asymptomatic carotid stenosis in patients with low surgical risk, these trials were completed at a time when the use of preventive medications, such as statins and ACE inhibitors, was not optimized. The CREST-2 trial, funded by the National Institute of Neurological Disorders and Stroke, will compare medical management vs revascularization with endarterectomy or stenting and has started enrollment. Of note, the effectiveness of stenting in asymptomatic patients with over 70% stenosis and low risk for perioperative stroke, MI, or death has not been established. Sickle Cell Disease The Basics • Children with sickle cell disease (SCD): transcranial Doppler (TCD) screening started at age 2 years, then annually through age 16 years • Children with increased stroke risk: transfusion therapy targeting hemoglobin S < 30% • Screen younger children and those with borderline abnormal TCD velocities more frequently • Continued transfusion is probably reasonable, even after TCD velocities revert to normal • High stroke risk and unable or unwilling to be treated with periodic transfusions: Consider hydroxyurea or bone marrow transplantation • MRI and magnetic resonance angiography criteria for selecting patients for primary stroke prevention with transfusion are not established; therefore, they are not recommended in place of TCD for this purpose The Bottom Line: Although the optimal screening interval has not been established, TCD is the most validated method of assessing stroke risk in children with SCD and is used to guide treatment with exchange transfusion. Studies assessing the efficacy of hydroxyurea are in progress. No trials have been done in adults with SCD for the primary prevention of stroke. Migraine The Basics • Women with migraine plus aura: smoking cessation • Women with active migraines plus aura: Consider alternatives to oral contraceptives • Consider treatments that reduce migraine frequency • PFO closure not indicated for stroke prevention The Bottom Line: Several studies have linked migraine with an increased risk for ischemic stroke. However, the absolute risk is small, and the mechanism behind this relationship is unknown. The Metabolic Syndrome The Basics • Manage components of the metabolic syndrome (per other sections of this guideline) - Lifestyle modification - Pharmacotherapy The Bottom Line: As the guidelines discuss, individual components of the metabolic syndrome can increase stroke risk and should be managed appropriately. Medications and lifestyle changes are used to treat hypertension and hyperlipidemia and provide glycemic control, as they would for persons with individual risk factors. Alcohol and Drug Use The Basics • Heavy drinkers: Reduce or stop consumption • Persons who continue drinking: ≤ 2 drinks/day for men; ≤ 1 drink/day for nonpregnant women • Abusing drugs associated with stroke: therapeutic/rehabilitation program The Bottom Line: The relationship between alcohol and the brain is complex. Alcohol reportedly has antiatherogenic and anti-inflammatory effects and has been linked with improved cholesterol profiles, platelet and clotting function, and insulin sensitivity and a lower risk for both ischemic and hemorrhagic stroke.[5-9] However, the key seems to be moderation: The potential cardiovascular benefits of alcohol appear to come with mild to moderate consumption, whereas heavy consumption is associated with increased risk for hemorrhagic stroke[10] and more severe ischemic cerebral events.[11] As the guidelines point out, several drugs of abuse beyond alcohol are also associated with both ischemic and hemorrhagic strokes; these drugs include cocaine, khat, and amphetamines. However, there are no trials showing an association between abstinence from these compounds and reduced stroke risk. Sleep-Disordered Breathing The Basics • Consider sleep apnea screening • Treat sleep apnea The Bottom Line: Sleep apnea is thought to contribute to stroke. Although no randomized trial data exist demonstrating that treating sleep apnea is effective for primary stroke prevention, the guidelines suggest consideration of screening and treatment of sleep apnea, which is also associated with other medical conditions, especially hypertension. Hyperhomocysteinemia The Basics • Consider B-complex vitamins The Bottom Line: Homocysteine is an amino acid that at high levels can injure the endothelium and increase the risk for thrombosis and cardiovascular disease. Although effectiveness has not been established, the guidelines recommend considering cobalamin, pyridoxine, and folic acid for the prevention of stroke in persons with hyperhomocysteinemia. B-vitamin deficiencies can lead to elevated homocysteine levels. Elevated Lipoprotein(a) The Basics • Consider niacin • Benefit of Lp(a) levels in stroke prevention is not well established The Bottom Line: Lp(a) is a low-density lipoprotein (LDL)-like particle in which apolipoprotein B100 is linked to the glycoprotein apoprotein(a). Some genetic and epidemiologic studies suggest that Lp(a) is a risk factor for cardiovascular disease, including stroke. Hypercoagulability The Basics • Usefulness of genetic screening to detect inherited hypercoagulability for stroke prevention is not well established • Asymptomatic patients with hereditary or acquired thrombophilia: Usefulness of specific treatments for stroke prevention is not well established • Persistently antiphospholipid antibody-positive patients: Low-dose aspirin is not indicated for primary stroke prevention The Bottom Line: Hypercoagulable states are associated with venous thrombosis, but the guidelines point out that it's unclear whether they're also associated with cerebral arterial infarction. Although antiphospholipid antibodies have been associated with arterial thrombosis, studies to date have not shown that aspirin is indicated for primary prevention in the presence of persistent antiphospholipid antibodies. nflammation and Infection The Basics • Chronic inflammatory conditions: Consider these patients to have increased stroke risk • Annual flu vaccine • Inflammatory markers • High-sensitivity C-reactive protein (hs-CRP) > 2 mg/dL: Consider a statin • Antibiotics for chronic infections as means to prevent stroke are not recommended The Bottom Line: Inflammation plays a major role in stroke risk, affecting the formation, growth, and stability of atherosclerotic plaques. However, the utility of measuring inflammatory markers in assessing stroke risk is still being investigated. Patients with higher hs-CRP levels have increased risk for cardiovascular disease and stroke. The JUPITER study[12] randomly assigned people without cardiovascular disease and normal LDL cholesterol levels but hs-CRP levels > 2 mg/dL to receive a statin or placebo, and found a reduction in cardiovascular events and stroke in the statin-treated patients. However, because patients with lower hs-CRP levels were not included, it is unknown whether the CRP played a role, and the usefulness of hs-CRP and other inflammatory markers is not well established. Patients with chronic inflammatory conditions, including rheumatoid arthritis and systemic lupus erythematosus, should be considered to have an increased stroke risk and are a "subgroup...worthy of enhanced risk factor measurement and control." Antiplatelet Agents and Aspirin The Basics • 10-year cardiovascular risk > 10%: aspirin for cardiovascular prophylaxis • Aspirin (81 mg/day or 100 mg every other day) is useful in first stroke prevention in women, including those with diabetes, whose cardiovascular risk is sufficiently high • Chronic kidney disease (estimated glomerular filtration rate < 45 mL/min/1.73 m2): Consider aspirin in first stroke prevention (does not apply to severe kidney disease, in which estimated glomerular filtration rate <30 mL/min/1.73 m2) • Peripheral arterial disease: Consider cilostazol for first stroke prevention • Low-risk patients: Aspirin is not useful in first stroke prevention • Diabetes without other high-risk conditions: Aspirin is not useful in first stroke prevention • Diabetes plus asymptomatic peripheral arterial disease: Aspirin is not useful in first stroke prevention • Antiplatelet regimens other than aspirin and cilostazol are not recommended for first stroke prevention The Bottom Line: Although there is some support for the use of aspirin in the primary prevention of stroke in women, the benefits are small; if opting for aspirin therapy, the potential risks of stroke should outweigh the risks of aspirin use Prevention in the ED, and Preventive Services The Basics • Emergency department (ED)-based smoking interventions • Identify AF and anticoagulation evaluation • Hypertension screening • Refer to therapeutic program for problem alcohol or drug abuse • Implement programs to identify and treat risk factors in all patients at risk for stroke The Bottom Line: The ED can play a very important role in providing services that can contribute to stroke prevention. Basic assessments, such as blood pressure measurement and evaluation for an irregular heart rhythm, can alert patients and their providers to such entities as hypertension or AF that may require interventions. Although it might make a certain amount of intuitive sense, the effectiveness of ED-based screening, brief intervention, and referral for treatment of diabetes has not been established. The role of preventive health services cannot be overemphasized in the prevention of stroke and its related disabilities. It is the responsibility of providers at every point of contact to recognize opportunities to identify and modify potential risk factors. System changes are needed to help implement care coordination and serve our aging population Post Comment Private Reply Ignore Thread
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