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UPDATED CLINICAL GUIDELINES PRIMARY PREVENTION OF STROKE
Stroke risk can be diminished by adopting specific lifestyles as part of a preventive care attitude. These have been incorporated in AHA´s Life´s Essential 8.
These strategies include the following:
➢ Quit tobacco
➢ Manage body weight
➢ Cholesterol control
➢ Blood sugar and blood pressure management
➢ Sleep well
➢ Healthy diet, and
➢ Keeping physical activity
RELEVANT ISSUES
Higher stroke rates are observed according to the presence of social determinants of health, such as:
➢ Lower levels of education
➢ Poor access to care
➢ Living in stressed geographical areas
➢ Socioeconomic disadvantage, and
➢ Lack of social support
Cognitive decline is a common consequence of stroke sequelae: disability and brain injury.
GLOBAL RISK FACTORS FOR STROKE
In some groups of patients, there is an elevated risk of stroke in apparent relation to specific factors such as:
➢ Endometriosis
➢ Early menopause
➢ Adverse pregnancy outcomes
➢ Systemic discrimination
➢ Inherited thrombophilia
➢ Sickle cell disease, and
➢ Access to care
(Just Class 1 and 2a of recommendation and Level A of evidence as per ACC/AHA guidelines are mentioned)
GENERAL RECOMMENDATIONS TO REDUCE RISK FOR STROKE
PATIENT ASSESSMENT AND DIET QUALITY
To estimate the risk for atherosclerotic cardiovascular disease (i.e., nonfatal stroke, among others) in people aged 40 to 79 years old every 1 to 5 years to guide the clinical approach.
A Mediterranean diet is recommended in adults without prior cardiovascular disease or at high to intermediate CVD risk.
In adults aged above 60 years old with uncontrolled blood pressure, with systolic blood pressure above 140 millimeters of mercury, and under treatment, salt substitution is recommended.
PHYSICAL ACTIVITY
Screening for physical activity is recommended in adults.
150 minutes of moderate-intensity or 75 minutes of high-intensity physical activity per week are advised. Additionally, to avoid excessive sedentary conduct, it is suggested to engage in aerobic exercise.
WEIGHT AND OBESITY
Screening for overweight and obesity is recommended in adults aged > 18 years old.
(According to recent data, stroke risk is enhanced by 10% for each 5 kg/m² increment of body mass index.)
GLYCEMIC LEVELS
In diabetic patients with high cardiovascular risk or established cardiovascular disease and A1c ≥7%, GLP-1 receptor agonist is suggested.
(Cumulative data from randomized clinical trials has demonstrated that GLP-1 receptor agonists diminish stroke risk.)
HYPERTENSION
In hypertensive patients (stage 2 / stage 1 with a higher risk of atherosclerotic cardiovascular disease), antihypertensive treatment to reach a goal of < 130/80 mmHg is recommended.
Suggested drugs as an initial approach are thiazide and thiazide-like diuretics/calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers.
≥2 antihypertensive drugs are indicated.
LIPIDS
In subjects on primary prevention of cardiovascular disease (CVD), eligible to receive lipid-lowering drugs, such as:
➢ 20-75 years old with LDL-C >190 mg/dL,
➢ 10-year atherosclerotic CVD risk ≥20% or
➢ 10-year ASCVD risk ≥7,5% - <20% plus ≥1 risk enhancer statin treatment is recommended.
At this moment, the effects of PCSK9 inhibitors on primary stroke prevention are not clear.
No evidence of reducing first-stroke risk by supplementing long-chain omega-3 fatty acids is available.
Additional studies are required to test the usefulness of bempedoic acid in this field.
TOBACCO USE
For active smokers, tobacco cessation pharmacotherapy along with behavioral counseling is currently recommended.
(Cigarette smoking is related to ischemic stroke and subarachnoid hemorrhage).
POINT OF VIEW
In the clinical setting, physicians are pivotal in providing preventive care to patients at risk of first stroke. A brief presented here about the guidelines for primary stroke prevention, recently delivered by Bushnell C et al. (AHA/American Stroke Association), is a contributing tool to help patients get a better quality of life.
