New guidelines focus on preventing first strokes through healthy living

Healthy lifestyle behaviors such as good nutrition, quitting smoking and being physically active, along with routine health screenings and controlling risk factors for cardiovascular disease and stroke with medications, can help prevent people from having a first stroke. Screening for stroke risk and educating people about how to reduce their risk of stroke ideally starts with their primary care physician and includes evidence-based recommendations, according to a new clinical guideline from the American Stroke Association, a division of the American Heart Association, and published today in the association’s journal Stroke.

A stroke occurs when blood flow to the brain is interrupted after a blood vessel becomes blocked by a blood clot or ruptures. The result is that the brain does not get the oxygen it needs to function properly. A stroke causes brain damage that can lead to significant disability, including problems with thinking, talking, walking and interacting with the environment. In the US, stroke is currently the fifth leading cause of death, causing nearly 160,000 deaths annually. More than 600,000 people in the US have a first stroke each year, even though up to 80% of strokes are preventable.

The most effective way to reduce the occurrence of stroke and associated mortality is to prevent the first stroke, also called primary prevention. Some populations are at increased risk of stroke, whether this is due to genetics, lifestyle, biological factors and/or social determinants of health, and in some cases people do not receive appropriate screening to identify their risk.”

Cheryl D. Bushnell, MD, MHS, FAHA, Chairman of the guideline writing group, professor and vice chairman of research in the department of neurology at Wake Forest University School of Medicine in Winston-Salem, North Carolina

The 2024 Guideline for the Primary Prevention of Stroke replaces the 2014 version and is an aid to clinicians implementing a variety of prevention strategies for individuals without a history of stroke. The new guideline provides evidence-based recommendations for strategies to support brain health and prevent strokes across a person’s lifespan by improving healthy lifestyle behaviors and receiving preventive care.

“This guideline is important because new discoveries have been made since the last update ten years ago. Understanding which people are at increased risk for a first stroke and providing support to maintain heart and brain health can help prevent a first stroke help prevent,” Bushnell said.

Key recommendations for stroke prevention include regular health examinations, identifying risk factors, lifestyle interventions, and medications, if indicated.

Identify and manage risk factors

Unidentified and unmanaged risk factors for cardiovascular disease can cause damage to blood vessels, the brain and the heart years before cardiovascular disease and stroke occur. Healthcare professionals should promote patients’ brain health through stroke prevention education, screenings, and addressing risk factors from birth through old age.

Modifiable risk factors for stroke, such as high blood pressure, overweight and obesity, elevated cholesterol, and elevated blood sugar, can be identified with physical exams and blood tests. These conditions should be addressed with healthy lifestyle and behavior changes and may include medications for selected patients. Antihypertensive medications to lower blood pressure and statin medications to lower cholesterol may help reduce the risk of a first stroke in adults at risk for cardiovascular disease and in those receiving cardiovascular care. A new recommendation is to consider glucagon-like protein 1 (GLP-1) receptor agonist medications, which are FDA-approved to reduce the risk of cardiovascular disease in people who are overweight or obese and/or type 2 diabetes .

Healthy lifestyle behavior

The most common, treatable lifestyle behaviors that can help reduce stroke risk are detailed in the Association’s Life’s Essential 8 cardiovascular health metrics. They include a healthy diet, regular exercise, avoiding tobacco, healthy sleep and weight, controlling cholesterol, and controlling blood pressure and blood sugar levels. The guideline recommends that adults without previous cardiovascular disease, as well as those at increased risk, follow a Mediterranean diet. Mediterranean diet programs have been shown to reduce the risk of stroke, especially when supplemented with nuts and olive oil.

Physical activity is also essential for reducing the risk of stroke and overall heart health. Physical activity can help improve important health measures such as blood pressure, cholesterol, inflammatory markers, insulin resistance, endothelial function and weight. The guideline urges healthcare professionals to routinely screen patients for sedentary behavior, a confirmed risk factor for stroke, and advise them to engage in regular physical activity. The association reinforces the recommendation from the U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion that adults get at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous-intensity aerobic activity, or a combination of both. preferably spread over the week.

Health equity and stroke risk

New in the guideline is the emphasis on social determinants of health and the impact they have on the risk of stroke. Social determinants of health are non-medical factors, including education, economic stability, access to care, discrimination, structural racism, and neighborhood factors (such as lack of walkability, lower availability of healthy food, and fewer health care services), that contribute to health care disparities and affect overall health. Healthcare professionals should ensure that patient education is available across educational and language levels, and advocate for their patients by choosing treatments and medications that are effective and affordable.

Healthcare professionals are also encouraged to connect patients with resources that help address health-related social needs, such as food and housing insecurity, refer them to programs that support healthy lifestyle changes, and alert them to support programs which can help cover healthcare costs, including medications. expenditure.

New sex and gender specific recommendations

The guideline also includes some new gender and sex-specific recommendations for women. Healthcare professionals should watch for conditions that may increase the risk of stroke in women, including use of oral contraceptives, high blood pressure during pregnancy, and other pregnancy complications such as preterm labor, endometriosis, premature ovarian failure, and premature menopause. Treatment of elevated blood pressure during pregnancy and within six weeks after delivery is recommended to reduce the risk of intracerebral hemorrhage in the mother.

Transgender women and gender diverse individuals who use estrogens to affirm their gender may also be at increased risk for stroke. Evaluation and modification of existing risk factors are necessary to reduce the risk of stroke for these individuals.

“Implementing the recommendations in this guideline would make it possible to significantly reduce the risk of people having a first stroke. “Most of the strategies we recommend for stroke prevention will also help reduce the risk of dementia, another serious health condition linked to vascular problems in the brain,” Bushnell said.

The writing group notes that writing recommendations aimed at preventing a first stroke has been challenging. There are limitations to some of the evidence underlying the guideline, including the fact that many clinical trials have enrolled adults who have already had a cardiovascular event, which may include a stroke. The writing group also identified knowledge gaps to help inform topics for future research.

The guideline emphasizes the need for risk assessment in primary stroke prevention and includes the use of risk prediction tools to estimate the risk of atherosclerotic cardiovascular disease so that patients receive timely prevention and treatment strategies. The association recently developed a new risk calculator Predicting Risk of Cardiovascular Disease Events (PREVENT) as a screening tool that can assist in making decisions about preventive treatments. The PREVENT calculator can estimate the risk of stroke and cardiovascular disease over 10 and 30 years in people over the age of 30 – a decade earlier than the Pooled Cohort Equations, another CVD risk calculator.

According to the American Stroke Association, learning the warning signs of a stroke and preventive measures are the best way to prevent strokes and prevent them from happening again. The acronym FAST – for facial droop, arm weakness, speech problems, time to call 911 – is a useful tool for recognizing the warning signs of a stroke and when to call for help.

This guideline was prepared by the volunteer group on behalf of the American Stroke Association and is endorsed by the Preventive Cardiovascular Nurses Association and the Society for Vascular Surgery. The American College of Obstetricians and Gynecologists supports the clinical value of this document as an educational tool.

Since 1990, the American Stroke Association has translated scientific evidence into clinical practice guidelines with recommendations to improve cerebrovascular health. The 2024 ‘Guideline for the Primary Prevention of Stroke’ replaces the 2014 ‘Guidelines for the Primary Prevention of Stroke’. This updated guideline is intended to help clinicians guide various prevention strategies in individuals without a history of stroke. The association supports the development and publication of clinical practice guidelines without commercial support, and members volunteer their time to write and review them.