The latest edition of the AHA/ASA (American Heart Association/American Stroke Association) guidelines for primary stroke prevention was recently published in the journal Stroke, with the aim of providing extensive and timely evidence-based recommendations for effective first-time stroke prevention. And this article will address each of these evidence-based recommendations, as follows.
In the United States, nearly 795,000 people suffer a stroke each year, of which approximately 60,000 are first-time episodes. Currently, stroke is ranked as the fourth leading cause of death in the United States. Globally, the incidence of stroke has decreased by 42% in high-income countries over the past 40 years, but has increased by more than 100% in low- and middle-income countries. Today, the incidence of stroke in low- and middle-income countries is much higher than in developed countries.
In addition, stroke is a major cause of functional impairment, which not only changes the life of the patient, but also the lives of family members and caregivers. Although patients with acute ischemic stroke can be treated with reperfusion therapy, for example, effective preventive measures are still the best way to reduce the burden of stroke. Given that more than 76% of strokes are first-episode, it is clear that primary prevention of stroke is particularly important. Therefore, this article summarizes the identified and newly discovered stroke risk factors and categorizes and elaborates on the evidence-based recommendations.
I. Assessment of first stroke risk (recommendations)
The use of stroke risk assessment tools (e.g. AHA/ACC
CV risk calculation tools) is justified because they help identify patients who can benefit from therapeutic interventions and those who cannot be treated with a single risk factor. These calculation tools, can alert clinicians and patients of possible risks, but treatment decisions need to be made with the overall patient risk in mind. (Class IIa recommendation; Level of evidence B)
II. Non-intervenable risk factors (age, sex, low birth weight, race, genetic factors)-recommendations
1. Ask about family history to help identify patients at increased risk of stroke; (Class IIa recommendation; Level of evidence Class A)
2. Genetic counseling may be considered recommended for stroke patients with rare genetic etiology; (Class IIb recommendation; Level of evidence Class C)
3, Fabry disease may be considered for enzyme replacement therapy, but it has not been shown to reduce stroke risk, while the effect is unknown; (Class IIb recommendation; Level of evidence Class C)
4. Non-invasive screening for unruptured intracranial aneurysms is reasonable in patients with more than 2 level 1 relatives with subarachnoid hemorrhage (SAH) or intracranial aneurysm (Class IIb recommendation; Level of evidence Class C)
5. Non-invasive screening for unruptured intracranial aneurysms should be considered in patients with AKDPD who have more than 1 relative with autosomal dominant polycystic kidney disease (AKDPD) with SAH or more than 1 relative with AKDPD with intracranial aneurysm; (Class IIb recommendation; Level of Evidence C)
6. Non-invasive screening for unruptured intracranial aneurysms should be considered in patients with fibromuscular dysplasia of the neck; (Class IIb recommendation; Level of Evidence C)
7. Pharmacologic dosing of vitamin K antagonists should be considered when initiating therapy; (Class IIb recommendation; Level of Evidence C)
8. Non-invasive screening for unruptured intracranial aneurysms is not recommended for patients with no more than 1 relative with SAH or intracranial aneurysm; (Class III recommendation; Level of evidence, Grade C)
9. For autosomal dominant polycystic kidney disease or Ehlers-Danlos
Non-invasive screening for unruptured intracranial aneurysms is not recommended for carriers of autosomal dominant polycystic kidney disease or Ehlers-Danlos type IV mutation; (Class III recommendation; Level of Evidence C)
10. Genetic screening for first stroke prevention in the general population is not recommended; (Class III recommendation; Level of evidence Class C)
11. Genetic screening for myopathy risk is not recommended when statin therapy is being considered; (Class III recommendation; Level of evidence Class C)
III. Detailed documented risk factors that can be intervened (recommendations)
(i) Lack of physical activity.
1. Physical activity is recommended because it is associated with a reduced risk of stroke; (Class I recommendation; Level of evidence B)
2. In healthy adults, moderate/intense aerobic exercise should be performed at least 3-4 times per week, each lasting at least 40 minutes; (Class I recommendation; Level of evidence Class B)
(II) Dyslipidemia.
1, 2013 “ACC/AHA Guidelines for Controlling Blood Cholesterol to Reduce the Risk of Atherosclerotic Cardiovascular Disease (ASCVD) in Adults” mentioned that for patients with a 10-year risk of cardiovascular events, in addition to lifestyle changes, HMG
Coenzyme A reductase inhibitors (statins) are recommended for primary prevention of ischemic stroke; (Class I recommendation; Level of evidence A)
2. Niacin therapy may be considered for patients with reduced high-density lipoprotein (HDL) cholesterol or elevated lipoprotein(a), but its effectiveness in preventing ischemic stroke in these patients is not known. Niacin is capable of increasing the risk of myopathy and should be used with caution; (Class IIb recommendation; Level of evidence B)
3. Fibrate derivatives may be considered for the treatment of patients with hypertriglyceridemia, but their effectiveness in preventing ischemic stroke is not clear; (Class IIb recommendation; Level of evidence Class C)
4. Lipid-lowering therapies other than statins, such as fibrate derivatives, bile acid chelators, niacin, and ezetimibe, may be considered for patients who cannot tolerate statins, but their effectiveness in preventing stroke has not been demonstrated; (Class IIb recommendation; Level of evidence Class C)
(iii) Diet and nutrition.
1. As recommended in the American Dietary Guidelines, sodium intake should be reduced and potassium intake increased to lower blood pressure (Class I recommendation; Level A of the evidence)
2, DASH diet (emphasizing the intake of fruits, vegetables and low-fat dairy products, and reducing saturated fatty acids) is recommended to reduce blood pressure; (Class I recommendation; Level A of the evidence)
3. A diet rich in fruits and vegetables is beneficial (increased potassium intake) and has the potential to reduce stroke risk; (Class I recommendation; level of evidence B)
4. A Mediterranean diet rich in nuts is likely to reduce the risk of stroke; (Class IIa recommendation; Level of evidence Class B)
(iv) Hypertension.
1. Routine screening for blood pressure and appropriate treatment of hypertensive patients by means of lifestyle changes and pharmacotherapy are recommended; (Class I recommendation; Level of evidence Class A)
2. For patients with prehypertension (systolic blood pressure 120-139 mmHg/diastolic blood pressure 80-89 mmHg), annual screening for hypertension and promotion of a healthy lifestyle are recommended; (Class I recommendation; Level of evidence A)
level)
3. Patients with hypertension requiring antihypertensive therapy should have a target blood pressure of less than 140/90 mmHg; (Class I recommendation; Level A of the evidence)
4. Successful blood pressure lowering is more important for stroke risk reduction than other factors and should be individualized; (Class I recommendation; Level of evidence Class A)
5. Self-measurement and self-monitoring of blood pressure are recommended to improve blood pressure control; (Class I recommendation; Level of evidence, Class A)
(E) Obesity and fat distribution.
1. For individuals who are overweight (BMI: 25-29 kg/m2) and obese (BMI >30 kmg/m2), it is recommended to reduce body weight so as to lower blood pressure; (Class I recommendation; Level of evidence A)
level)
2. For overweight and obese individuals, weight loss is recommended to reduce the risk of stroke (Class I recommendation; Level B of the evidence)
(vi) Diabetes mellitus.
1. For patients with type 1 and type 2 diabetes, blood pressure control is recommended, consistent with the AHA/ACC/CDC statement for hypertension management, i.e., <140/90 mmHg; (Class I recommendation; Level of Evidence A
level)
2. For patients with diabetes mellitus, especially those with other risks, statin therapy is recommended to reduce the risk of first stroke; (Class I recommendation; Level of Evidence A)
3. In patients with diabetes mellitus with low 10-year cardiovascular risk factors, the effect of aspirin in preventing first stroke is unknown (Class IIb recommendation; Level of Evidence B)
4. In patients with diabetes mellitus treated with statins, the combination of fibrates has no beneficial effect on stroke risk reduction; (Class III recommendation; Level of evidence Class B)
(vii) Smoking.
1. Combination of nicotine, bupropion, or varenicline as an adjunct to smoking cessation by counseling is recommended; (Class I recommendation; Level of evidence, Level A)
2. advise patients without a history of smoking not to smoke because of the correlation between smoking and ischemic stroke and subarachnoid hemorrhage based on epidemiologic studies; (Class I recommendation; Level of Evidence B)
3. community or statewide smoking cessation is reasonable in order to reduce the risk of stroke as well as heart attack; (IIa recommendation; Level of evidence B)
(viii) Atrial fibrillation/AF.
1, CHA2DS2-VASc
Patients with valvular AF with a score ≥2 have a higher risk of stroke and a lower risk of bleeding complications; long-term anticoagulation with oral warfarin and a target INR of 2.0-3.0 is recommended; (Class I recommendation; Level of evidence A
level)
2. For CHA2DS2-VASc
score ≥2, patients with non-valvular atrial fibrillation who are at low risk of developing bleeding complications are recommended for oral anticoagulant therapy (Class I recommendation). Options include warfarin (INR:2.0-3.0) (Level of Evidence A), dabigatranate (Level of Evidence B), apixaban (Level of Evidence B), and rivaroxaban (Level of Evidence B). Individualized selection of antithrombotic drugs is based on patient risk factors (especially in patients with risk of intracranial hemorrhage), cost, tolerability, patient preference, and potential drug-drug interactions.
3, In primary care facilities, patients >65 years of age should be proactively screened for AF, and pulse taking and subsequent ECG can be useful; (Class IIa recommendation; Level of Evidence B)
4, For patients with non-valvular AF with a CHA2DS2-VASc score of 0, it is reasonable to ignore antithrombotic therapy; (Class IIa recommendation; Level of Evidence B)
5. In patients with non-valvular AF with a CHA2DS2-VASc score of 1, the risk of developing bleeding complications is low and anticoagulation or aspirin therapy may be considered (Class IIb recommendation; Level of Evidence C). In addition, individualized antithrombotic drug selection is based on patient risk factors (especially in patients with intracranial hemorrhage), cost, tolerability, patient preference, and potential drug-drug interactions.
6. For high-risk AF patients who are not suitable for anticoagulation, left-ear occlusion may be considered; (Class IIb recommendation; Level of evidence B)
(ix) Other cardiac problems.
1, For patients with mitral stenosis with embolic events, anticoagulation is recommended; (Class I recommendation; Level of Evidence B)
2, For patients with mitral stenosis with left atrial thrombus, anticoagulation is recommended; (Class I recommendation; Level of Evidence B)
3. Warfarin (target INR: 2.0-3.0) and low-dose aspirin are recommended for patients undergoing aortic valve replacement (bileaflet mechanical valve) (Class I recommendation; Level of Evidence B); warfarin (target INR: 2.5-3.5) and low-dose aspirin are recommended for patients undergoing aortic valve replacement (mechanical valve) and risk factors (Class I recommendation; Level of Evidence B); Warfarin (target INR: 2.5-3.5) and low-dose aspirin are recommended for patients undergoing mitral valve replacement (mechanical valve) (Class I recommendation; Level of Evidence B). Risk factors include AF, thromboembolic events, left ventricular insufficiency, hypercoagulable state
4, Patients with atrial mucinous tumors, surgical resection is recommended for treatment (Class I recommendation; Level of Evidence C)
5.Recommended surgical treatment for elastic fibroids >1cm or appearing to move, even if asymptomatic; (Class I recommendation; Level of Evidence C)
6. Aspirin is reasonable for aortic or mitral valve replacement (biosynthetic valve) (Class IIa recommendation; Level of evidence, Grade B)
7. Warfarin therapy to achieve INR: 2.0-3.0 is reasonable in the first 3 months after aortic or mitral valve replacement (biosynthetic valve); (Class IIa recommendation; Level of Evidence C)
8, In patients with heart failure without a history of atrial fibrillation or thromboembolism, anticoagulation or antiplatelet agents are reasonable; (Class IIa recommendation; Level of Evidence A)
9. Vitamin K antagonist therapy is reasonable in patients with acute ST-segment elevation myocardial infarction and asymptomatic left ventricular appendage thrombosis; (Class IIa recommendation; Level of evidence Class C)
10, asymptomatic patients with left atrial diameter ≥55 mm and severe mitral stenosis as demonstrated by echocardiography may be considered for anticoagulation; (Class IIb recommendation; Level of Evidence B)
11, For patients with severe mitral stenosis and enlarged left atrium as demonstrated by echocardiography, anticoagulation may be considered; (Class IIb recommendation; Level of evidence Class C)
12, For patients with acute ST-segment elevation myocardial infarction (STEMI) combined with anterior apical wall loss of motion or inversion, anticoagulation may be considered; (Class IIb recommendation; Level of evidence Class C)
13. Anticoagulation is not recommended for patients with patent foramen ovale (PFO) as primary prevention of stroke; (Class III recommendation; Level of evidence Class C)
(x) Asymptomatic carotid stenosis.
1. Patients with asymptomatic carotid stenosis should follow medical advice and take aspirin or statins daily. Patients should be screened for other treatable stroke risk factors, treated appropriately and have lifestyle changes; (Class I recommendation; Level of evidence Class C)
2. In patients undergoing carotid endarterectomy (CEA), aspirin is recommended perioperatively and postoperatively, except when contraindicated; (Class I recommendation; Level of evidence Class C)
3. In asymptomatic patients with >70% internal carotid artery stenosis, it is reasonable to consider CEA if the risk of perioperative stroke, infarction, and death is low (<3%). However efficacy has not been established; (Class IIa recommendation; Level of evidence A)
4, In patients with atherosclerotic stenosis >50%, annual ultrasound Doppler examination by a technologist is reasonable to assess disease progression or regression and response to therapy; (Class IIa recommendation; Level of Evidence C)
5. For patients with highly selective asymptomatic carotid stenosis (≥60% angiographic stenosis and ≥70% ultrasound Doppler stenosis), prophylactic carotid stenting (CAS) may be considered, but its efficacy is not yet clear; (Class IIa recommendation; Level of Evidence B)
6. For asymptomatic patients at high risk of complications from carotid revascularization, the effectiveness of revascularization is not yet clear (Class IIb recommendation; Level of Evidence B)
7. Screening for asymptomatic carotid stenosis is not recommended for low-risk groups; (Class III recommendation; Level of evidence Class C)
(xi) Sickle cell disease/SCD
1. In children with SCD, ultrasound Doppler screening (TCD) is recommended after 2 years of age and repeated annually until 16 years of age; (Class I recommendation; Level of Evidence B)
2. For children at increased risk, blood transfusion therapy (hemoglobin S, down to less than 30%) is effective in reducing stroke risk; (Class I recommendation; Level of evidence B)
3. Although the optimal screening interval has not been determined, more frequent screening in younger children and in those with borderline abnormal TCD flow rates should be performed.
Although the optimal screening interval has not been determined, it is reasonable to screen younger children and those with borderline abnormal TCD flow rates more frequently to identify high-risk TCD indications requiring intervention (Class IIa recommendation; Level of Evidence B)
4. Continued transfusion may be justified even in patients with normalized TCD flow rates (Class IIa recommendation; Level of Evidence B)
5. It may be reasonable to consider hydroxyurea or bone marrow transplantation in children at high risk of stroke who are unable or unwilling to undergo regular red blood cell transfusion therapy (Class IIb recommendation; Level of Evidence B).
6. At present, the criteria for MRI and MRA screening of children requiring transfusion as primary stroke prevention have not been established, and therefore they are not recommended to replace TCD; (Class III recommendation; Level of evidence B)
level).
IV. Risk factors that have not been adequately identified and that are potentially amenable to intervention (recommendations)
(i) Migraine.
1. For women with migraine with aura, smoking cessation is strongly recommended (Class I recommendation; Level B of the evidence)
2. Alternative oral contraceptive pills (OCs) therapy (especially containing estrogen) may be considered for women with migraine with aura (Class IIb recommendation; Level of Evidence B)
3. Treatment to reduce the frequency of migraine may be a reasonable way to reduce the risk of stroke (Class IIb recommendation; Level C evidence)
4. Ovarian foramen occlusion is not recommended for stroke prevention in patients with migraine; (Class III, Level B)
(ii) Metabolic syndrome.
Recommended approaches for the management of metabolic syndrome, including: lifestyle (e.g., exercise, appropriate weight reduction, proper diet), pharmacotherapy (antihypertensive agents, lipid-lowering agents, glycemic control, and antiplatelet therapy), are mentioned in other sections of this guideline; (see specific recommendation categories and levels of evidence for each section)
(iii) Alcohol consumption.
1.According to the updated recommendations of the 2004 U.S. Preventive Services Task Force for heavy drinkers, alcohol consumption should be reduced or abstained from; (Class I recommendation; Level of Evidence A)
2. For drinkers, ≤2 drinks per day for men and ≤1 drink per day for nonpregnant women may be reasonable; (Class IIb recommendation; Level of Evidence B)
(iv) Substance abuse.
Referral to an appropriate treatment program for stroke related substance abusers (including: cocaine, amphetamines, khat) is reasonable (Class IIa recommendation; Level of Evidence C)
(v) Sleep disordered breathing.
1. Because sleep breathing disorders are associated with stroke risk, screening for sleep apnea by taking a detailed history is recommended; (Class IIb recommendation; Level of Evidence C)
2. It is reasonable to reduce the risk of stroke by treating sleep apnea, although its effectiveness in preventing first-degree stroke has not been established; (Class IIb recommendation; Level of evidence Class C)
(vi) Hyperhomocysteinemia.
B complex, pyridoxine (vitamin B6), cobalamin (vitamin B12), and folic acid may be considered for the prevention of ischemic stroke events in patients with hyperhomocysteinemia, but its effectiveness has not been demonstrated (Class IIb
Class II recommendation; Level of evidence B)
(vii) Elevated lipoprotein(a)/LP(a)
1. In patients with high LP(a), it may be reasonable to use niacin to reduce LP(a) and thereby prevent ischemic stroke, but the effect of niacin has not been demonstrated (Class IIb recommendation; Level of Evidence, Grade B)
2. The clinical benefit of using LP(a) to predict stroke risk has not been established; (Class IIb recommendation; Level of Evidence, Grade B)
(viii) Hypercoagulable states.
1. The effectiveness of using genetic screening instruments to detect hereditary hypercoagulable states and thereby prevent first stroke has not been established; (Class IIb recommendation; Level of evidence Class C)
2. The effectiveness of specific treatment to prevent first stroke in patients with asymptomatic hereditary or acquired embolism has not been established; (Class IIb recommendation; Level of evidence Class C)
3. Low-dose aspirin (81 mg/d) is not recommended for first stroke prevention in patients with persistent positive antiphospholipid antibodies; (Class III recommendation; Level of evidence Class B)
(ix) Inflammation and infection.
1. Patients with chronic inflammatory conditions (rheumatoid arthritis or systemic lupus erythematosus) should be considered at increased risk of stroke (Class I recommendation; Level of Evidence B)
2. Annual influenza vaccination is effective in reducing the risk of stroke in patients at high risk of stroke (Class IIa recommendation; Level of evidence, Grade B).
3. In patients without cardiovascular disease, inflammatory markers such as serum high-sensitivity C-reactive protein (hs-CRP) or lipoprotein-associated phospholipase A2 may be considered to identify increased risk of stroke, although their effects are not well established in routine clinical work; (Class IIb recommendation; Level of evidence, Class B)
4. Statins may be considered for the treatment of patients with hs-CRP >2.0 mg/dL, thereby reducing the risk of stroke; (Class IIb recommendation; Level of evidence B)
5. Antibiotics are not recommended for the treatment of chronic infections as one of the stroke prevention methods; (Class III recommendation; Level of evidence Class A)
V. Antiplatelet agents and aspirin.
1. The use of aspirin for prevention of cardiovascular disease (including stroke, but not specific to it) is reasonable, and in patients at high risk (10-year risk >10%), the benefits far outweigh the risks associated with treatment; (Class IIa recommendation; Level of Evidence A)
2. Aspirin (81 mg/day or 100 mg/every other day) can be used for first stroke prevention in women, including those with diabetes, where the benefits far outweigh the risks; (Class IIa recommendation; Level of evidence Class B)
3. Aspirin may be considered for the prevention of first stroke in patients with chronic kidney disease (glomerular rate filtration <45 ml/min/1.732m2) (Class IIb recommendation; Level of Evidence C). This recommendation does not apply to severe kidney disease (stages 4 and 5, glomerular rate filtration <30 ml/min/1.732m2)
4. cilostazol may be reasonable for first stroke prevention in patients with peripheral arterial disease; (Class IIb recommendation; Level of Evidence B)
5. For prevention of first stroke in low-risk individuals, aspirin is not effective (Class III recommendation; Level of evidence Class A)
6. Aspirin is not effective for the prevention of first stroke in patients with diabetes mellitus but without other risk factors (Class III recommendation; Level of evidence, Class A)
7. Aspirin is not effective for the prevention of first stroke in patients with diabetes mellitus with asymptomatic (ankle-arm pressure index ≤0.99) peripheral artery disease (Class III recommendation; Level of evidence, Class B).
8. The use of aspirin in other special cases (e.g., AF, carotid stenosis, etc.) has been discussed in the relevant section of this article;
9. Due to the lack of relevant clinical trials, antiplatelet agents other than aspirin and cilostazol are not recommended for first stroke prevention; (Class III recommendation; Level of evidence Class C)
VI. Primary prevention of stroke in the emergency room
1. Smoking cessation programs and interventions in the ED are recommended; (Class I recommendation; Level of evidence, Grade B)
2. Identification and anticoagulation assessment of AF in the ED is recommended (Class I recommendation; Level B)
3, It is reasonable to screen patients in the emergency room for hypertension; (Class IIa recommendation; Level of evidence Class C)
4. When a patient is found to have a drug or alcohol abuse problem, it is reasonable to refer him or her to an appropriate treatment program; (Class IIa recommendation; Level of evidence Class C)
5. The effectiveness of screening, brief interventions and treatment for diabetes, lifestyle (obesity, alcohol/substance abuse, sedentary lifestyle) within the emergency room setting has not been clarified; (Class IIb recommendation; Level of Evidence C)
VII. Preventive health services
Systematic identification and treatment of patients at risk of developing stroke through the implementation of appropriate programs is reasonable (Class IIa recommendation; Level of Evidence A).