The latest edition of the AHA/ASA (American Heart Association/American Stroke Association) guidelines for primary stroke prevention, published recently in Stroke, aims to provide broad and timely evidence-based recommendations for effective first-time stroke prevention. 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 calculators) 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 Class B) II. Recommendations for non-interventional risk factors (age, sex, low birth weight, race, genetic factors) 1. Asking about family history can help identify patients at increased risk of stroke; (Class IIa recommendation; Level of evidence Class A) 2. For stroke patients with rare genetic causes, consider recommending genetic counseling; (Class IIb recommendation; Level of evidence Class C) ) 3. Enzyme replacement therapy may be considered for Fabry disease, 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. 7. Pharmacologic dosing of vitamin K antagonists should be considered when initiating therapy; (Class IIb recommendation, Level C of the evidence) 8. Non-invasive screening for unruptured intracranial aneurysms is not recommended in patients with no more than 1 relative with SAH or intracranial aneurysms; (Class III recommendation, Level C of the evidence) 9, Non-invasive screening for unruptured intracranial aneurysms is not recommended for carriers of autosomal dominant polycystic kidney disease or Ehlers-Danlos type IV mutations; (Class III recommendation; Level C of the evidence). 10. Genetic screening for first stroke prevention is not recommended for the general population; (Class III recommendation; Level C of the evidence). 11. Genetic screening for risk of myopathy is not recommended; (Class III recommendation; Level of evidence Class C) III. Documented risk factors for intervention (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 Class B) 2. Healthy adults, at least 3-4 times per week, should engage in at least 40 minutes of (b) Dyslipidemia: 1. The 2013 ACC/AHA Guidelines for Controlling Blood Cholesterol to Reduce the Risk of Atherosclerotic Cardiovascular Disease (ASCVD) in Adults mention 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 can increase 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 known; (Class IIb recommendation; Level of Evidence C) 4. Lipid-lowering therapies other than statins, such as fibrate derivatives, bile acid chelators, niacin, and ezetimibe (c) 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 evidence). 2. intake and reduce saturated fatty acids) to lower blood pressure; (Class I recommendation; Level of evidence Class A) 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 Class B) 4. A Mediterranean diet rich in nuts has the potential to reduce stroke risk; (Class IIa recommendation; Level of evidence Class B) (iv) Hypertension: 1. Routine screening for blood pressure and appropriate treatment of patients with hypertension by means of lifestyle changes and pharmacotherapy; (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 Class A) 3, Patients with hypertension require antihypertensive therapy with a target blood pressure of less than 140/90 mmHg; (Class I recommendation; Level of evidence Class A) 4. (e) Obesity and fat distribution: 1. For overweight (BMI: 25-29 kg/m2) and obese (BMI >30 kmg/m2) individuals, weight loss is recommended to reduce blood pressure; (Class I recommendation; Level of evidence, Level A) 2. (vi) Diabetes mellitus: 1. For patients with type 1 and type 2 diabetes mellitus, blood pressure control is recommended, consistent with the AHA/ACC/CDC Statement on the Management of Hypertension, i.e., <140/90 mmHg; (Class I recommendation; Level of evidence, Class A). 2. 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, Level B). 4. (Class I recommendation; Level A) 2. Patients without a history of smoking are advised not to smoke because of the correlation between smoking and ischemic stroke and subarachnoid hemorrhage based on epidemiologic studies; (Class I recommendation; Level B) 3. (viii) AF/AF: 1. Patients with valvular AF with a CHA2DS2-VASc score ≥2 are at higher risk for stroke and lower risk for 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, Level A) 2. Patients with non-valvular atrial fibrillation with a CHA2DS2-VASc score ≥2, who are at low risk of developing bleeding complications, oral anticoagulant therapy is recommended (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 play a role; (Class IIa recommendation; Level of Evidence B) 4. In 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 CHA2DS2 -Patients with non-valvular AF with a VASc score of 1 are at low risk of developing bleeding complications and may be considered for anticoagulation or aspirin therapy (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 patients with high-risk AF who are not candidates for anticoagulation, consider left-ear occlusion; (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. Level of Evidence B) 3. Warfarin (target INR: 2.0-3.0), as well as low-dose aspirin, is recommended for patients undergoing aortic valve replacement (bileaflet mechanical valve) (Class I recommendation; Level of Evidence B); warfarin (target INR: 2.5-3.5) with low-dose aspirin is recommended for patients undergoing aortic valve replacement (mechanical valve) as well as risk factors (Class I recommendation; Level of Evidence Level 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 B of the evidence). Risk factors include AF, thromboembolic events, left ventricular insufficiency, and hypercoagulable states. 4. Surgical resection is recommended for patients with atrial mucinous aneurysms (Class I recommendation; Level of Evidence C). 5. Surgery is recommended for the treatment of elastic fibroids >1 cm or appearing to move, even if asymptomatic (Class I recommendation; Level of Evidence C). 6. Aspirin for aortic or mitral valve replacement ( 7. Warfarin therapy to achieve an INR of 2.0-3.0 in the first 3 months after aortic or mitral valve replacement (biosynthetic valve) is reasonable; (Class IIa recommendation; Level of Evidence, Level C) 8. Class IIa recommendation; Level of evidence, Level A) 9, for patients with acute ST-segment elevation myocardial infarction and asymptomatic left ventricular appendage thrombosis, treatment with vitamin K antagonists is reasonable; (Class IIa recommendation; Level of evidence, Level C) 10, for asymptomatic patients with left atrial diameter ≥55 mm and severe mitral stenosis as demonstrated by echocardiography, anticoagulation may be considered; (Class IIb recommendation; Level of evidence, Level B) 11, Anticoagulation may be considered in patients with severe mitral stenosis and left atrial enlargement on echocardiography; (Class IIb recommendation; Level of evidence Class C) 12, Anticoagulation may be considered in patients with acute ST-segment elevation myocardial infarction (STEMI) combined with anterior apical wall loss of motion or inversion; (Class IIb recommendation; Level of evidence Class C) 13, Patients with unclosed foramen ovale (PFO) patients are not recommended for anticoagulation 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 given lifestyle changes; (Class I recommendation; Level of evidence Class C) 2. In patients undergoing carotid endarterectomy (CEA), aspirin is recommended perioperatively and postoperatively, except where contraindicated; (Class I recommendation; Level of evidence Class C) 3. the risk of perioperative stroke, infarction, and death is low (<3%), it is reasonable to consider CEA. 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. In patients with highly selective asymptomatic carotid stenosis (angiographic stenosis ≥60% and ≥70% stenosis by ultrasound Doppler), 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 efficacy of revascularization is not yet clear (Class IIb recommendation; Level of Evidence B) 7. In low-risk groups, it is not recommended to perform screening for asymptomatic carotid stenosis; (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 Class B) 2. For children at increased risk, transfusion therapy (hemoglobin S, down to less than 30%) 3. 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 B of the evidence). (Class IIa recommendation; Level of Evidence B) 5. Consideration of hydroxyurea or bone marrow transplantation may be reasonable for 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, Level 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 in place of TCD; (Class III recommendation; Level of Evidence, Level B). (i) Migraine: 1. For women with migraine with aura, smoking cessation is strongly recommended (Class I recommendation; Level B evidence). 2. Alternative oral contraceptive (OCs) therapy (especially containing estrogen) may be considered for women with migraine with aura (Class IIb recommendation; Level B evidence). 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, Pharmacologic therapies (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 use: 1. For heavy drinkers, reduce alcohol use or abstain from alcohol use, according to the 2004 U.S. Preventive Services Task Force update; (Category I recommendation; Level of Evidence A) 2. For drinkers, men (d) Substance abuse: Referral to an appropriate treatment program for stroke related substance abuse (including cocaine, amphetamines, khat) is reasonable (Class IIa recommendation; Level of Evidence C) (e) Sleep disordered breathing: 1. (vi) Hyperhomocysteinemia: B complex, pyridoxine (vitamin B6), cobalamin (vitamin B12), and cobalamin (vitamin B12). (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, Level B) (viii) Hypercoagulable states: 1. The effectiveness of using genetic screening to detect hereditary hypercoagulable states and thereby prevent first stroke has not been established; (Class IIb recommendation; Level of evidence, Level C) 2. The efficacy of specific therapy to prevent first stroke in patients with 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 B). 2. CRP) or lipoprotein-associated phospholipase A2 to identify increased stroke risk, although their effects are not well established in routine clinical workup; (Class IIb recommendation; Level of evidence B) 4. Consider statins to reduce stroke risk in patients with hs-CRP >2.0 mg/dL; (Class IIb recommendation; Level of evidence B) 5. Treatment of chronic infections as a method of stroke prevention; (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 Class A) 2. 2. Aspirin (81 mg/day or 100 mg/every other day) can be used for first stroke prevention in women, including diabetic patients, where the benefits far outweigh the risks; (Class IIa recommendation; Level of evidence Class B) 3. Aspirin can be considered for first stroke prevention in patients with chronic kidney disease (glomerular rate filtration <45 ml/min/1.732 m2) (Class IIb recommendation; Level of evidence Grade C). This recommendation does not apply to severe renal 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 Class B). 5. Aspirin is not effective for first stroke prevention in individuals at low risk (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 lacking other risk factors (Class III recommendation; Level of Evidence, Class A) 7. 9. Due to the lack of clinical trials, antiplatelet agents other than aspirin and cilostazol are not recommended for first-time stroke prevention (Class III recommendation; Level C evidence). 2. Identification and anticoagulation evaluation for AF is recommended in the ED; (Class I recommendation; Level of evidence, Level B) 3. Screening patients for hypertension in the ED is reasonable; (Class IIa recommendation; Level of evidence, Level C) 4. The effectiveness of screening, brief interventions and treatment for diabetes, lifestyle (obesity, alcohol/substance abuse, sedentary lifestyle) in the emergency room setting has not been established; (Class IIb recommendation; Level C of the evidence). vii. Preventive health services It is reasonable to systematically identify and treat patients at risk for stroke through the implementation of appropriate programs (Class IIa recommendation; Level A of the evidence). Level A).