Self-motivation for stroke prevention

Amid rising U.S. stroke rates, internal medicine physicians can provide a primary prevention bulwark, encouraging behavioral changes and prescribing preventive medications, including glucagon-like protein-1 (GLP-1) receptor agonists in eligible patients, according to the latest evidence-based guideline.

More than 600,000 Americans annually have a first stroke, with as many as 80% of strokes considered preventable. But while the prevalence of stroke decreased 3.7% from 2006 to 2010, it's since been on the upswing, increasing by 7.8% from 2011-2013 to 2020-2022, according to data published on May 23, 2024, in Morbidity and Mortality Weekly Report. Among racial and ethnic groups, Native American adults have the highest prevalence (5.3%), followed by Pacific Islander adults (4.4%) and Black adults (4.3%), with the lowest prevalence among Asian adults (1.6%). Adults without a high school diploma are three times more vulnerable to stroke than college graduates.

The American Heart Association/American Stroke Association (AHA/ASA) primary stroke prevention guideline, which was published in the December 2024 Stroke and had previously been updated in 2014, highlights the protective role of medication, including the cardiovascular benefits of GLP-1 receptor agonists, along with research showing that two or more medications are frequently needed to achieve blood pressure control. Guideline authors also provide sex- and gender-specific recommendations about screening for risk factors related to pregnancy and menopause.

Physicians should regularly screen for modifiable stroke risk factors, as well as any social determinants of health, beginning in young adulthood, said Walter Kernan, MD, FACP, a co-vice chair of the guideline's writing committee and a professor emeritus of medicine and senior research scientist at Yale School of Medicine in New Haven, Conn.

“Part of our effort as physicians is to recognize that stroke differentially affects different communities, for example, men and women and people of different economic means. For every community, however, we can do more to bridge the prevention gap for stroke,” Dr. Kernan said. “Our available treatments are not reaching nearly enough of those people who are eligible to receive them, so we get this gap between knowledge and practice.”

For instance, he noted, roughly half of American adults have hypertension. But one JAMA analysis he cited, published in 2020, found that only 43.7% have their blood pressure under control, with Black adults less likely than White adults—41.5% versus 48.2%, respectively.

Early prevention efforts also help counteract other risky trends, such as the rising rate of type 2 diabetes among adolescents and young adults, said Donna K. George, MD, director of the comprehensive stroke center at the Hospital of the University of Pennsylvania in Philadelphia. New type 2 diabetes diagnoses among those ages 10 to 19 years have increased by 5.3% annually from 2002 to 2018, with higher increases in Asian, Black, and Hispanic adolescents and young adults, according to data published in 2023 in Lancet Diabetes & Endocrinology.

“If you get diagnosed at age 20 or 25, and you have 10 years of uncontrolled diabetes, you're only in your 30s and you're at a very elevated stroke risk,” Dr. George said. “We see these patients admitted to the hospital who were diagnosed in their early 20s and they're only in their late 30s or 40s, and they have had a stroke.”

Sex, gender vulnerabilities

In female patients, risk factors related to reproduction can heighten stroke risk, according to the AHA/ASA guideline. Physicians should screen women for not only hypertensive disorders of pregnancy and other complications, including preeclampsia and eclampsia, but also a history of endometriosis and the age at which they reached menopause, the guideline said.

Endometriosis, premature ovarian failure (before age 40 years), and early-onset menopause (before age 45 years), either occurring naturally or following surgery, have been associated with an increased stroke risk, according to the guideline. That risk runs 32% higher among women who experience menopause before age 40 years, according to a meta-analysis cited by the guideline. But research gaps persist, including whether women with premature menopause benefit from hormone replacement therapy to reduce their long-term cardiovascular risk, the authors wrote.

While Dr. Kernan doesn't know of any risk calculators that incorporate these female risk factors, internal medicine physicians can still weigh early menopause and other aspects of a woman's reproductive history when treating hypertension, he said. “Everybody needs better attention paid to hypertension control,” he said. “But if a woman comes in with hypertension who says she had premature menopause, that's really somebody you don't want to be in that 50% who is uncontrolled.”

No clinical studies underpin that guidance, Dr. Kernan added. “We recognize that we're in an evidence-free zone here,” he said. “But it just seems to make sense.”

Patients with normal blood pressure who have a history of early menopause or adverse pregnancy outcomes can be educated about their heightened cardiovascular risk, to help motivate them to stay on top of exercise and other healthy habits, said Kathryn Rexrode, MD, MPH, an internal medicine physician who is chief of the division of women's health at Brigham and Women's Hospital and professor of medicine at Harvard Medical School in Boston. She coauthored a Circulation Research article in 2022 exploring the impact of sex and gender on stroke.

Reproductive factors such as preeclampsia or menopause before age 40 years are listed as enhancing risk for cardiovascular disease in the most recent guidance on cholesterol control from the American College of Cardiology/AHA Task Force on Clinical Practice Guidelines, published in Circulation in 2018. This could potentially influence the threshold for statin prescribing, and these risk factors could also tip the balance toward medication if a patient's blood pressure inches upward, Dr. Rexrode said. While similar treatment guidance has not been provided in the AHA/ASA stroke prevention guideline, that approach would be reasonable, she noted.

Studies also indicate that transgender women taking gender-affirming hormone therapy may be more vulnerable to stroke, and thus the therapy represents a risk factor, according to the AHA/ASA guideline. But related research is highly limited and there's a need “to define more precisely the potential risk, to identify the mechanisms driving this effect, and to assess interventions,” the guideline authors wrote.

It's unclear whether physicians should select the patient's biological or hormonal sex when calculating cardiovascular risk in transgender patients, such as by using the AHA's PREVENT calculator, Dr. Rexrode said. Until better data are available, to gain a more balanced sense of risk, physicians may consider running the calculation twice, using both male and female, she said.

Nonmedical influences

Since much of stroke prevention occurs outside the medical office, physicians should strive to learn more about a patient's education, economic stability, food access, experiences with racism, and other social determinants of health, according to the AHA/ASA guideline. With those insights, physicians can provide health education at the appropriate literacy level, select more cost-effective medications, and connect patients with resources to assist with food and housing insecurity, among other measures, the guideline authors wrote.

Telehealth's recent expansion has provided patients with an alternative if they lack transportation or face other obstacles to reaching the office, Dr. Kernan said. Other patients, he said, might prefer a phone call.

Bruce Ovbiagele, MD, FACP, suggested that primary care physicians delve further if they encounter a patient who appears unable to keep their blood pressure under control. Sometimes switching patients to mail order or introducing them to a case manager makes all the difference, said Dr. Ovbiagele, a professor of neurology and associate dean at the University of California, San Francisco.

“You can write the prescription again and again and again,” he said. “But it's not going to change the notion that the person lives too far away from where they are supposed to pick up the refills for that medication.”

Physicians have ramped up their efforts to screen for social risk factors, according to an analysis published on Jan. 3 in JAMA Network Open. In 2022, 27% of practices screened for five social risks—food insecurity, housing instability, utility needs, interpersonal violence, and transportation needs—compared with 15% in 2017.

But screening alone doesn't enable primary care physicians to resolve often intractable underlying challenges, said Sara K. Rostanski, MD, an assistant professor of neurology at NYU Grossman School of Medicine in New York City. “How do we translate that into helping patients? And frequently we are actually powerless to do so.”

As one example, she cited the emphasis on healthy sleep in the AHA's Life's Essential 8, which recommends seven to nine hours nightly for adults. But patients may work overnight shifts, making that goal more difficult, she said.

Primary care physicians can discuss good sleep hygiene strategies, such as maximizing sleep on days that patients aren't working and avoiding screens before bedtime. But sometimes, the hours may simply not add up, Dr. Rostanski said. “What if that person works at night because they take care of their kids during the day?”

Medication, motivation strategies

Among their new recommendations, the AHA/ASA guideline authors suggest that physicians consider prescribing GLP-1 receptor agonists in patients with diabetes and high cardiovascular risk, as well as those already diagnosed with cardiovascular disease. When these medications first became available, they were primarily prescribed by endocrinologists, Dr. George said. “But now there's a big push that all doctors who interact with patients who have cardiovascular and diabetes risk factors should be paying attention to these medications,” she said.

In addition, optimal blood pressure control frequently requires prescribing two or more medications, according to the guideline. Research shows that only 30% of patients reach their goal with a single medication.

Resist therapeutic inertia, Dr. Kernan stressed to his physician colleagues. “Don't let the patient leave the office until there's a plan for getting blood pressure to goal,” he said. “That plan might be to get more [blood pressure] values at home. The point is not to look at an abnormal value and do nothing.”

Prescribing a combination pill, with two blood pressure drugs in a single tablet, may not only be more effective, since it works on different mechanisms of action, but could risk fewer side effects, since physicians can prescribe each drug at a lower dose, Dr. George said. Plus, patients may be more amenable to taking fewer tablets each day, she said.

Other stroke prevention measures, which are rooted in behavioral change, may not be easy to achieve, depending on patients' circumstances, Dr. Rostanski said. Physicians can meet patients halfway by, for instance, not focusing on hours of formal exercise but rather brainstorming how they can boost daily movement, she said. Promote the benefits of taking the stairs and pulling weeds and doing other light gardening in the backyard.

Similarly, Dr. Rostanski steers clear of using dietary monikers, such as the Mediterranean diet, and instead talks about which foods patients should try to reduce or avoid, such as packaged goods and items that list trans fats.

One behavioral strategy, Dr. Kernan said, is to ask patients which prevention measures listed on the AHA's Essential 8 they would like to tackle first. “Say, ‘Look, you have a number of opportunities to improve the care of your brain and heart. For you, which one of these would you like to work on first?’ And then factor their preference into a plan of care.”

With patients who have a high Framingham Risk Score of 20% or more, physicians should check in to make sure they can describe the warning signs of stroke, as detailed by the ASA's F.A.S.T. educational tool, Dr. Ovbiagele said. They should also remind patients that seeking medical care quickly boosts their eligibility for drugs that may preserve brain function, he said.

“You have a captive audience,” he said. “That might be the last time they hear about that before, God forbid, they have the signs of a stroke.”

To encourage better stroke prevention habits, physicians can talk up other payoffs, such as the potential to reduce myocardial infarction risk, Dr. Kernan said. Limiting stroke risk factors, including diabetes, obesity, physical inactivity, and hypertension, also reduces the likelihood of developing dementia, according to findings from the Lancet Commission, he pointed out.

But fear of stroke alone can spur patients to become more proactive, Dr. Rexrode said. “Rightfully, many individuals recognize that a stroke is that thing that could cause them to have to be dependent on others, to lose their own function,” she said. “And that can be particularly motivating.”