Guidelines issued for preventing first strokes

Prevention remains the best approach for reducing the burden of stroke, and at-risk people can be identified and targeted for specific interventions, according to guidelines from the American Heart Association and the American Stroke Association.

The new paper is a complete revision of the organizations' 2006 statement on strokes. The guidelines were published online on Dec. 6 by Stroke.

The guidelines included recommendations on how physicians should deal with patients' modifiable and nonmodifiable risk factors. Among the nonmodifiable factors, family history can be useful to identify those who may be at increased risk of stroke. Dosing with vitamin K antagonists on the basis of pharmacogenetics is not recommended. Genetic screening of the general population is not recommended, although referrals for genetic counseling may be considered for patients with rare genetic causes of stroke. Noninvasive screening for unruptured intracranial aneurysms in patients with a relative with subarachnoid hemorrhage or intracranial aneurysms was also not recommended, except in certain patients with particularly high-risk family histories.

The guidelines also found well-documented evidence for treating a number of modifiable risk factors, including blood pressure (to a goal of less than 140/90 mm Hg or 130/80 mm Hg in patients with diabetes or renal disease) and smoking (which should be addressed at every patient encounter). Physical activity (150 minutes of moderate exercise per week) and healthy eating (such as the DASH diet) are also recommended.

For patients with diabetes and hypertension, the guidelines suggest an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker; statins, especially in those with additional risk factors, to lower risk of a first stroke, and possibly monotherapy with a fibrate to lower stroke risk. Adding a fibrate to a statin is not useful for decreasing stroke risk, the guidelines said.

The guidelines also addressed the role of aspirin for primary stroke prevention, recommending that it be used for cardiovascular (including but not specific to stroke) prophylaxis in persons whose risk is sufficiently high for the benefits to outweigh the risks associated with treatment (a 10-year risk of cardiovascular events of 6% to 10%). They concluded that it is not useful for preventing a first stroke in low-risk people or persons with diabetes or diabetes plus asymptomatic peripheral artery disease in the absence of other established cardiovascular disease.