AHA/ASA releases updated guidelines for primary prevention of stroke

The American Heart Association/American Stroke Association last week released updated guidelines on the primary prevention of stroke that included new recommendations on the use of statins, blood pressure management, and risk stratification for atrial fibrillation.

The guidelines are updated from the 2011 version. New recommendations include the following:

• In addition to recommending lifestyle changes, treat with statins those patients estimated to have a high 10-year risk for cardiovascular events (Class I recommendation, Level A evidence).
• Perform regular blood pressure screening on patients with hypertension, and treat with drug therapy and lifestyle modification. Perform annual screening for patients with prehypertension, i.e., systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg. Recommend that patients self-measure blood pressure to improve control (Class I recommendation, Level A evidence for all).
• For patients with valvular atrial fibrillation (AF), a CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease) score of ≥2, and an acceptably low risk of hemorrhagic complications, treat with warfarin at a target international normalized ratio (INR) of 2.0 to 3.0 (Class I recommendation, Level A evidence).
• For patients with nonvalvular AF, a CHA₂DS₂-VASc score of ≥2, and acceptably low risk of hemorrhagic complications, treat with oral anticoagulants (Class I recommendation). Options include warfarin at a target INR of 2.0 to 3.0 (Level A evidence), or dabigatran, apixaban, or rivaroxaban (Level B evidence for each). Drug selection should be individualized based on patient risk, including factors like cost, tolerability, patient preference, and potential for drug interactions.
• For patients with nonvalvular AF, a CHA₂DS₂-VASc score of 1, and acceptably low risk of hemorrhagic complications, consider no antithrombotic therapy, anticoagulant therapy, or aspirin (Class IIb recommendation, Level C evidence). For patients with nonvalvular AF and a CHA₂DS₂-VASc of 0, it's reasonable to omit antithrombotic therapy (Class IIa recommendation, Level B evidence).
• For patients with heart failure but no AF or previous thromboembolic event, anticoagulants or antiplatelets are reasonable (Class IIa recommendation, Level A evidence).
• Prescribe daily aspirin and a statin for patients with asymptomatic carotid stenosis. Also, screen these patients for other treatable risk factors for stroke, and institute appropriate medical therapies and lifestyle changes (Class I recommendation, Level C evidence).
• Strongly recommend smoking cessation for women with migraine headaches (Class I recommendation, Level B evidence). Consider alternatives to oral contraceptives (especially those containing estrogen) in women with active migraines with aura (Class IIb recommendation, Level B evidence).
• Recommend that healthy adults perform moderate-to-vigorous-intensity aerobic physical activity at least 40 minutes a day, 3 to 4 days a week (Class I recommendation, Level B evidence).

The guidelines, published online Oct. 28 by Stroke, are endorsed by the American Academy of Neurological Surgeons, the Congress of Neurological Surgeons, and Preventive Cardiovascular Nurses Association and are affirmed as a valuable educational tool by the American Academy of Neurology.