New recommendations released on primary prevention of stroke

All individuals from birth to old age should have access to regular primary care visits to help promote brain health, according to the American Heart Association and American Stroke Association.

That and other recommendations are included in the organizations' 2024 Guideline for the Primary Prevention of Stroke, which replaces the 2014 guideline on this topic and is intended to help guide stroke prevention in patients without a history of stroke.

The guideline aligns with the American Heart Association's Life's Essential 8 and includes a section addressing each of these factors: diet quality, physical activity, weight and obesity, sleep, blood glucose levels, blood pressure, lipids, and tobacco use.

Regarding diet, the guideline recommends that adults with no cardiovascular disease (CVD) and those at high or intermediate CVD risk follow the Mediterranean diet. The guideline recommends regular to moderate vigorous physical activity and includes a new recommendation on screening for sedentary behavior and counseling patients to avoid being sedentary. It also adds a new recommendation for use of glucagon-like protein-1 receptor agonists in patients with diabetes who are at high cardiovascular risk or have established CVD.

Regarding blood pressure, the guideline recommends at least two antihypertensive medications in most patients whose hypertension requires pharmacological treatment, based on evidence from randomized controlled trials. In addition, antiplatelet therapy is recommended to prevent stroke in patients with antiphospholipid syndrome or systemic lupus erythematosus who do not have a history of stroke or unprovoked venous thromboembolism, the guideline said. Patients with antiphospholipid syndrome who have had a previous unprovoked venous thrombosis will likely benefit from vitamin K antagonist therapy with a target international normalized ratio of 2 to 3 rather than direct oral anticoagulants, according to the guideline.

Sex- and gender-specific recommendations are a new addition to this update. The guideline notes that prevention of pregnancy-related stroke can be achieved primarily by managing hypertension and recommends treatment of verified systolic blood pressure of 160 mm Hg or higher or diastolic blood pressure of 110 mm Hg or higher during pregnancy and within six weeks postpartum to reduce risk for fatal maternal intracerebral hemorrhage. The guideline also recommends screening for a history of adverse pregnancy outcomes that are associated with chronic hypertension and elevated stroke risk later in life.

Among other recommendations in this new section, the guideline notes that screening for endometriosis, premature ovarian failure (before age 40 years), and early-onset menopause (before age 45 years) is reasonable since all three conditions are associated with higher stroke risk. In addition, the guideline states that evaluating and modifying risk factors for stroke in transgender women taking estrogen could help reduce risk for stroke.

The guideline also includes recommendations for other specific populations, including patients with sickle cell disease, genetic stroke syndromes, coagulation and inflammatory disorders, and substance use and substance use disorders, among other topics. It was published by Stroke on Oct. 21.