SUMMARY:

After 10 years, the American Heart Association and American Stroke Association come together to provide updated guidelines on primary stroke prevention. 600,000 Americans suffer a first stroke each year, and over half could be prevented with better risk factor control. With an emphasis on social determinants of health, the updated guideline provides recommendations to aid primary care clinicians as well as administrators and policymakers in closing the prevention gap for primary stroke events. Please see original guidelines under “Learn More” below for level of evidence behind each recommendation.

KEY POINTS:

• Adverse social determinants of health play a major role in stroke risk.
  • Incorporate screening and community support to address these non-medical risk factors for first stroke
• Assess ASCVD risk every 1-5 years in adults 40-79 years of age
• Use CHA2DS2-VASc score to guide anticoagulation use in individuals with atrial fibrillation (AF)
• Periodically screen for stroke risk factors in all adults ≥18 years of age T such as hypertension | cigarette smoking | diabetes | dyslipidemia | physical inactivity | sleep disorders | SDOH
• AHA/ASA organizes evidence-based health behaviors to lower risk of stroke and cardiovascular disease into eight categories (“Life’s Essential 8”): diet | physical activity | BMI | sleep health | blood glucose | blood pressure | lipids | nicotine exposure
• Continued recommendations include following a Mediterranean diet, routine physical activity, statin use for qualifying patients and tobacco cessation/abstinence
• Notable new recommendations for primary stroke prevention:
  • Limiting sedentary behavior
  • GLP-1 use for diabetics and those with high CV risk
  • Routine use of ≥2 antihypertensive medications for most patients who require pharmacologic treatment of hypertension due to RCTs that show BP control in only 30% of patients on medication  

Disease-Specific Recommendations

Asymptomatic carotid artery stenosis
Asymptomatic cerebral small vessel disease (CSVD)
Migraine, with or without aura
Sickle cell disease (SCD)
Genetic stroke syndromes
Recent MI
Autoimmune
Malignancy
Infection
Heavy alcohol and illicit drug use (including cannabis)
Pregnancy
Contraception
Menopause
Transgender women
Hypogonadism
Heart Disease
Antiplatelets

Asymptomatic carotid artery stenosis

• Do not routinely screen for carotid artery stenosis in asymptomatic patients to reduce stroke risk.
• If stenosis is >70%, shared decision-making on whether medical management (HIS[RK2]  statin use) and/or revascularization is the best option
• If stenosis >50% consider annual monitoring

Asymptomatic cerebral small vessel disease (CSVD)

• Definition: radiographic evidence of white matter hyperintensities | recent small subcortical infarct | lacune of presumed vascular origin| cerebral microbleeds | enlarged perivascular spaces| cerebral atrophy
• If patients do not otherwise qualify for statin use, consider low-intensity statins
• Unclear if the use of aspirin or other antiplatelet therapy outweighs the risks

Migraine, with or without aura

• Known to increase stroke risk
• Mitigate other risk factors (ie tobacco use, hypertension)
• Avoid estrogen-containing contraception in favor of progesterone-only or nonhormonal methods.

Sickle cell disease (SCD)

• Perform transcranial Doppler (TCD) for children ages 2-16 yo
  • Increased velocity on TCD is correlated with increased stroke risk
  • If TCD demonstrates increased risk, treatment options include blood transfusions or hydroxyurea

Genetic stroke syndromes

• Examples: Fabry disease and hereditary hemorrhagic telangiectasia
• Require additional screening and multidisciplinary care to reduce stroke risk.

Recent MI

• Consider adding low dose colchicine to intensive statin therapy

Autoimmune

• Use antiplatelet therapy for patients with antiphospholipid syndrome or SLE.
• No strong disease-specific recommendations for most other autoimmune conditions

Malignancy

• Too variable to make broad recommendations for stroke risk reduction among cancer patients.

Infection

• Transient increased stroke risk may be mitigated with good dental hygiene in the case of periodontal disease.

Heavy alcohol and illicit drug use (including cannabis)

• Increases stroke risk independent of other cardiovascular risk factors
• Screen for and treat substance use disorders

Pregnancy

• Pregnant or early postpartum (within 6 weeks of delivery):
  • BP-lowering treatment to a target <160/110 mm Hg as soon as possible is recommended to reduce the risk of fatal maternal ICH
• For all hypertensive disorders of pregnancy (HDP), a treatment goal of <140/90 mm Hg is reasonable to reduce risk of pregnancy-associated stroke.
• Clinicians should screen for a history of adverse pregnancy outcomes i.e. HDP | preterm birth | gestational diabetes | placental disorders since these are associated with an increased risk of chronic hypertension and stroke later in life.

Contraception

• Use the lowest effective dose of estrogen
• Avoid estrogen-containing contraception in those with specific stroke risk factors:
  • Age >35 years
  • Tobacco use
  • Hypertension
  • Migraine with aura

Menopause

• Endometriosis, premature ovarian failure (before 40 years of age), and early-onset menopause (before 45 years of age) are all associated with an increased risk for stroke.
  • Evaluate and modify concurrent stroke risk factors in such patients
• Use shared decision-making to continue estrogen replacement in postmenopausal women if:
  • ≥60 years of age
  • More than 10 years after natural menopause
  • Have other factors increasing their risk of stroke

Transgender women

• Estrogen use increases stroke in this population
• Evaluate and modify concurrent stroke risk factors in such patients

Hypogonadism

• Testosterone can safely be continued in patients with confirmed hypogonadism and does not itself confer additional stroke risk

Heart Disease

• Anticoagulation is no longer indicated to reduce stroke risk in this population.
• Stroke prevention in atrial fibrillation | valvular heart disease| congenital heart disease| acute MI covered in other recent and more specific guidelines

Antiplatelets

• Avoid aspirin in:
  • Adults ≥70 years of age
  • Individuals of any age with CKD
• Its effectiveness in younger patients with diabetes or other vascular risk factors is not well established.
• Long-term dual-antiplatelet therapy with ticagrelor and aspirin may be beneficial to reduce risk of ischemic stroke in patients with established, stable CAD and low bleeding risk.

Learn More – Primary Sources 

2024 Guideline for the Primary Prevention of Stroke: A Guideline from the American Heart Association and American Stroke Association