Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]
2014 AHA/ASA Guidelines for the Primary Prevention of Stroke[1]
Genetic Factors: Recommendations
Physical Inactivity: Recommendations
| Class I
|
| "1.Physical activity is recommended because it is associated with a reduction in the risk of stroke (Level of Evidence: B)"
|
| "2. Healthy adults should perform at least moderate- to vigorous-intensity aerobic physical activity at least 40 min/d 3 to 4 d/wk(Level of Evidence: B)"
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Dyslipidemia: Recommendations
| Class I
|
| "1. In addition to therapeutic lifestyle changes, treatment with an HMG coenzyme-A reductase inhibitor (statin) medication is recommended for the primary prevention of ischemic stroke in patients estimated to have a high 10-year risk for cardiovascular events as recommended in the 2013 “ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults” (Level of Evidence: A)"
|
| Class IIb
|
| "1. Niacin may be considered for patients with low HDL cholesterol or elevated Lp(a), but its efficacy in preventing ischemic stroke in patients with these conditions is not established. Caution should be used with niacin because it increases the risk of myopathy (Level of Evidence: B)"
|
| "2. Fibric acid derivatives may be considered for patients with hypertriglyceridemia, but their efficacy in preventing ischemic stroke is not established(Level of Evidence: C)"
|
| "3. Treatment with nonstatin lipid-lowering therapies such as fibric acid derivatives, bile acid sequestrants, niacin, and ezetimibe may be considered in patients who cannot tolerate statins, but their efficacy in preventing stroke is not established (Level of Evidence: C)"
|
Diet and Nutrition: Recommendations
| Class I
|
| "1. Reduced intake of sodium and increased intake of potassium as indicated in the US Dietary Guidelines for Americans are recommended to lower BP (Level of Evidence: A)"
|
| "2. A DASH-style diet, which emphasizes fruits, vegetables, and low-fat dairy products and reduced saturated fat, is recommended to lower BP (Level of Evidence: A)"
|
| "3. A diet that is rich in fruits and vegetables and thereby high in potassium is beneficial and may lower the risk of strok (Level of Evidence: B)"
|
Hypertension: Recommendations
| Class I
|
| "1. Regular BP screening and appropriate treatment of patients with hypertension, including lifestyle modification and pharmacological therapy, are recommended (Level of Evidence: A)"
|
| "2. Annual screening for high BP and health-promoting lifestyle modification are recommended for patients with prehypertension (SBP of 120 to 139 mmHg or DBP of 80 to 89 mm Hg) (Level of Evidence: A)"
|
| "3. Patients who have hypertension should be treated with antihypertensive drugs to a target BP of <140/90 mm Hg (Level of Evidence: A)"
|
| "4. Successful reduction of BP is more important in reducing stroke risk than the choice of a specific agent, and treatment should be individualized on the basis of other patient characteristics and medication tolerance (Level of Evidence: A)"
|
| "5. Self-measured BP monitoring is recommended to improve BP control. (Level of Evidence: A)"
|
Obesity and Body Fat Distribution: Recommendations
| Class I
|
| "1. Among overweight (BMI=25 to 29 kg/m2) and obese (BMI >30 kg/m2) individuals, weight reduction is recommended for lowering BP (Level of Evidence: A)"
|
| "2.Among overweight (BMI=25 to 29 kg/m2) and obese (BMI >30 kg/m2) individuals, weight reduction is recommended for reducing the risk of stroke (Level of Evidence: B)"
|
Diabetes: Recommendation
| Class I
|
| "1. Control of BP in accordance with an AHA/ACC/ CDC Advisory218 to a target of <140/90 mm Hg is rec- ommended in patients with type 1 or type 2 diabetes mellitus (Level of Evidence: A)"
|
| "2.Treatment of adults with diabetes mellitus with a statin, especially those with additional risk factors, is recommended to lower the risk of first stroke (Level of Evidence: A)"
|
Cigarette Smoking: Recommendations
| Class I
|
| "1.Counseling, in combination with drug therapy using nicotine replacement, bupropion, or varenicline, is recommended for active smokers to assist in quitting smoking (Level of Evidence: A)"
|
| "2.Abstention from cigarette smoking is recommended for patients who have never smoked on the basis of epidemiological studies showing a consistent and overwhelming relationship between smoking and both ischemic stroke and SAH (Level of Evidence: B)"
|
Atrial Fibrillation: Recommendations
| Class I
|
| "1. For patients with valvular AF at high risk for stroke, defined as a CHA2DS2-VASc score of ≥2 and accept- ably low risk for hemorrhagic complications, long- term oral anticoagulant therapy with warfarin at a target INR of 2.0 to 3.0 is recommended (Level of Evidence: A)"
|
| "2.For patients with nonvalvular AF, a CHA2DS2-VASc score of ≥2, and acceptably low risk for hemorrhagic complications, oral anticoagulants are recommended. Options include:
The selection of antithrombotic agent should be individualized on the basis of patient risk factors (particularly risk for intracranial hemorrhage), cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including the time that the INR is in therapeutic range for patients taking warfarin.
|
| Class IIb
|
| "1. For patients with nonvalvular AF, a CHA2DS2-VASc score of 1, and an acceptably low risk for hemorrhagic complication, no antithrombotic therapy, anticoagulant therapy, or aspirin therapy may be considered (Level of Evidence: C)"
The selection of antithrombotic agent should be individualized on the basis of patient risk factors (particularly risk for intracranial hemorrhage), cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including the time that the INR is in the therapeutic range for patients taking warfarin.
|
| "2. Closure of the LAA may be considered for high-risk patients with AF who are deemed unsuitable for anticoagulation if performed at a center with low rates of periprocedural complications and the patient can tolerate the risk of at least 45 days of post procedural anticoagulation (Level of Evidence: B)"
|
Other Cardiac Conditions: Recommendations
Asymptomatic Carotid Stenosis: Recommendations
| Class I
|
| "1. Patients with asymptomatic carotid stenosis should be prescribed daily aspirin and a statin. Patients should also be screened for other treatable risk factors for stroke, and appropriate medical therapies and lifestyle changes should be instituted (Level of Evidence: C)"
|
| "2. In patients who are to undergo CEA, aspirin is recommended perioperatively and postoperatively unless contraindicated (Level of Evidence: C)"
|
| Class IIa
|
| "1. It is reasonable to consider performing CEA in asymptomatic patients who have >70% stenosis of the internal carotid artery if the risk of periopera- tive stroke, MI, and death is low (<3%). However, its effectiveness compared with contemporary best medical management alone is not well established (Level of Evidence: A)"
|
| "2. It is reasonable to repeat duplex ultrasonography annually by a qualified technologist in a certified laboratory to assess the progression or regression of disease and response to therapeutic interventions in patients with atherosclerotic stenosis >50% (Level of Evidence: C)"
|
| Class IIa
|
| "1. Prophylactic CAS might be considered in highly selected patients with asymptomatic carotid stenosis (minimum, 60% by angiography, 70% by validated Doppler ultrasound), but its effectiveness compared with medical therapy alone in this situation is not well established (Level of Evidence: B)"
|
| "2. In asymptomatic patients at high risk of complications for carotid revascularization by either CEA or CAS, the effectiveness of revascularization versus medical therapy alone is not well established (Level of Evidence: B)"
|
Sickle Cell Disease: Recommendations
| Class I
|
| "1. TCD screening for children with SCD is indicated starting at 2 years of age and continuing annually to 16 years of age (Level of Evidence: B)"
|
| "2. Transfusion therapy (target reduction of hemoglobin S, <30%) is effective for reducing stroke risk in those children at elevated risk (Level of Evidence: B)"
|
| Class III (Harm)
|
| "1. MRI and MRA criteria for selection of children for primary stroke prevention with transfusion have not been established, and these tests are not recommended in place of TCD for this purpose (Level of Evidence: B)"
|
| Class IIa
|
| "1. Although the optimal screening interval has not been established, it is reasonable for younger children and those with borderline abnormal TCD velocities to be screened more frequently to detect the development of high-risk TCD indications for intervention (Level of Evidence: B)"
|
| "2. Pending further studies, continued transfusion, even in those whose TCD velocities revert to normal, is probably indicated (Level of Evidence: B)"
|
Migraine: Recommendations
Alcohol Consumption: Recommendations
| Class I
|
| "1. Reduction or elimination of alcohol consumption in heavy drinkers through established screening and counseling strategies as described in the 2004 US Preventive Services Task Force update is recommended (Level of Evidence: A)"
|
| Class IIb
|
| "1. For individuals who choose to drink alcohol, con- sumption of ≤2 drinks per day for men and ≤1 drink per day for nonpregnant women might be reasonable (Level of Evidence: B)"
|
Drug Abuse: Recommendation
Sleep-Disordered Breathing: Recommendations
| Class IIb
|
| "1. Because of its association with stroke risk, screening for sleep apnea through a detailed history, including structured questionnaires such as the Epworth Sleepiness Scale and Berlin Questionnaire, physical examination, and, if indicated, polysomnography may be considered (Level of Evidence: C)"
|
| "2. Treatment of sleep apnea to reduce the risk of stroke may be reasonable, although its effectiveness for primary prevention of stroke is unknown (Level of Evidence: C)"
|
Hyperhomocysteinemia: Recommendation
Elevated Lp(a): Recommendations
| Class IIb
|
| "1. The use of niacin, which lowers Lp(a), might be reasonable for the prevention of ischemic stroke in patients with high Lp(a), but its effectiveness is not well established (Level of Evidence: B)"
|
| "2. The clinical benefit of using Lp(a) in stroke risk prediction is not well established (Level of Evidence: B)"
|
Hypercoagulability: Recommendations
| Class III (Harm)
|
| "1.Low-dose aspirin (81 mg/d) is not indicated for primary stroke prevention in individuals who are persistently aPL positive (Level of Evidence: B)"
|
| Class IIb
|
| "1. The usefulness of genetic screening to detect inherited hypercoagulable states for the prevention of first stroke is not well established (Level of Evidence: C)"
|
| "2. The usefulness of specific treatments for primary stroke prevention in asymptomatic patients with a hereditary or acquired thrombophilia is not well established (Level of Evidence: C)"
|
Inflammation and Infection: Recommendations
| Class IIb
|
| "1. Measurement of inflammatory markers such as hs- CRP or lipoprotein-associated phospholipase A2 in patients without CVD may be considered to identify patients who may be at increased risk of stroke, although their usefulness in routine clinical practice is not well established (Level of Evidence: B)"
|
| "2. Treatment of patients with hs-CRP >2.0 mg/dL with a statin to decrease stroke risk might be considered (Level of Evidence: B)"
|
Antiplatelet Agents and Aspirin: Recommendations
| Class IIa
|
| "1. The use of aspirin for cardiovascular (including but not specific to stroke) prophylaxis is reasonable for people whose risk is sufficiently high (10-year risk >10%) for the benefits to outweigh the risks associated with treatment. (Level of Evidence: A)"
|
| "2. Aspirin (81 mg daily or 100 mg every other day) can be useful for the prevention of a first stroke among women, including those with diabetes mellitus, whose risk is sufficiently high for the benefits to outweigh the risks associated with treatment (Level of Evidence: B)"
|
Primary Prevention in the ED: Recommendations
| Class IIa
|
| "1. ED population screening for hypertension is reasonable (Level of Evidence: C)"
|
| "2. When a patient is identified as having a drug or alcohol abuse problem, ED referral to an appropriate therapeutic program is reasonable (Level of Evidence: C)"
|
| Class IIb
|
| "1. The effectiveness of screening, brief intervention, and referral for treatment of diabetes mellitus and life style stroke risk factors (obesity, alcohol/substance abuse, sedentary lifestyle) in the ED setting is not established (Level of Evidence: C)"
|
Preventive Health Services: Recommendation
| Class IIa
|
| "1. It is reasonable to implement programs to systematically identify and treat risk factors in all patients at risk for stroke (Level of Evidence: A)"
|
References
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