AHA/ASA guideline recommendations for prevention of stroke

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];

2014 AHA/ASA Guidelines for the Primary Prevention of Stroke

Genetic Factors: Recommendations

Class III (Harm)

"1.Genetic screening to determine risk for myopathy is not recommended when initiation of statin therapy is being considered (Level of Evidence: C)"

"2. Genetic screening of the general population for the prevention of a first stroke is not recommended (Level of Evidence: C)"

"3.Screening for intracranial aneurysms in every car- rier of autosomal-dominant polycystic kidney disease or Ehlers-Danlos type IV mutations is not recommended (Level of Evidence: C)"

"4. Noninvasive screening for unruptured intracranial aneurysms in patients with no more than 1 relative with SAH or intracranial aneurysms is not recommended (Level of Evidence: C)"

Class IIa

"1. Obtaining a family history can be useful to help identify persons who may be at increased risk of stroke (Level of Evidence: A)"

Class IIb

"1. Referral for genetic counseling may be considered for patients with rare genetic causes of stroke (Level of Evidence: C)"

"2. Treatment of Fabry disease with enzyme replacement therapy might be considered, but has not been shown to reduce the risk of stroke, and its effectiveness is unknown (Level of Evidence: C)"

"3. Noninvasive screening for unruptured intracranial aneurysms in patients with ADPKD and ≥1 relatives with ADPKD and SAH or intracranial aneurysm may be considered(Level of Evidence: C)"

"4. Noninvasive screening for unruptured intracranial aneurysms in patients with ≥2 first-degree relatives with SAH or intracranial aneurysms might be reasonable (Level of Evidence: C)"

"5. Noninvasive screening for unruptured intracranial aneurysms in patients with cervical fibromuscular dysplasia may be considered(Level of Evidence: C)"

"6.Pharmacogenetic dosing of vitamin K antagonists may be considered when therapy is initiated(Level of Evidence: C)"

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)"

Dyslipidemia: Recommendations

Class I

"1. In addition to therapeutic lifestyle changes, treat- ment 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 pre- venting 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 pre- venting 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)"

Class IIa

"1. A Mediterranean diet supplemented with nuts may be considered in lowering the risk of stroke (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)"

Class III (Harm)

"1. Adding a fibrate to a statin in people with diabetes mellitus is not useful for decreasing stroke risk (Level of Evidence: B)"

Class IIb

"1. The usefulness of aspirin for primary stroke prevention for patients with diabetes mellitus but low 10-year risk of CVD is unclear (Level of Evidence: B)"

References

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