Updated clinical guidelines have been released, highlighting lifestyle modifications, prevention strategies, and treatment alternatives aimed at lowering the chances of experiencing a first stroke.
Adopting a healthy lifestyle, which includes proper nutrition, quitting smoking, and staying physically active, combined with regular health screenings and effective management of cardiovascular disease risk factors through medication, can significantly decrease the likelihood of having a first stroke. The American Stroke Association, a branch of the American Heart Association, emphasizes that stroke risk screening and education on preventive measures should ideally start with a primary care provider and follow evidence-based recommendations, as detailed in a new guideline published in the journal Stroke.
A stroke happens when blood flow to the brain is obstructed by a blood clot or a ruptured blood vessel, preventing the brain from receiving essential oxygen. This results in brain damage, which can lead to severe disabilities such as difficulties in thinking, speaking, walking, and interacting with surroundings. In the United States, stroke ranks as the fifth leading cause of death, with nearly 160,000 fatalities each year. Over 600,000 Americans experience a first stroke annually, despite the fact that up to 80% are preventable.
“The most effective strategy for lowering the incidence of stroke and stroke-related fatalities is to prevent the first stroke, known as primary prevention,” explained Dr. Cheryl D. Bushnell, Chair of the guideline writing group and a professor at Wake Forest University School of Medicine. “Certain groups of individuals possess a higher risk of stroke due to genetic, lifestyle, biological factors, or social determinants of health. In some instances, individuals may not receive the necessary screening to assess their risk.”
The “2024 Guideline for the Primary Prevention of Stroke” supersedes the 2014 version and serves as a guide for healthcare providers to implement various preventive approaches for individuals without previous stroke history. This updated guideline offers evidence-based recommendations on ways to enhance brain health and stave off stroke throughout a person’s life by promoting healthy lifestyle choices and access to preventive healthcare.
“This guideline is crucial since new findings have emerged since the last update a decade ago. Identifying individuals at higher risk of a first stroke and assisting in maintaining cardiovascular and brain health can aid in stroke prevention,” said Bushnell.
Essential stroke prevention suggestions encompass regular health evaluations, risk factor identification, lifestyle improvements, and the use of medication when necessary.
Identifying and Managing Risk Factors
Unrecognized and unmanaged cardiovascular disease risk factors can inflict damage on arteries, the heart, and the brain long before cardiovascular disease or strokes happen. Primary care providers should advocate for brain health by educating patients on stroke prevention, conducting screenings, and addressing risk factors from childhood to old age.
Adjustable stroke risk factors, including high blood pressure, obesity, high cholesterol, and high blood sugar, can be detected through physical examinations and blood tests. These issues should be managed with healthy lifestyle modifications and may also warrant medication for specific patients. Medications to control blood pressure and statin drugs to lower cholesterol can help diminish the risk of first strokes in individuals at elevated cardiovascular disease risk. A new recommendation includes considering glucagon-like protein-1 (GLP-1) receptor agonist medications, which are FDA-approved to lower cardiovascular disease risk for those who are overweight, obese, and/or have Type 2 diabetes.
Healthy Lifestyle Behaviors
The most common and treatable lifestyle habits that can help reduce stroke risk are outlined in the Association’s Life’s Essential 8 cardiovascular health metrics. These habits encompass healthy eating, regular exercise, avoiding tobacco, achieving healthy sleep and weight, managing cholesterol levels, and controlling blood pressure and blood sugar. The guideline recommends that adults without prior cardiovascular disease—as well as those at increased risk—follow a Mediterranean dietary pattern, which has been linked to lowered stroke risk, particularly when complemented with nuts and olive oil.
Engaging in regular physical activity is also vital for lowering stroke risk and promoting overall heart health. It can positively affect key health indicators such as blood pressure, cholesterol levels, inflammatory markers, insulin sensitivity, endothelial function, and weight. The guideline encourages healthcare providers to routinely screen for sedentary behaviors, a known stroke risk factor, and advise patients on incorporating regular exercise. The Association backs the U.S. Department of Health and Human Services’ recommendation that adults participate in at least 150 minutes of moderate-intensity aerobic activity per week or 75 minutes of vigorous activity, preferably spread throughout the week.
Health Equity and Stroke Risk
A new focus within the guideline highlights social determinants of health and their influence on stroke risk. Social determinants include non-medical factors like education, economic stability, access to healthcare, discrimination, systemic racism, and environmental conditions (such as limited walkability, scarcity of healthy food options, and fewer health resources), all of which contribute to healthcare disparities and affect overall health. Healthcare providers should ensure that educational resources are accessible across varied educational and language backgrounds, and advocate for their patients by selecting effective and affordable treatment options.
Additionally, healthcare professionals are encouraged to connect patients with resources addressing social needs like food and housing insecurity, recommend programs that promote healthy lifestyle changes, and offer connections to support initiatives that help mitigate healthcare costs, including medication expenses.
New Sex- and Gender-Specific Recommendations
The guideline also introduces new recommendations focusing on gender and sex for women. Healthcare providers are advised to screen for risk factors that could heighten a woman’s stroke risk, such as oral contraceptive use, pregnancy-related high blood pressure, other pregnancy complications (like premature birth), endometriosis, premature ovarian failure, and early menopause. To reduce the likelihood of maternal intracerebral hemorrhage, monitoring and managing high blood pressure during pregnancy and the six weeks following delivery is recommended.
Transgender women and gender-diverse individuals who are taking estrogen for gender affirmation may also face an increased stroke risk. It’s essential to review and address any existing risk factors for these individuals.
“By executing the recommendations outlined in this guideline, we can significantly lessen the risk of individuals experiencing a first stroke. The majority of the proposed strategies for stroke prevention will also aid in decreasing dementia risk, another serious health condition related to vascular problems in the brain,” remarked Bushnell.
The writing group acknowledges that formulating recommendations targeting the prevention of a first stroke posed challenges due to certain limitations in the related evidence. Many clinical trials included participants with prior cardiovascular events, including strokes, while some knowledge gaps were identified that could guide future research.
The guideline stresses the importance of risk assessment in primary stroke prevention and advises on using risk prediction tools to evaluate the likelihood of atherosclerotic cardiovascular disease, ensuring that patients receive timely preventive and therapeutic strategies. The Association has recently introduced the Predicting Risk of Cardiovascular Disease Events (PREVENT) risk calculator as a tool to enhance preventive treatment decisions. This calculator can project 10-year and 30-year stroke and heart disease risks for individuals starting at age 30—ten years earlier than the previously used Pooled Cohort Equations CVD risk calculator.
According to the American Stroke Association, recognizing the warning signals of a stroke and understanding prevention techniques are the best approaches to avert strokes and prevent recurrences. The acronym F.A.S.T.—indicating face drooping, arm weakness, speech difficulties, and the need to call 911—serves as a practical tool for acknowledging stroke warning signs and determining when to seek help.
