AHA/ASA guideline recommendations for prevention of stroke

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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

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 carrier 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, 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)"
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)"

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)"
Class IIa
"1.Community-wide or statewide bans on smoking in public spaces are reasonable for reducing the risk of stroke and MI (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 IIa
"1. Active screening for AF in the primary care setting in patients >65 years of age by pulse assessment followed by ECG as indicated can be useful (Level of Evidence: B)"
"2. For patients with nonvalvular AF and CHA2DS2- VASc score of 0, it is reasonable to omit antithrom- botic therapy (Level of Evidence: B)"
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

Class I
"1. Anticoagulation is indicated in patients with mitral stenosis and a prior embolic event, even in sinus rhythm (Level of Evidence: B)"
"2. Anticoagulation is indicated in patients with mitral stenosis and left atrial thrombus (Level of Evidence: B)"
"3. Warfarin (target INR, 2.0–3.0) and low-dose aspirin are indicated after aortic valve replacement with bileaflet mechanical or current-generation, single- tilting-disk prostheses in patients with no risk factors(Level of Evidence: B)"

Risk factors include AF, previous thromboembolism, left ventricular dysfunction, and hypercoagulable condition.

"4. Surgical excision is recommended for the treatment of atrial myxomas (Level of Evidence: C)"
"5. Surgical intervention is recommended for symptomatic fibroelastomas and for fibroelastomas that are >1 cm or appear mobile, even if asymptomatic (Level of Evidence: C)"
Class III (Harm)
"1. Antithrombotic treatment and catheter-based closure are not recommended in patients with PFO for primary prevention of stroke (Level of Evidence: C)"
Class IIa
"1. Aspirin is reasonable after aortic or mitral valve replacement with a bioprosthesis (Level of Evidence: B)"
"2. It is reasonable to give warfarin to achieve an INR of 2.0 to 3.0 during the first 3 months after aortic or mitral valve replacement with a bioprosthesis (Level of Evidence: C)"
"3. Anticoagulants or antiplatelet agents are reasonable for patients with heart failure who do not have AF or a previous thromboembolic even (Level of Evidence: A)"
"4. Vitamin K antagonist therapy is reasonable for patients with STEMI and asymptomatic left ventricular mural thrombi (Level of Evidence: C)"
Class IIb
"1. Anticoagulation may be considered for asymptomatic patients with severe mitral stenosis and left atrial dimension ≥55 mm by echocardiograph (Level of Evidence: B)"
"2. Anticoagulation may be considered for patients with severe mitral stenosis, an enlarged left atrium, and spontaneous contrast on echocardiography (Level of Evidence: C)"
"3. Anticoagulant therapy may be considered for patients with STEMI and anterior apical akinesis or dyskinesis (Level of Evidence: C)"

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 III (Harm)
"1. Screening low-risk populations for asymptomatic carotid artery stenosis is not recommended (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)"
Class IIb
"1. In children at high risk for stroke who are unable or unwilling to be treated with periodic red cell transfusion, it might be reasonable to consider hydroxyurea or bone marrow transplantation (Level of Evidence: B)"

Migraine: Recommendations

Class I
"1. Smoking cessation should be strongly recommended in women with migraine headaches with aura (Level of Evidence: B)"
Class III (Harm)
"1. Closure of PFO is not indicated for preventing stroke in patients with migrain (Level of Evidence: B)"
Class IIb
"1. Alternatives to OCs, especially those containing estrogen, might be considered in women with active migraine headaches with aura (Level of Evidence: B)"
"2. Treatments to reduce migraine frequency might be reasonable to reduce the risk of stroke (Level of Evidence: C)"

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

Class IIa
"1. Referral to an appropriate therapeutic program is reasonable for patients who abuse drugs that have been associated with stroke, including cocaine, khat, and amphetamines (Level of Evidence: C)"

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

Class IIb
"1. The use of the B complex vitamins, cobalamin (B12), pyridoxine (B6), and folic acid might be considered for the prevention of ischemic stroke in patients with hyperhomocysteinemia, but its effectiveness is not well established (Level of Evidence: B)"

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 I
"1. Patients with chronic inflammatory disease such as RA or SLE should be considered at increased risk of stroke (Level of Evidence: B)"
Class III (Harm)
"1. Treatment with antibiotics for chronic infections as a means to prevent stroke is not recommended (Level of Evidence: A)"
Class IIa
"1. Annual influenza vaccination can be useful in lowering stroke risk in patients at risk of stroke (Level of Evidence: B)"
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 III (Harm)
"1. Aspirin is not useful for preventing a first stroke in low-risk individuals (Level of Evidence: A)"
"2. Aspirin is not useful for preventing a first stroke in people with diabetes mellitus in the absence of other high-risk conditions (Level of Evidence: A)"
"3. As a result of a lack of relevant clinical trials, anti-platelet regimens other than aspirin and cilostazol are not recommended for the prevention of a first stroke (Level of Evidence: C)"
"4. Aspirin is not useful for preventing a first stroke in people with diabetes mellitus and asymptomatic peripheral artery disease (defined as asymptomatic in the presence of an ankle brachial index ≤0.99) (Level of Evidence: B)"
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)"
Class IIb
"1. Aspirin might be considered for the prevention of a first stroke in people with chronic kidney disease (ie, estimated glomerular filtration rate <45 mL/min/1.73 m2). This recommendation does not apply to severe kidney disease (stage 4 or 5; estimated glomerular filtration rate <30 mL/ min/1.73 m2) (Level of Evidence: C)"
"2. Cilostazol may be reasonable for the prevention of a first stroke in people with peripheral arterial disease (Level of Evidence: B)"

Primary Prevention in the ED: Recommendations

Class I
"1. ED-based smoking cessation programs and interventions are recommended (Level of Evidence: B)"
"2. Identification of AF and evaluation for anticoagulation in the ED are recommended (Level of Evidence: B)"
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

  1. 2014 AHA/ASA Guidelines for the Primary Prevention of Stroke http://stroke.ahajournals.org/content/early/2014/10/28/STR.00000000000000467 Accessed on November 17, 2016




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