New Published Guideline Provides Recommendations for Primary Stroke Prevention Across Life Span

Cheryl D. Bushnell, MD, MHS, FAHA

(Credit: Wake Forest University School of Medicine)

A new clinical guideline from the American Stroke Association published in Stroke provided evidence-based recommendations for strategies to support brain health and prevent stroke through improving healthy lifestyle behaviors and preventive care. This guideline, supported also as a clinically valuable educational tool by The American College of Obstetricians and Gynecologists, replaces the previous 2014 version and is intended to be a resource for clinicians in the implementation various prevention strategies for patients who do not have a prior history of stroke.^1,2

In this guideline, endorsed by the Preventive Cardiovascular Nurses Association and the Society for Vascular Surgery, a volunteer writing group conducted a literature search of evidence between May and November 2023 involving human participants published since the prior 2024 guideline from multiple databases and reviewed other previously published documents related to the studies. Based on the evidence, the group identified key recommendations for preventing incident stroke which included regular health screenings, recognizing risk factors, lifestyle interventions and medications, when appropriate.

“We really want to emphasize that these are relatively simple things we're recommending. There's reason for hope due to these new advancements, and it's important to remember that what benefits stroke prevention also benefits dementia prevention and brain health overall. That was another key point we wanted to emphasize in the guideline, serving as a general introduction and an umbrella for what we're trying to accomplish," chair of the guideline writing group Cheryl D. Bushnell, MD, MHS, FAHA, professor and vice chair of research in the department of neurology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, told NeurologyLive^®.

Recognizing and Addressing Risk Factors

Prior studies have shown that unidentified and unmanaged cardiovascular risk factors can lead to significant damage long before cardiovascular disease or stroke occurs. This new guideline recommended that primary care providers should prioritize stroke prevention and brain health through education, early screenings, and addressing modifiable risk factors across the lifespan. The guideline emphasized that high blood pressure, obesity, elevated cholesterol, and high blood sugar can be detected via exams and blood tests and managed with lifestyle changes or medications. Furthermore, antihypertensive drugs, statins, and now in this new update glucagon-like peptide-1 (GLP-1) receptor agonists were regarded as key interventions to reduce stroke risk among patients.

"We believe this is incredibly important and timely for several reasons. First, since 2014, there have been several groundbreaking clinical trials in prevention treatments, particularly with GLP-1 receptor agonists. These have been shown not only to significantly improve diabetes control but also to lead to substantial weight loss, which in turn improves cardiovascular outcomes. This is one of the key areas we felt was important to address,” Bushnell commented. "Of course, we have to specify the population with the most data and evidence, and that includes patients with diabetes who, while not having had a stroke, are at reduced risk of stroke with GLP-1 receptor agonists."

Health-Promoting Habits

The latest guideline also highlighted the importance of adopting key lifestyle behaviors to reduce stroke risk, based on the American Heart Association's Life’s Essential 8 cardiovascular health metrics. These include healthy eating, regular physical activity, maintaining a healthy weight, managing cholesterol and blood pressure, avoiding tobacco, and ensuring proper sleep. The updated guideline specifically recommended a Mediterranean diet, particularly one supplemented with nuts and olive oil, for adults with or without cardiovascular disease.

In an additional recommendation, authors noted that regular physical activity was a critical component in stroke prevention, encouraging health care providers to screen for sedentary behavior and promote exercise. All told, the recommended physical activity levels align with the U.S. Department of Health guidelines—150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity per week.

"What’s particularly new is the evidence around sedentary behavior during waking hours as another risk factor for stroke. We've included recommendations to screen for sedentary behavior and to counsel patients on avoiding it. For example, getting up and walking or standing for 10 minutes every hour can significantly reduce the risk of poor outcomes. These are some of the newer recommendations we've incorporated into this guideline," Bushnell said.

Stroke Risk and Health Equity

Further in the newly published guideline, experts underscored the importance of addressing social determinants of health, such as education, economic stability, access to care, and neighborhood factors, in managing stroke risk. Authors urged health care professionals to provide patient education tailored to diverse needs, advocate for cost-effective treatments, and connect patients to resources that address food, housing insecurity, and promote healthy lifestyle changes. Moreover, the volunteer writing group noted that professionals should guide patients to support programs that help reduce health care and medication expenses.

"We acknowledge that there are many social determinants of health that prevent minoritized populations from participating—not only in trials but also from accessing care. We included a section on screening for adverse social determinants of health. While there may not be many interventions or approaches currently, there’s ongoing research in this area," Bushnell said. "We clearly highlight the need for more work to be done. It’s important to be aware of the challenges our patients face because it makes us better doctors. It helps us understand why they didn’t take their medication, why they missed an appointment, or why they lack transportation or insurance. Acknowledging these factors is crucial as we work to improve prevention in high-risk patients."

Updated Recommendations Based on Sex and Gender

Another new recommendation in the guideline noted that gender- and sex-specific stroke risk factors, suggesting that health professionals should screen women for conditions such as oral contraceptive use, high blood pressure during pregnancy, and pregnancy-related complications. Authors also advised the management of elevated blood pressure during and after pregnancy to lower the risk of maternal stroke. In addition, the experts recommended that transgender women and gender-diverse patients on estrogen therapy should be assessed for stroke risk, with appropriate modification of any existing risk factors.

Experts highlighted the challenges of developing stroke prevention recommendations because of evidence limitations from clinical trials that primarily involved adults with prior cardiovascular events and also identified knowledge gaps to guide future research efforts in the publication. “Another area we've expanded on in this guideline is women's cardiovascular health, particularly female-specific risk factors. For context, I was the writing group chair for the 2014 guideline on the primary prevention of stroke in women. There was consideration of updating that guideline separately, but instead, we decided to integrate women's specific issues into the broader primary prevention guideline. This approach emphasizes the lifespan, including pregnancy, menopause, and any risks specific to these stages,” Bushnell added.

The new guideline stressed the significance of risk assessment in primary stroke prevention and recommended the use of tools such as the newly developed PREVENT calculator to estimate atherosclerotic cardiovascular disease risk. Authors noted that the PREVENT calculator can estimate 10-year and 30-year risks for stroke and heart disease starting at age 30, providing earlier intervention compared with the Pooled Cohort Equations. The American Stroke Association also continued to signify the importance of recognizing stroke warning signs, using the F.A.S.T. acronym (Face drooping, Arm weakness, Speech difficulty, Time to call 911) to ensure timely medical intervention.

REFERENCES
1. Bushnell C, Kernan WN, Sharrief AZ, et al. 2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. Published online October 21, 2024. doi:10.1161/STR.0000000000000475
2. New guideline: Preventing a first stroke may be possible with screening, lifestyle changes. News Release. American Heart Association. Published October 21, 2024. Accessed October 21, 2024. https://newsroom.heart.org/news/new-guideline-preventing-a-first-stroke-may-be-possible-with-screening-lifestyle-changes