In the February 1, 2011 issue of Stroke, the American Heart Association/American Stroke Association (AHA/ASA) released new guidelines for the primary prevention of stroke. The guideline reviews evidence on established and emerging risk factors for stroke. A significant change in these guidelines, which update a previous statement from 2006, is that clinicians are urged to address primary prevention of both ischemic and hemorrhagic stroke because the risk factors and prevention strategies for these events largely overlap. The critical role of a healthy lifestyle in the prevention of stroke is also emphasized. Areas of particular interest include emergency department (ED) screening, aspirin use among low-risk patients, asymptomatic carotid artery stenosis, and atrial fibrillation (AF), among other updates.
ED screening for stroke risk represents an entirely new recommendation. Due to a lack of resources, there has been a surge in the number of people who receive care through the ED. This setting represents a unique opportunity to capture individuals at high risk of stroke and to offer information on smoking cessation programs, referrals for alcohol/drug abuse programs, screening for hypertension, and identification of AF.
A notable point in the AHA/ASA scientific statement is that aspirin is not recommended for preventing a first stroke in people at low risk or in those with diabetes or diabetes plus asymptomatic peripheral artery disease. Use of aspirin to prevent cardiovascular events—including but not limited to stroke—is recommended for those at sufficiently high risk. However, it’s important to weigh the risks, primarily bleeding, associated with treatment.
Managing Asymptomatic Carotid Artery Stenosis
Population screening for asymptomatic carotid artery stenosis is not recommended. An area that has become more complex is deciding whether to recommend revascularization for patients who have asymptomatic carotid stenosis. The usefulness of carotid artery stenting as an alternative to carotid endarterectomy in asymptomatic patients at high risk is uncertain.
There is also a paucity of data comparing carotid artery surgery versus stenting versus current medical therapy. As such, selection of asymptomatic patients for carotid revascularization should be based upon an assessment of comorbid conditions and life expectancy, as well as other individual factors. It should include a thorough evaluation of the risks and benefits of the procedure with an understanding of patient preferences.
“Clinicians are urged to address primary prevention of both ischemic and hemorrhagic stroke because the risk factors and prevention strategies for these events largely overlap.”
The Changing Paradigm in AF
Numerous modifications have been made to the recommendations on managing AF. Systematic pulse assessment during routine clinic visits is recommended for patients aged 65 and older. Warfarin is recommended for the prevention of stroke among those at high and moderate risk. Antiplatelet therapy (aspirin) is recommended for low-risk and some moderate-risk patients with AF. Dual antiplatelet therapy (aspirin and clopidogrel) may be reasonable for high-risk patients with AF who are unsuitable for anticoagulation. However, this carries a risk of bleeding similar to warfarin. Aggressive management of blood pressure coupled with antithrombotic prophylaxis in elderly patients with AF can be useful.
Readings & Resources (click to view)
Goldstein LB, Bushnell CD, Adams RJ, et al; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, Council for High Blood Pressure Research, Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Guidelines for the primary prevention of stroke. A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010 Dec 6. [Epub ahead of print]. Available at: http://stroke.ahajournals.org/cgi/reprint/STR.0b013e3181fcb238v1.
Goldstein LB, Adams R, Alberts MJ, et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Stroke. 2006;37:1583-1633.
Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1655-1711.
Sturgeon JD, Folsom AR, Longstreth WT Jr, Shahar E, Rosamond WD, Cushman M. Risk factors for intracerebral hemorrhage in a pooled prospective study. Stroke. 2007;38:2718-2725.