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AHA/ASA: Diet, exercise, BP control key for primary prevention of stroke
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A healthy diet, physical activity and BP control are among the most important components of an effective strategy for primary prevention of stroke, according to a new guideline released by the American Heart Association and American Stroke Association.
“We have a huge opportunity to improve how we prevent new strokes, because risk factors that can be changed or controlled — especially high [BP] — account for 90% of strokes,” James F. Meschia, MD, FAHA, chair of the panel that wrote the guideline and professor and chairman of neurology at Mayo Clinic, Jacksonville, Fla., said in a press release.
The updated guideline recommends a Mediterranean or Dietary Approaches to Stop Hypertension (DASH)-style diet supplemented with nuts, reduced sodium intake, and increased potassium, fruit and vegetable intake to help lower risk for stroke.
The panel also recommended more physical activity, a healthy diet and weight management to prevent prehypertension from developing into high BP, which is a major risk factor for stroke.
BP control crucial
Several recommendations focus on BP control. The panel advised that people should monitor their BP at home, visit their health care provider annually for BP evaluation and let their doctor know of their antihypertensive medication is not working or causing adverse events, so alternative therapies can be implemented.
Patients with hypertension should be treated with antihypertensive drugs to a target systolic BP of <140 mm Hg and a target diastolic BP of <90 mm Hg, the panel wrote, noting that treatment should be individualized according to patient characteristics and medication tolerance.
The panel also strongly recommended not smoking and avoiding secondhand smoke, with caution that women who smoke and take oral contraceptives or have migraines with aura are at elevated risk for stroke.
For adults with diabetes, control of BP to <140 mm Hg/90 mm Hg and treatment with statins are recommended for primary stroke prevention, but adding a fibrate to a statin is not useful and the role of aspirin for primary stroke prevention is unclear, according to the panel.
AF and stroke
For patients with valvular atrial fibrillation at high risk for stroke, long-term oral anticoagulant therapy with warfarin is recommended.
For patients with nonvalvular AF at high risk for stroke and low risk for hemorrhagic complications, oral anticoagulants including warfarin, dabigatran (Pradaxa, Boehringer Ingelheim), apixaban (Eliquis, Bristol-Myers Squibb/Pfizer) and rivaroxaban (Xarelto, Janssen Pharmaceuticals) are recommended, and selection should be made based on risk factors, cost, tolerability, patient preference, potential for drug interactions and other clinical characteristics, according to the panel.
Left atrial appendage closure may be considered for patients with AF at high risk for stroke if they are deemed unsuitable for anticoagulation but can tolerate it for at least 45 days post-procedure, and if the procedure is performed at a center with low rates of periprocedural complications, Meschia and colleagues wrote.
Patients with asymptomatic carotid stenosis should be prescribed daily aspirin and a statin, and it is not clear whether carotid endarterectomy and carotid artery stenting are more effective than medical management in these patients.
The use of aspirin for CV (not limited to stroke) prophylaxis is reasonable in those with 10-year risk for CVD >10%, and aspirin can be useful for prevention of a first stroke in women.
The guideline was endorsed by the American Association of Neurological Surgeons, the Congress of Neurological Surgeons and the Preventive Cardiovascular Nurses Association, and was affirmed as an educational tool for neurologists by the American Academy of Neurology.
Disclosure: See the full guideline for a list of the authors’ and reviewers’ relevant financial disclosures.
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