New stroke primary prevention guideline calls for more screening of risk factors
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Key takeaways:
- A new guideline on prevention of a first stroke calls for more screening of risk factors in primary care settings.
- Lifestyle counseling is also essential for stroke prevention, the authors wrote.
The new guideline on primary prevention of stroke from the American Heart Association and American Stroke Association calls for more screening of risk factors such as high BP, high cholesterol and high blood glucose.
In addition, primary prevention of stroke would improve with more efforts to publicize the benefits of lifestyle changes such as better diet, increased physical activity, smoking cessation and better sleep, the authors of the guideline wrote.
Identifying patients at risk
“The medical community has the ability to prevent stroke with medications that are very effective, such as those for lowering blood pressure and cholesterol, and managing diabetes,” 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, and chair of the writing committee, told Healio. “The challenge for preventing a first stroke is to identify the patients who are at risk and making sure those patients have access to care. This could be primary care or specialist care depending on the patient’s medical history. There is much room for improvement, however. We know that 60% of strokes are preventable by identifying risk factors and managing them. In the U.S., there is a renewed cause for alarm because stroke has risen from the fifth leading cause of death to the fourth leading cause. Therefore, focusing on screening and identifying patients at risk, applying guideline-recommended therapies for prevention, and counseling on lifestyle are more important than ever if we want to reduce the burden of strokes in this country.”
Bushnell told Healio that in the past 10 years, new medications such as GLP-1 receptor agonists and SGLT2 inhibitors have shown a potential role in stroke prevention. The new guideline states that GLP-1 receptor agonist use is effective (class IA recommendation) for stroke prevention in patients with diabetes, high CV risk or established CVD and HbA1c 7% or more.
“GLP-1 receptor agonists have been shown to not only drastically reduce blood sugars in patients with diabetes, but they also lead to significant weight loss in these patients, which has many downstream benefits,” Bushnell told Healio. “Together, this reduces the risk of stroke and other complications of diabetes. The PCSK9 inhibitors ... are very effective at lowering LDL (the bad) cholesterol. These medications have also been shown to reduce the risk of stroke.”
She said other key recommendations of the new guideline include:
- increasing physical activity and avoiding sedentary behavior during waking hours;
- screening for sedentary behavior and encouraging clinicians to counsel patients to avoid sedentary behavior;
- lowering BP if it is high in pregnant women;
- screening for pregnancy complications, premature ovarian failure, early-onset menopause (before age 45 years) and endometriosis; and
- screening for adverse social determinants of health (SDOH).
“There is abundant evidence that adverse SDOH can be barriers to prevention (inability to afford health insurance and medications, access to health care, etc) and therefore increase stroke risk,” Bushnell told Healio.
Screening in primary care settings
Bushnell said she hopes that the guideline leads to increased screening for stroke risk factors in primary care practices.
“This would hopefully lead to additional attention to identifying other classic risk factors in individuals at younger ages than current practice,” she said in an interview. “For example, if a woman had a history of preeclampsia (toxemia) during her pregnancy, then she should be screened for other cardiovascular and stroke risk factors immediately after delivery, specifically high blood pressure, because of the evidence that preeclampsia increases the risk of hypertension by fourfold and the risk of stroke by twofold in the 10 years after delivery. We also encourage using the very effective classes of drugs for diabetes and cholesterol for the appropriate patients to reduce stroke risk. We also believe there could be increased attention on lifestyle factors (diet, physical inactivity, obesity, sleep, smoking) and future counseling regarding behavior change.”
Future priorities include figuring out whether any lifestyle interventions can be effective at reducing risk for stroke, developing tools that would simplify the implementation of screening for stroke risk factors in primary care practices and conducting randomized trials on stroke prevention in women who have had pregnancy complications, Bushnell said.
“All of our recommendations will not only lead to better stroke prevention, but also improve brain health,” Bushnell told Healio. “The risks for dementia are essentially the same as the risks for stroke. “
Reference:
- New guideline: Preventing a first stroke may be possible with screening, lifestyle changes. https://newsroom.heart.org/news/new-guideline-preventing-a-first-stroke-may-be-possible-with-screening-lifestyle-changes. Published Oct. 21, 2024. Accessed Oct. 21, 2024.
For more information:
Cheryl D. Bushnell, MD, MHS, FAHA, can be reached at cbushnel@wakehealth.edu.
Perspective
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There are roughly 600,000 first strokes per year. This is a large public health problem that needs to be addressed, hence why these guidelines are being published.
One of the most important updates is the identification of special populations. Prior guidelines did not put much emphasis on them, including pregnant women, patients with endometriosis and people impacted by social determinants of health. Poor access to care is a risk factor for stroke, and being able to screen for that on a regular basis will be helpful. Asking women if they have a history of endometriosis or early-onset menopause is important because those confer increased risk for stroke. In addition, transgender health has not been a focus of prior guidelines, and now, it’s necessary because transgender women are taking estrogen for gender affirmation, and that can increase risk for stroke, so being able to guide those patients through that is going to be important.
The guideline should make us think more about patients holistically. There are so many risk factors they could present with. Screening in terms of asking patients about things like pregnancy complications, and other topics that do not come up in a typical conversation, is important. We also need to routinely ask about social determinants of health. Routinely asking those kinds of screening questions and incorporating the answers into decision-making and risk stratification will be an important modification in our day-to-day practice.
There is still work that needs to be done on figuring out associations with stroke risk. For some conditions, the effect on overall CV risk is known but the effect on stroke risk specifically is not. Some studies did not directly measure stroke risk. Hopefully there will be studies down the line that are powered to look at stroke risk specifically.
The earlier we can do primary prevention, the better. Over the past 10 to 20 years, there has been increased risk for stroke in the middle-aged population, and part of that has to do with modifiable risk factors. This is why the guideline emphasizes screening for stroke risk for people in younger age groups. The message needs to be, you should not wait for your first doctor visit to be when you’re 50 years old. The earlier you can talk to clinicians about your risk factors, the earlier they can be addressed with you, and the less stroke risk you will have.
Addressing stroke risk factors also benefits overall brain health and keeps the brain functioning longer. The guideline emphasizes this.
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