Most primary and secondary stroke prevention recommendations focus on ischemic stroke, but some apply to hemorrhagic stroke, or to cerebral venous thrombosis.
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Primary stroke prevention refers to the treatment of individuals with no history of stroke. Secondary stroke prevention refers to the treatment of individuals who have already had a stroke or transient ischemic attack. Risk-reduction measures may include the use of antihypertensive medications; warfarin; platelet antiaggregants; 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins); smoking cessation; dietary intervention; weight loss; and exercise.
Secondary prevention refers to the treatment of individuals who have already had a stroke or transient ischemic attack (TIA). Measures may include the use of platelet antiaggregants, antihypertensives, statins, and lifestyle interventions.
Review: In 2010 The American Heart Association (AHA) and the American Stroke Association (ASA) published newly revised Guidelines for the Primary Prevention of Stroke. The guideline provides an overview of established and emerging risk factors for stroke, and gives evidence-based recommendations to reduce the likelihood of a first stroke in individuals at risk. Modifiable risk factors and recommendations for management are summarized below. While the previous version of the guidelines focused only on ischemic stroke, the 2010 revision added recommendations for prevention of hemorrhagic stroke.
Essential update: Updated guidelines on primary prevention of stroke released
New recommendations include the following:
- Use of new oral anticoagulants, including dabigatran, apixaban, and rivaroxaban, in patients with nonvalvular atrial fibrillation
- Home self-monitoring of blood pressure in hypertensive patients
- Use of nonestrogen oral contraceptives in female patients with migraine with aura
- All patients should follow the Mediterranean diet supplemented with nuts and reduce sodium intake
- Screening for sleep apnea
- Smoking cessation
Primary Prevention of Stroke
Risk-reduction measures in primary stroke prevention may include the use of antihypertensive medications; warfarin; platelet antiaggregants; 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins); smoking cessation; dietary intervention; weight loss; and exercise.
Modifiable risk factors include the following:
- Cigarette smoking
- Atrial fibrillation
- Sickle cell disease
- Postmenopausal HRT
- Diet and activity
- Weight and body fat
Secondary Prevention of Stroke
Secondary prevention can be summarized by the mnemonic A, B, C, D, E, as follows:
- A – Antiaggregants (aspirin, clopidogrel, extended-release dipyridamole, ticlopidine) and anticoagulants (warfarin)
- B – Blood pressure–lowering medications
- C – Cessation of cigarette smoking, cholesterol-lowering medications, carotid revascularization
- D – Diet
- E – Exercise
Smoking cessation, blood pressure control, diabetes control, a low-fat diet (eg, Dietary Approaches to Stop Hypertension [DASH] or Mediterranean diets), weight loss, and regular exercise should be encouraged.
Apixaban, dabigatran, rivaroxaban, and edoxaban are alternatives to warfarin for high-risk patients (including those with a history of stroke) who have atrial fibrillation.
Smoking cessation, blood pressure control, diabetes control, a low-fat diet (eg, Dietary Approaches to Stop Hypertension [DASH] or Mediterranean diets), weight loss, and regular exercise should be encouraged as strongly as the medications described above. Written prescriptions for exercise and medications for smoking cessation (nicotine patch, bupropion, varenicline) increase the likelihood of success with these intervention
Article on Stroke Prevention Tips Series edited by CertifiedCare.org and ElderCareAdvice. Author: Brian Silver, MD, FRCPC, FAHA, FAAN Director, Stroke Center, Rhode Island Hospital; Associate Professor of Neurology, The Warren Alpert Medical School of Brown University