Slide1 :
Slide2 : Primary Prevention of Ischemic Stroke A Guideline from the American Heart Association/ American Stroke Association Stroke Council
Larry B. Goldstein, Chair; Robert Adams, Mark J. Alberts, Lawrence J. Appel, Lawrence M. Brass, Cheryl D. Bushnell, Antonio Culebras, Thomas J. DeGraba, Philip B. Gorelick, John R. Guyton, Robert G. Hart, George Howard, Margaret Kelly-Hayes, J.V. (Ian) Nixon, Ralph L. Sacco Stroke 2006;37:1583 - 1633
Presentation Compiled by the ASA Professional Education Committee : Presentation Compiled by the ASA Professional Education Committee Susan C. Fagan, Chair
Deborah Bergman
Dawn Bravata
Cheryl D. Bushnell
Seemant Chaturverdi
Dawn Kleindorfer
Bruce Ovbiagele
Richard M. Zweifler
Kathryn Taubert, Staff Scientist
Karen Modesitt, Staff
Introduction : Introduction This slide set was adapted from the AHA/ASA Guidelines for Primary Prevention of Stroke.
From the American Heart Association/American Stroke Association Council on Stroke
Co-Sponsored 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
Affirmed by the American Academy of Neurology
The full-text guidelines are available on the Web site of the AHA (www.americanheart.org)
Introduction : Introduction Systematic literature reviews (2001- Jan 2005), previous guidelines, personal files and expert opinion were used.
Evidence was summarized, gaps identified and recommendations developed
Extensive peer review was conducted
Introduction : Introduction Risk factors were categorized as either : non-modifiable, modifiable or potentially modifiable.
In addition, risk factors were judged to be either well documented or less well documented
AHA Classes and Levels of Evidence : AHA Classes and Levels of Evidence Class I Agreement the treatment is useful and effective
Class II Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a treatment.
Class IIa Weight of evidence is in favor of the treatment.
Class IIb Usefulness/efficacy is less well established by evidence
Class III Evidence and/or general agreement that the treatment is not useful/effective and in some cases may be harmful.
Levels of Evidence
A: Data derived from multiple randomized trials.
B: Data derived from a single randomized trial or nonrandomized studies.
C: Consensus opinion of experts.
Assessing the Risk of a First Stroke : Assessing the Risk of a First Stroke Each patient should have an assessment of his or her stroke risk (Class I, Level of Evidence A).
Risk assessment tools such as the Framingham Stroke Profile should be considered as they can help identify individuals who could benefit from therapeutic interventions and who may not be treated based on any 1 risk factor (Class IIa, Level of Evidence B).
Non-modifiable Risk Factors : Non-modifiable Risk Factors Age
Race
Sex
Low birth weight
Family history of stroke/TIA
Genetic Causes of Stroke : Genetic Causes of Stroke Referral for genetic counseling may be considered for patients with rare genetic causes of stroke (Class IIb, Level of Evidence C).
There remain insufficient data to recommend genetic screening for the prevention of a first stroke.
Modifiable, Well-Documented Risk Factors : Modifiable, Well-Documented Risk Factors Dyslipidemia
Diet
Obesity
Physical Inactivity
Postmenopausal Hormone Therapy Hypertension
Cigarette Smoking
Diabetes
Carotid Disease
Atrial fibrillation
Sickle Cell Disease
Hypertension : Hypertension Regular screening for hypertension (at least every 2 years in adults and more frequently in minority populations and the elderly) and appropriate management (Class I, Level of Evidence A), including dietary changes, lifestyle modification, and pharmacological therapy as summarized in JNC 7, are recommended.
Cigarette Smoking : Cigarette Smoking Abstention from cigarette smoking and smoking cessation for current smokers are recommended (Class I, Level of Evidence B).
Avoidance of environmental tobacco smoke for stroke prevention should also be considered (Class IIa, Level of Evidence C).
The use of counseling, nicotine products, and oral smoking cessation medications should be considered (Class IIa, Level of Evidence B).
Diabetes : Diabetes It is recommended that hypertension be tightly controlled in both type 1 and type 2 diabetes (the JNC 7 recommendation of <130/80 mmHg in diabetics is endorsed) as part of a comprehensive risk-reduction program (Class I, Level of Evidence A).
Treatment of adult diabetics, especially those with additional risk factors, with a statin to lower the risk of a first stroke is recommended (Class I, Level of Evidence A).
Atrial Fibrillation-1 : Atrial Fibrillation-1 Anticoagulation of patients with AF and valvular heart disease (particularly those with mechanical heart valves) is recommended. (Class I, Level of Evidence A).
Antithrombotic therapy is recommended to prevent stroke in patients with non-valvular atrial fibrillation based on assessment of their absolute stroke risk, estimated bleeding risk and considering patient preferences and access to high quality anticoagulation monitoring (Class I, Level of Evidence A).
Atrial Fibrillation-2 : Atrial Fibrillation-2 Warfarin (INR 2.0 to 3.0) is recommended for high-risk (>4% annual risk of stroke) patients (and many moderate-risk patients based on patient preferences) with atrial fibrillation who have no clinically significant contraindications to oral anticoagulants (Class I, Level of Evidence A).
Atrial Fibrillation-3 : Atrial Fibrillation-3 Hylek EM. NEJM 2003;349:1019-1026.
Other Cardiac Conditions : Other Cardiac Conditions It is reasonable to prescribe warfarin to post–ST-segment elevation patients with MI and left ventricular dysfunction with extensive regional wall-motion abnormalities (Class IIa, Level of Evidence A).
Warfarin may be considered in patients with severe LV dysfunction, with or without congestive heart failure (Class IIb, Level of Evidence C).
Dyslipidemia : Dyslipidemia It is recommended that patients with known CHD and high-risk hypertensive patients even with normal LDL-C levels, be treated with lifestyle measures and a statin (Class I, Level of Evidence A).
Suggested treatments for patients with known CHD and low HDL cholesterol include weight loss, increased physical activity, smoking cessation, and possibly niacin or gemfibrozil (Class IIa, Level of Evidence B).
Relationship Between Stroke and LDL-C Reduction : Relationship Between Stroke and LDL-C Reduction Amarenco P et al. Stroke 2004;35:2902-2909.
Effect of Statins on Stroke Prevention : Effect of Statins on Stroke Prevention Amarenco P et al. Stroke 2004;35:2902-2909.
VA-HIT Cumulative Incidence of Stroke by Treatment Group : VA-HIT Cumulative Incidence of Stroke by Treatment Group Bloomfield Rubins H et al. Circulation 2001;103:2828-2833
Asymptomatic Carotid Stenosis-1 : Asymptomatic Carotid Stenosis-1 It is recommended that patients with asymptomatic carotid artery stenosis be screened for other treatable causes of stroke and that intensive therapy of all identified stroke risk factors be pursued (Class I, Level of Evidence C).
The use of aspirin is recommended unless contraindicated (Class I, Level of Evidence B).
Asymptomatic Carotid Stenosis-2 : Asymptomatic Carotid Stenosis-2 Prophylactic carotid endarterectomy is recommended in highly selected patients with high-grade asymptomatic carotid stenosis performed by surgeons with <3% morbidity/mortality (Class I, Level of Evidence A).
Patient selection should be guided by an assessment of comorbid conditions and life expectancy.
Asymptomatic Carotid Stenosis-3 : Asymptomatic Carotid Stenosis-3 Carotid angioplasty–stenting might be a reasonable alternative to endarterectomy in asymptomatic patients at high risk for the surgical procedure (Class IIb, Level of Evidence B)
Given the reported periprocedural and overall 1-year event rates, it remains uncertain whether this group of patients should have either carotid endarterectomy or carotid angioplasty–stenting.
Infection : Infection Data are insufficient to recommend antibiotic therapy for stroke prevention based on seropositivity for one or a combination of putative pathogenic organisms. Future studies on stroke risk reduction based on treatment of infectious diseases will require careful stratification and identification of patients at risk for organism exposure.
Sickle Cell Disease-1 : Sickle Cell Disease-1 It is recommended that children with sickle cell disease be screened with transcranial Doppler (TCD) ultrasound starting at 2 years of age (Class I, Level of Evidence B).
It is recommended that transfusion therapy be considered for those at elevated stroke risk (Class I, Level of Evidence B).
Sickle Cell Disease-2 : Sickle Cell Disease-2 Although the optimal screening interval has not been established, it is reasonable that younger children and those with TCD velocities in the conditional range should be rescreened more frequently to detect development of high-risk TCD indications for intervention (Class IIa, Level of Evidence B).
Transfusion is reasonable to continue even in those whose TCD velocities revert to normal pending further studies (Class IIa, Level of Evidence B).
Sickle Cell Disease-3 : Sickle Cell Disease-3 MRI/MRA criteria for selection of children for primary stroke prevention using transfusion have not been established, and these tests should not be substituted for TCD (Class III, Level of Evidence B).
Adults with SCD should be evaluated for known stroke risk factors and managed according to the general guidelines in this statement (Class I, Level of Evidence A).
Postmenopausal Hormone Therapy : Postmenopausal Hormone Therapy It is recommended that postmenopausal hormone therapy (with estrogen with or without a progestin) not be used for primary prevention of stroke (Class III, Level of Evidence A).
The use of hormone replacement therapy for other indications should be informed by the risk estimate for vascular outcomes provided by the reviewed clinical trials.
Clinical trials with selective estrogen receptor modulators (tamoxifen and raloxifene) suggest that overall stroke risk may be lower with raloxifene.
Women’s Health Initiative : Women’s Health Initiative 16,608 postmenopausal women, 50-79 years, with an intact uterus at baseline were recruited by 40 U.S. clinical centers for the period 1993-1998.
Received conjugated equine estrogens, 0.625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, in 1 tablet (n = 8506) or placebo (n = 8102).
After a mean of 5.2 years of follow-up, the trial was stopped because of high rates of invasive breast cancer and the global index statistic supported risks exceeding benefits. Rossouw et al. JAMA 2002;288(3):321-333.
Estimates of Cumulative Hazards for Strokes in Women’s Health Initiative Study : Estimates of Cumulative Hazards for Strokes in Women’s Health Initiative Study Rossouw et al. JAMA 2002;288(3):321-333. Time (Years) Cumulative Hazard 0.030 0.025 0.020 0 1 2 3 4 5 6 7 0.015 0.010 0.005 0 Estrogen + Progestin
Placebo
Diet and Nutrition : Diet and Nutrition A reduced intake of sodium and increased intake of potassium are recommended to lower blood pressure in persons with hypertension (Class I, Level of Evidence A).
The DASH diet, which emphasizes fruit, vegetables, and low-fat dairy products and is reduced in saturated fat, also lowers blood pressure and is recommended (Class I, Level of Evidence A).
A diet that is rich in fruits and vegetables may lower the risk of stroke and may be considered (Class IIb, Level of Evidence C).
Physical Activity : Physical Activity Increased physical activity is recommended because it is associated with a reduction in the risk of stroke (Class I, Level of Evidence B).
Exercise guidelines as recommended by the Centers for Disease Control and Prevention and the National Institutes of Health of regular exercise (30 min or more of moderate-intensity activity daily) as part of a healthy lifestyle are reasonable (Class IIa, Level of Evidence B).
Obesity : Obesity Obesity is classified by body mass index (BMI) > 30 kg/m2
Waist-hip ratio >0.86 in women and >0.93 in men correlates with a 3-fold increased risk of stroke
Weight reduction is recommended because it lowers blood pressure (Class I, Level of Evidence A).
Alcohol Abuse : Alcohol Abuse Reduction of alcohol consumption in heavy drinkers is endorsed
through established screening and counseling methods, as outlined in the U.S. Preventive Services Task Force Update 2004
No more than 2 drinks per day for men and 1 drink per day for non-pregnant women
best reflects the state of the science for alcohol and stroke risk (Class IIb, Level of Evidence B).
Drug Abuse : Drug Abuse When a patient is identified as having a drug addiction problem, referral for appropriate counseling may be considered (Class IIb, Level of Evidence C).
Oral Contraceptives : Oral Contraceptives The incremental risk of stroke associated with use of low-dose oral contraceptives in women without additional risk factors, if one exists, appears low (Class III, Level of Evidence B).
It is suggested that oral contraceptives be discouraged in women with additional risk factors (e.g., cigarette smoking or prior thromboembolic events) (Class III, Level of Evidence C).
For those who elect to assume the increased risk, aggressive therapy of stroke risk factors may be useful (Class IIb, Level of Evidence C).
Sleep-Disordered Breathing (SDB) : Sleep-Disordered Breathing (SDB) Questioning bed partners and patients, particularly those with obesity and hypertension, about symptoms of SDB (e.g., daytime sleepiness, snoring) and referral to a sleep specialist for further evaluation as appropriate may be useful, especially in the setting of drug-resistant hypertension (Class IIb, Level of Evidence C).
Migraine : Migraine There are insufficient data to recommend a specific treatment approach that would reduce the risk of first stroke in women with migraine, including migraine with aura.
Hyperhomocysteinemia : Hyperhomocysteinemia Recommendations to meet current guidelines for daily intake of folate (400 µg/d), B6 (1.7 mg/d), and B12 (2.4 µg/d) may be useful in reducing the risk of stroke (Class IIb, Level of Evidence C).
There are insufficient data to recommend a specific treatment for reducing the risk of first stroke in patients with elevated homocysteine levels.
Use of folic acid and B vitamins in patients with known elevated homocysteine levels may be useful given their safety and low cost (Class IIb, Level of Evidence C).
Elevated Lipoprotein (a) : Elevated Lipoprotein (a) Although no definitive recommendations regarding Lp(a) modification can be made because of an absence of outcome studies showing clinical benefit, treatment with niacin (extended-release or immediate-release formulation at a total daily dose of 2,000 mg/d as tolerated) can be considered because it reduces Lp(a) levels by approximately 25% (Class IIb, Level of Evidence C).
Elevated Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) : Elevated Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) No recommendations regarding Lp-PLA2 modification can be made because of an absence of outcome studies showing clinical benefit with reduction in its blood levels.
Hypercoagulability : Hypercoagulability The majority of case-control studies have not found an association between hereditary hypercoagulable states and ischemic stroke.
Young women with acquired antiphospholipid syndrome may represent a high risk group.
There are insufficient data to support specific recommendations for primary stroke prevention in patients with a hereditary or acquired thrombophilia.
Inflammation : Inflammation There is currently no evidence to support the use of hs-CRP screening of the entire adult population as a marker of general vascular risk.
Aggressive risk factor modification is recommended for patients at high risk for stroke given exposure to traditional risk factors regardless of hs-CRP level.
In agreement with AHA/CDC guidelines, hs-CRP can be useful when considering the intensity of risk factor modification in those at moderate general cardiovascular risk based on traditional risk factors (Class IIa, Level of Evidence B).
Aspirin-1 : Aspirin-1 Aspirin is not recommended for the prevention of a first stroke in men (Class III, Level of Evidence A).
Aspirin can be useful for prevention of a first stroke among women whose risk is sufficiently high for the benefits to outweigh the risks associated with treatment (Class IIa, Level of Evidence B).
Women’s Health Study - Aspirin : Women’s Health Study - Aspirin
Aspirin-2 : Aspirin-2 The use of aspirin is recommended for cardiovascular (including but not specific to stroke) prophylaxis among persons whose risk is sufficiently high for the benefits to outweigh the risks associated with treatment (a 10-year risk of cardiovascular events of 6% to 10%) (Class I, Level of Evidence A).
Summary : Summary All individuals should have their risk of stroke assessed.
All modifiable risk factors should be aggressively treated.
Individuals with non-modifiable risk factors should be aggressively studied for the identification and treatment of modifiable risk factors.