New Guidelines on How to Prevent a Stroke

You can’t change certain risk factors for a first-time stroke, such as your age and family history. But you can control other risk factors, and these account for about 90 percent of all strokes.

The American Heart Association (AHA) and the American Stroke Association (ASA) have introduced important strategies to prevent first-time stroke. The updated guidelines reinforce the importance of exercise, weight loss, quitting smoking, controlling diabetes, curbing heavy drinking, and treating sleep disorders to reduce stroke risk.

Below are highlights of their updated guidelines that you should be aware of, especially if you’re at high risk for stroke.

A bigger role for anticoagulants

Atrial fibrillation (AF), a type of abnormal heart rhythm, is associated with a four- to fivefold increased risk of ischemic stroke. (Consequently, the guidelines recommend primary care doctors screen people over age 65 for AF.) The blood-thinning drug warfarin (Coumadin), the most commonly prescribed drug to control AF in patients at high risk of stroke, is still recommended. But many AF patients are reluctant to take warfarin because of its burdensome monitoring regimen—frequent blood tests— dietary restrictions, and potential adverse effects such as a high risk of bleeding.

The updated guidelines add dabigatran (Pradaxa), apixaban (Eliquis), and rivaroxaban (Xarelto) as recommended anticoagulants for patients with nonvalvular AF and a high risk of stroke. Compared with warfarin, all three drugs have an easier regimen, are safer and don’t restrict diet— but they’re more expensive and, unlike warfarin, lack an antidote, such as vitamin K, to reverse any severe bleeding.

However, if you have valvular AF and are at high stroke risk, the guidelines recommend only warfarin. This includes patients with valvular heart disease and/or valvular prostheses.

The Mediterranean diet

Past and current guidelines tout the benefits of a low-sodium, high-potassium diet rich in fruits and vegetables to help keep blood pressure in check and, subsequently, lower stroke risk. But this is the first time the guidelines suggest people consider the Mediterranean diet to help lower first-time stroke risk.

The eating plan focuses on olive oil, tree nuts and peanuts, fresh fruits, vegetables, fish, legumes, poultry and fish, and optional wine with meals. It discourages soda, commercial bakery goods, red meat, and fatty spreads such as butter and margarine.

What’s more, the stroke guidelines encourage supplementing the diet with a daily serving of nuts instead of the typical Mediterranean diet’s recommendation of one serving of nuts at least three times a week.

Do-it-yourself blood pressure monitoring

If you have hypertension (high blood pressure) and you’re not already monitoring your blood pressure at home, you should be, say the guidelines. Lowering blood pressure is the most effective strategy for stroke prevention.
Studies show that routine self-measured monitoring with a digital upper-arm cuff device, along with continued regular screenings by doctors, can help patients better control blood pressure.

Hypertension prevention

The updated recommendations place added emphasis on preventing prehypertension—defined by the guidelines as 120 to 139/80 to 89 mm Hg—from becoming full-blown hypertension. If you’re prehypertensive, get screened for hypertension at least once a year by your doctor. Lifestyle changes such as regular physical activity and a healthful diet low in sodium can help lower blood pressure. If you have hypertension, consider antihypertensive drugs to lower blood pressure to 140/90 mm Hg or below.

A move away from LDL targets

While the revised guidelines still recommend statins for the primary prevention of ischemic stroke, your doctor will no longer look to your low-density lipoprotein (LDL), or “bad,” cholesterol level to decide whether you’re a candidate for the therapy. Instead, he or she will base your eligibility on a calculation of your 10-year risk for stroke or heart attack. The higher your risk—not your cholesterol levels—the more intensive your statin therapy should be. This portion of the guideline is controversial and currently in dispute
by many experts who still recommend target LDL levels as before.

A warning for migraine sufferers

Migraines with visual disturbances, or auras, are associated with a significantly increased ischemic stroke risk, especially in women younger than age 55. Evidence is lacking on whether treating women for migraines would prevent a first stroke, but the guidelines say treatment may be reasonably considered. However, if you have aural migraines and smoke, you can take immediate action—quit lighting up. Smoking significantly boosts stroke risk in women who have migraine with aura.

More restrictions for smokers

The guidelines acknowledge the dangers of secondhand smoke when it comes to increas- ing stroke and heart attack risk and call for bans on smoking in public places.

An aspirin-therapy update

If your doctor deems you at high risk for stroke, he or she can consider prescribing aspirin therapy—typically reserved for heart attack prevention—say the guidelines, as long as the drug’s risks (like bleeding in the stomach or brain) don’t outweigh its benefits.

Drug therapy for certain health conditions

The guidelines make new recommendations regarding treatment for certain cardiac and other conditions associated with increased stroke risk. In some cases, these conditions warrant drug therapy, such as anticoagulants, statins, and aspirin or other antiplatelets. Ask your doctor whether you should consider new stroke-prevention strategies if you have had a heart attack or currently have any of the following:

• Chronic kidney disease

• Peripheral artery disease (plaque buildup in the limbs)

• Valvular heart disease

• Aortic atherosclerosis (hardening of the arteries)

• Heart failure

• Carotid stenosis (plaque build-up in the carotid artery)

• Atrial septal aneurysms (a congenital abnormality of the heart’s interatrial septum)

• Cardiomyopathy (diseases of the heart muscle)

• Patent foramen ovale (a hole between two heart chambers)

A new way to assess risk

Doctors should use a risk assessment tool to aid in predicting their patients’ chances of having a stroke. The guidelines encourage them to use the same risk calculator introduced in 2013 guidelines on managing cholesterol. The tool takes into account a number of factors to identify people at elevated risk for heart attack and stroke, helping to guide treatment when combined with a patient’s individual risk profile.

The updated stroke guidelines also recommend that doctors consider obtaining their patients’ family history to help assess risk and referring patients with rare genetic causes of stroke for genetic counseling to help guide more targeted treatment.

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HealthAfter50 was published by the University of California, Berkeley, School of Public Health, providing up-to-date, evidence-based research and expert advice on the prevention, diagnosis, and treatment of a wide range of health conditions affecting adults in middle age and beyond. It was previously part of Remedy Health Media's network of digital and print publications, which also include HealthCentral; HIV/AIDS resources The Body and The Body Pro; the UC Berkeley Wellness Letter; and the Berkeley Wellness website. All content from HA50 merged into in 2018.