The 2024 Guideline for the Primary Prevention of Stroke from the American Heart Association/American Stroke Association outlined updates for stroke prevention strategies.
Key recommendations addressed hypertension, lipid management, diabetes, and social determinants of health.
Blood Pressure Control
Randomized trials demonstrated that lowering systolic blood pressure to below 130/80 mm Hg reduced stroke risk by 30-40%. The guidelines recommend most patients require treatment with 2 or more antihypertensive medications to achieve the necessary blood pressure control. Thiazide and thiazide-like diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers were recommended as initial therapies.
Lipid Management
Statin therapy was recommended for patients with LDL cholesterol levels above 190 mg/dL or those with a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 20% or more, reducing the risk of first stroke by approximately 20%. For statin-intolerant patients with LDL-C over 100 mg/dL and elevated cardiovascular risk, bempedoic acid should be considered, though its benefit for primary stroke prevention is not well established.
Diabetes Management
In patients with diabetes and high cardiovascular risk or established cardiovascular disease, and hemoglobin A1c of 7% or higher, treatment with a GLP-1 receptor agonist was recommended to reduce the risk of stroke. The SUSTAIN-6 trial demonstrated semaglutide reduced stroke risk by 39% compared to placebo.
Social Determinants of Health
The guidelines emphasized the importance of screening for social determinants of health in adults 18 years or older. Factors such as food insecurity, transportation challenges, and other socioeconomic conditions contribute to stroke risk. While interventions for addressing these factors are evolving, screening was recommended to identify at-risk individuals.
Screening for obstructive sleep apnea (OSA) remains unclear in terms of stroke prevention, but continuous positive airway pressure might be reasonable to reduce stroke risk in patients with OSA. In individuals with asymptomatic cerebral small vessel disease, including silent infarcts, managing risk factors was recommended.
For individuals with migraine with aura who desire contraception, progestin-only or nonhormonal forms were recommended to avoid increased stroke risk associated with combined hormonal contraception. Treatment of systolic blood pressure of 160 mm Hg or higher or diastolic blood pressure of 110 mm Hg or higher during pregnancy was recommended to reduce the risk of fatal maternal intracerebral hemorrhage. Additionally, screening for a history of endometriosis is considered reasonable to assess stroke risk.
