Features February 2015 Issue

New Stroke Prevention Guidelines Emphasize Lifestyle Changes

The new recommendations also stress the importance of new anticoagulant medications for individuals who have atrial fibrillation.

Stroke continues to be one of the leading causes of death in the U.S., even though several of the most serious stroke risk factors can often be managed with lifestyle changes and medications. Attention to those factors was at the heart of the most recent update of primary stroke prevention guidelines from the American Heart Association/American Stroke Association (AHA/ASA).

Image: Wikimedia / Blausen

A blood clot in a brain artery can cause a stroke.

The new guidelines also focus on medication use to help prevent strokes in people with atrial fibrillation (AF), a common heart rhythm disturbance and a major risk factor for stroke.

“I would recommend that the majority of people continue to focus on evaluation and treatment of modifiable risk factors for stroke, such as hypertension, dyslipidemia, obesity, diabetes, and smoking,” says Cleveland Clinic neurologist and stroke expert Megan Donohue, MD. “Certainly, if someone has any specific risk factors, such as atrial fibrillation, certain cardiac conditions, or severe carotid artery stenosis, specific recommendations can be found within the updated guidelines.”  

Understanding stroke risk
The AHA/ASA guidelines are updated periodically to help make sure applicable new research becomes part of the recommendations physicians use with their patients. The guidelines released near the end of 2014 include four years of literature on the subject.

“I think they offer an excellent guide on how to prevent stroke in people who have never had a stroke or transient ischemic attack (TIA) before,” Dr. Donohue says. A TIA is a brief event in which a person has stroke symptoms, but only temporarily. Usually there are no lasting effects of a TIA, but the events are often precursors to full-blown strokes and must be taken seriously.

Of the nearly 800,000 strokes that occur in the U.S. annually, about three quarters are first-time strokes. But research shows that an estimated 90 percent of stroke risk is associated with modifiable risk factors, such as high blood pressure, obesity, and smoking. Researchers noted that while managing these risk factors can’t completely eliminate your stroke risk, it can substantially lower the odds.

Guideline highlights
Among the updated recommendations in the new guidelines are the use of statins, along with diet and exercise, to help lower the stroke risk in people who are determined to have high stroke risk within the next 10 years. An online risk calculator developed a little more than a year ago uses certain criteria to determine your 10-year risk of stroke, though some experts are divided on the accuracy of the calculator and its role in guiding a patient’s preventive care.

There is little dispute, however, about the role of new anticoagulants for patients with AF. In recent years, alternatives to the widely used drug warfarin (Coumadin ®), have emerged. Though some of these new drugs are more expensive than warfarin, they do require less ongoing monitoring, and therefore represent reasonable options for patients and their physicians.

The new guidelines also recommend that people with asymptomatic carotid artery stenosis take a daily aspirin and statin. Carotid artery stenosis is a narrowing of the blood vessels that carry blood up each side of the neck to the brain. A restriction of blood flow in the carotid arteries caused by a buildup of plaque is a common cause of ischemic stroke.

The two main types of strokes are ischemic, which is caused by a blockage of blood flow in an artery supplying blood to brain tissue; and hemorrhagic, which occurs when a weakened blood vessel in the brain ruptures and bleeds into surrounding brain tissue.

Women and stroke
The updated guidelines also include language specifically geared toward stroke prevention in women. They note the elevated stroke risks associated with women-only issues, such as pregnancy, oral contraception use and hormone replacement therapy (HRT), as well as conditions more common to women, such as migraine headaches and depression.

Because migraines with aura are associated with a higher stroke risk, if you experience these severe headaches, you should tell your doctor and consider more aggressive stroke prevention behaviors. HRT is also associated with higher risks of cardiovascular disease and stroke.

“I think these guidelines are important for several reasons,” Dr. Donohue says. “First, the addition of separate guidelines helps recognize some of the different risk factors that women face throughout their life. Secondly, the document summarizes the data behind these risk factors and the treatment into a reference that clinicians can quickly refer to. Finally, the authors suggest that we need to use these separate risks to develop a female-specific stroke risk calculator to better provide accurate stroke risk assessment for women.”

Blood pressure control is key
What is true for both men and women is the need for blood pressure control to help prevent stroke. The new guidelines emphasize the importance of lowering blood pressure, the primary risk factor for stroke. The document stresses cutting back on sodium, while also making sure your diet is rich in potassium. Foods high in potassium include sweet potatoes, tomatoes (as well as tomato paste and tomato puree), white beans, yogurt, halibut and tuna, bananas, and spinach.

“Elevated blood pressure remains the most important modifiable risk factor for stroke,” Dr. Donohue says. “One of the dangers of hypertension is that people might not know if they have it unless they see a doctor regularly.”

The new guidelines therefore recommend you monitor your own blood pressure at home to help maintain control.

Dr. Donohue also emphasizes the relationship between stroke risk and elevated blood pressure that may be considered below the “official” cutoff for hypertension: 140/90 mm Hg. Systolic blood pressure readings (the top numbers) of 120 to 139 and diastolic readings (bottom numbers) of 80 to 89 are considered prehypertension.

The treatment of prehyper­tension through lifestyle changes can significantly lower your stroke risk,” Dr. Donohue says. “The lifestyle changes include a diet rich in fruits, vegetables, nuts, and low-fat dairy products, while being low in sodium. You should combine that with vigorous aerobic activity 40 minutes per day, at least three to four days per week.”

The takeaway
Guidelines to help prevent stroke will continue to be updated as new research emerges. But several key points aren’t likely to change.

Control your blood pressure with a combination of a healthy lifestyle and medications. If you don’t know your blood pressure or your blood pressure target, talk with your doctor about what you can do to reach and maintain your goals.

The other steps include living an overall healthier life, which includes no smoking, drinking alcohol in moderation (if at all), reducing stress in your life, staying physically active, and getting regular checkups. The final piece of advice is to treat conditions such as AF and carotid artery disease, even if surgery is required.

Strokes can be profoundly debilitating, but reducing your odds of having a stroke are well within your grasp.

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