For the first time, nonmedical factors have been listed in new clinical guidelines relating to stroke. Released on October 21 by the American Stroke Association, the 2024 Guideline for the Primary Prevention of Stroke requires health practitioners to consider lifestyle factors when assessing a patient’s stroke risk.
The new requirements replace the last set of guidelines published a decade ago. They contain recommendations for strategies to support brain health and prevention strategies for those who have no prior history of stroke.
“The most effective way to reduce the occurrence of a stroke-related death is to prevent the first stroke—referred to as primary prevention,” chair of the guideline writing group Cheryl D. Bushnell, MD, MHS, FAHA, said.
The four main components clinicians must now consider are:
Identification and management
Primary causes for stroke include unidentified and unmanaged cardiovascular disease risk factors, which can damage arteries, the brain, and the heart years before heart disease or stroke presents in patients.
Modifiable risk factors for stroke include high blood pressure, overweight and obesity, elevated cholesterol, and elevated blood sugar.
These conditions should be addressed with healthy lifestyle and behaviour modifications, which may include medications for select patients, such as antihypertensive medications, statins, and the novel consideration of glucagon-like peptide 1 receptor agonist medications.
Healthy lifestyle behaviours
The American Heart Association’s Life’s Essential 8 cardiovascular health metrics include nutrition, regular physical activity, avoiding tobacco, healthy sleep and weight, controlling cholesterol, and managing blood pressure and sugar.
Specifically, the guideline recommends a Mediterranean diet even for adults with no prior cardiovascular risk. The guideline also emphasises the importance of physical activity as an essential tool for stroke risk reduction and overall heart health.
The US Department of Health and Human Services, reemphasised by the recent stroke guidelines, recommends that adults should get at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity.
Emphasis on health equity
A new aspect of the guideline update is their emphasis on social determinants of health and their impact on stroke risk.
These are nonmedical factors, including education, economic stability, access to care, discrimination, structural racism, and neighbourhood factors (such as living in a food desert). Healthcare professionals should ensure accessibility to patient education of various educational and language levels.
Sex and gender-specific recommendations
Updated gender- and sex-specific recommendations for women have been named.
Factors such as the use of oral contraception, high blood pressure during pregnancy, premature birth, endometriosis, premature ovarian failure, and early onset menopause should be screened and considered for elevating stroke risk.
Transgender women and gender-diverse individuals taking oestrogen for gender affirmation may also be at an increased risk for stroke. Therefore, these factors need to be considered in evaluating stroke risk in these populations, the new guidelines state.
