Guidelines for the Primary Prevention of Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
Abstract
Background and Purpose—: This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke. Methods—: Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria ( Tables 1 and 2 ). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results—: Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed. Conclusion—: Extensive evidence identifies a variety of specific factors that increase the risk of a first stroke and that provide strategies for reducing that risk.
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In that heart failure trial, intense interval training was associated with a 40% decrease in pro-brain natriuretic peptide.
“Intense activity (an aerobic interval-training program 3 times per week for 12 weeks) was associated with a significant 35% improvement in left ventricular ejection fraction (EF) and decreases in pro-brain natriuretic peptide (40%), left ventricular end-diastolic volume (18%), and left ventricular end-systolic volume (25%) compared with control and endurance-training groups.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
In that heart failure trial, intense interval training was associated with a 25% decrease in left ventricular end-systolic volume.
“Intense activity (an aerobic interval-training program 3 times per week for 12 weeks) was associated with a significant 35% improvement in left ventricular ejection fraction (EF) and decreases in pro-brain natriuretic peptide (40%), left ventricular end-diastolic volume (18%), and left ventricular end-systolic volume (25%) compared with control and endurance-training groups.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
In a trial of 27 patients with stable, medically treated heart failure, intense aerobic interval training 3 times per week for 12 weeks was associated with a 35% improvement in left ventricular ejection fraction compared with control and endurance-training groups.
“Intense activity (an aerobic interval-training program 3 times per week for 12 weeks) was associated with a significant 35% improvement in left ventricular ejection fraction (EF) and decreases in pro-brain natriuretic peptide (40%), left ventricular end-diastolic volume (18%), and left ventricular end-systolic volume (25%) compared with control and endurance-training groups.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
In that heart failure trial, intense interval training was associated with an 18% decrease in left ventricular end-diastolic volume.
“Intense activity (an aerobic interval-training program 3 times per week for 12 weeks) was associated with a significant 35% improvement in left ventricular ejection fraction (EF) and decreases in pro-brain natriuretic peptide (40%), left ventricular end-diastolic volume (18%), and left ventricular end-systolic volume (25%) compared with control and endurance-training groups.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
Relative risks for hemorrhagic stroke were 1.01 and 1.24 for overweight and obese individuals, respectively.
“RRs for hemorrhagic stroke were 1.01 (0.88–1.17) and 1.24 (0.99–1.54) for overweight and obese individuals, respectively.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
Among FHS participants with diabetes, the age- and sex-adjusted CVD incidence rate was 286.4 per 10,000 person-years in the earlier period and 146.9 per 10,000 person-years in the later period, a 35.4% decline.
“Among participants with DM, the age- and sex-adjusted CVD incidence rate was 286.4 per 10 000 person-years in the earlier period and 146.9 per 10 000 person-years in the later period, a 35.4% decline.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
Hazard ratios for diabetes as a predictor of incident CVD were not significantly different in the earlier period (risk factor-adjusted HR 2.68; 95% CI 1.88-3.82) versus the later period (HR 1.96; 95% CI 1.44-2.66).
“HRs for DM as a predictor of incident CVD were not significantly different in the earlier (risk factor–adjusted HR, 2.68; 95% CI, 1.88–3.82) versus later (HR, 1.96; 95% CI, 1.44–2.66) period.34”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
FHS data show that despite improvements in CVD morbidity and mortality, diabetes continues to be associated with incremental CVD risk.
“Data from FHS show that despite improvements in CVD morbidity and mortality, DM continues to be associated with incremental CVD risk.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
Metabolic syndrome is linked to greater healthcare use and costs in people with and without DM.
“The metabolic syndrome is associated with increased healthcare use and healthcare-related costs among individuals with and without DM.”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
Each additional metabolic syndrome component is associated with about a 24% rise in healthcare costs.
“Overall, healthcare costs increase by ≈24% for each additional metabolic syndrome component present.34”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
Having both albuminuria/proteinuria and reduced eGFR places people at especially high risk for CVD, CVD outcomes, and death.
“People with both albuminuria/proteinuria and reduced eGFR are at particularly high risk for CVD, CVD outcomes, and death.34”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
Individuals who have a TIA and survive the initial high-risk period have a 10-year stroke risk of roughly 19%.
“Individuals who have a TIA and survive the initial high-risk period have a 10-year stroke risk of roughly 19% and a combined 10-year stroke, MI, or vascular death risk of 43% (4% per year).34”
From Heart Disease and Stroke Statistics—2013 Update: A Report From the American Heart Association (2013) · cites this paper as [34]
There are reports suggesting that the outcome of cerebral infarction that occurs during the course of treatment with statins is satisfactory.
“There are also other reports suggesting that the outcome of cerebral infarction that occurs during the course of treatment with statins is satisfactory866), and that cerebral infarction risk increases as a result of discontinuing statin treatment867).”
From Japan Atherosclerosis Society (JAS) guidelines for prevention of atherosclerotic cardiovascular diseases 2017 (2018) · cites this paper as [866]
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- Authors
- Goldstein, L. B., Bushnell, C. D., Adams, R. J., Appel, L. J., Braun, L. T., Chaturvedi, S., Creager, M. A., Culebras, A., Eckel, R. H., Hart, R. G., Hinchey, J. A., Howard, V. J., Jauch, E. C., Levine, S. R., Meschia, J. F., Moore, W. S., Nixon, J. V. (., & Pearson, T. A.
- Affiliations
- American Heart Association (US)
- ORCID
- Venue
- Stroke
- Published
- 2011-02
- Volume
- 42
- Issue
- 2
- Pages
- 517-584
- ISSN
- 0039-2499 (ISSN-L)
- 1524-4628
- OpenAlex
- W4211201192
- Semantic Scholar
- 3d07af22ceda0b5c157f83800d855a75eb4ea554
- Cited by
- 1,306
- References
- 719
- Citations by year
- 2026: 25 · 2025: 25 · 2024: 39 · 2023: 39 · 2022: 39 · 2021: 46 · 2020: 68 · 2019: 72 · 2018: 82 · 2017: 96 · 2016: 99 · 2015: 124 · 2014: 187 · 2013: 126 · 2012: 162
- FWCI
- 85.19
- Type
- journal article
- Language
- en
- Update notices
- correction (2011-02-01)
- Open access
- closed
- Locations
- Stroke (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Keywords
- primary prevention, stroke risk factors, risk assessment, modifiable risk factors, hypertension, atrial fibrillation, dyslipidemia, carotid artery stenosis, diabetes mellitus, obesity, aspirin, hyperhomocysteinemia, metabolic syndrome, alcohol consumption, sleep-disordered breathing, migraine, hypercoagulability, inflammation, infection, hormone replacement therapy, sickle cell disease, cigarette smoking
- MeSH terms
- American Heart Association, Health Personnel, Humans, Primary Prevention, Risk Factors, United States, Evidence-Based Medicine, Stroke
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