What are the strategies for preventing a cerebrovascular accident (CVA) or stroke?

From the Guidelines

Preventing strokes requires a comprehensive approach focusing on modifiable risk factors, with blood pressure management being critical, and the use of ≥ 2 antihypertensive medications recommended for primary stroke prevention in most patients who require pharmacological treatment of hypertension, as stated in the 2024 guideline for the primary prevention of stroke 1. To achieve this, start by maintaining healthy blood pressure (below 120/80 mmHg) through regular monitoring, medication if prescribed, and reducing sodium intake. Some key points to consider include:

• Control cholesterol with statins like atorvastatin (20-80mg daily) if levels are elevated
• For those with atrial fibrillation, anticoagulants such as apixaban (5mg twice daily), rivaroxaban (20mg daily), or warfarin (dose adjusted to maintain INR 2-3) are essential
• Adopt a Mediterranean-style diet rich in fruits, vegetables, whole grains, fish, and olive oil while limiting processed foods and saturated fats
• Exercise regularly, aiming for at least 150 minutes of moderate activity weekly
• If you smoke, quit immediately using cessation aids if needed
• Limit alcohol to no more than one drink daily for women and two for men
• Manage diabetes by maintaining blood glucose levels within target ranges These measures work by reducing arterial plaque formation, preventing blood clots, improving blood vessel health, and enhancing overall cardiovascular function, significantly lowering your stroke risk over time. Additionally, specific populations such as those with antiphospholipid syndrome, systemic lupus erythematosus, or transgender women taking estrogens for gender affirmation may require special consideration and evaluation of risk factors to reduce stroke risk, as highlighted in the 2024 guideline 1.

In terms of specific medication recommendations, the use of antiplatelet agents, such as aspirin, is recommended for patients with ischemic stroke, as stated in the 2008 Australian clinical guidelines for acute stroke management 1. Furthermore, the 2011 guidelines for the prevention of stroke in patients with stroke or transient ischemic attack emphasize the importance of controlling risk factors, including hypertension, hyperlipidemia, and diabetes mellitus, and using antithrombotic treatments for cardioembolism 1. The 2014 guidelines for the primary prevention of stroke also highlight the importance of lifestyle changes, including cessation of smoking and changes in diet, in addition to medical or surgical measures to prevent recurrent stroke 1. Overall, a comprehensive approach to stroke prevention, incorporating both medical and lifestyle interventions, is essential for reducing the risk of stroke and improving outcomes.

From the Research

Stroke Prevention Strategies

• Hypertension is considered the main classic vascular risk factor for stroke, and lowering blood pressure is well established as a key strategy for stroke prevention 2, 3, 4
• The relationship between blood pressure and stroke risk is strong and continuous, with higher blood pressure associated with a greater risk of stroke 4
• Regular blood pressure screening and appropriate treatment of patients with hypertension, including lifestyle modification and pharmacotherapy, are recommended 4

Antihypertensive Therapy

• Angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), dihydropyridine calcium channel blockers (CCB), and thiazide diuretics have been shown to reduce the risk of stroke compared with placebo or no treatment 2, 5
• Combination antihypertensive therapy with a renin-angiotensin-aldosterone system (RAAS) blocker and a CCB may help reduce stroke incidence to a greater extent than either of the monotherapies 5
• Fixed-dose combination therapy is an important consideration in optimizing blood pressure control and patient adherence to therapy in stroke prevention 5

Treatment Goals

• Current guidelines recommend a systolic/diastolic BP goal of <140/<90 mmHg in the general population and <130/80 mmHg in diabetics and in subjects with high cardiovascular risk and renal disease 2, 4
• In patients with lacunar infarction, those taking antithrombotic drugs, cerebral hemorrhage, and subarachnoid hemorrhage, a lower level, <130/80 mmHg, should be targeted if possible 4

Choice of Antihypertensive Agent

• ACE inhibitors and ARBs have been shown to be effective in stroke prevention, with no difference in efficacy between the two classes of agents 6
• However, ACE inhibitors are associated with a higher risk of adverse events, such as cough and angioedema, compared with ARBs 6