Stroke Prevention

Primary prevention refers to the treatment of individuals with no previous history of stroke. Measures
may include the use of platelet antiaggregants; 3-hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase inhibitors (ie, statins); and exercise.
Secondary prevention refers to the treatment of individuals who have already had a stroke. Measures
may include the use of platelet antiaggregants, antihypertensives, HMG-CoA reductase inhibitors
(statins), and lifestyle interventions.
Smoking cessation, blood pressure control, diabetes control, a low-fat diet, weight loss, and regular
exercise should be encouraged as strongly as the medications described above. Written prescriptions
for exercise and medications for smoking cessation (nicotine patch, bupropion, varenicline) increase
the likelihood of success with these interventions.
The use of aspirin for primary stroke prevention is not recommended for persons at low risk. Aspirin
is recommended for this purpose only in persons with at least a 6-10% risk of cardiovascular events
over 10 years.[75]
For patients with stroke risk due to asymptomatic carotid artery stenosis, the 2011 AHA/ASA
primary prevention guidelines state that older studies that showed revascularization surgery as more
beneficial than medical treatment may now be obsolete due to improvements in medical therapies.
Therefore, individual patient comorbidities, life expectancy, and preferences should determine
whether medical treatment alone or carotid revascularization is selected.[75]
Atrial fibrillation is a major risk factor for stroke. The 2011 ACC Foundation (ACCF)/AHA/Heart
Rhythm Society (HRS) atrial fibrillation guideline update on dabigatran states that the new
anticoagulant dabigatran is useful as an alternative to warfarin in patients with atrial fibrillation who
do not have a prosthetic heart valve or hemodynamically significant valve disease.[76]
The 2011 AHA/ASA primary stroke prevention guideline recommends that EDs screen for AF and
assess patients for anticoagulation therapy if AF is found.[75]
For patients with atrial fibrillation after stroke or TIA, the 2010 AHA/ASA secondary stroke
prevention guideline is in accord with the standard recommendation of warfarin, with aspirin as an
alternative for patients who cannot take oral anticoagulants. However, clopidogrel should not be used
in combination with aspirin for such patients because the bleeding risk of the combination is
comparable to that of warfarin. The guideline states that the benefit of warfarin after stroke or TIA in
patients without atrial fibrillation has not been established.[77]
The 2011 AHA/ASA guideline recommends ED-based smoking cessation interventions,
and considers it reasonable for EDs to screen patients for hypertension and drug abuse.
[75]