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• The most important way to prevent ASCVD is to promote a healthy lifestyle
throughout life. Prevention strategies must include a strong focus on lifestyle
optimization (improvements in diet, physical activity, and avoidance of smoking)
to minimize the risk of future ASCVD events.
• Only when a person’s risk is sufficiently high should medications to reduce ASCVD
risk be considered as part of a shared decision-making process for optimal
treatment.
Stroke modifiable risk factors
Ten potentially modifiable risk factors account for 90% of the
population attributable risks of stroke:
hypertension,
regular physical activity,
dyslipidemia,
diet,
obesity,
psychosocial factors,
smoking,
cardiac causes,
alcohol consumption, and
diabetes mellitus
Up to 75 percent of this burden may be reduced by both
therapeutic lifestyle changes (TLCs) and adjunctive drug
therapies of proven benefit.
Yusuf S, et al. Lancet 2004;336:937-
INTRODUCTION
RISK FACTORS AND MECHANISMS
INTERVENTIONS
SUMMARY AND RECOMMENDATIONS
The major modifiable risk factors for stroke
Hypertension
Diabetes mellitus
Smoking
Dyslipidemia
Physical inactivity
Important risk factors amenable to
effective secondary prevention
Atrial fibrillation
Carotid artery stenosis
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Important but unmodifiable risk factors
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RISKESDAS 2013
Physical Inactivity
Low physical activity and prolonged sitting increases
the risk of cardiovascular disease, including stroke.
Studies showing the benefit of increased physical
activity and exercise for reducing the risk of
cardiovascular events.
Copyrights apply
Atrial Fibrillation
The most common cause of cardioembolic ischemic
stroke
Amenable to effective secondary prevention with
anticoagulation
Large and small vessel disease
The risk of ischemic stroke due to symptomatic carotid
artery stenosis can be effectively treated with
revascularization combined with intensive medical
management.
The mainstay of secondary prevention of large and
small vessel ischemic stroke or TIA is intensive medical
management including treatment with:
antiplatelet agents,
antihypertensive drugs,
statins, and
lifestyle modification
Metabolic Syndrome
Defined by the presence of three or more of the following:
abdominal obesity,
hypertriglycerides ≥150 mg/dL,
high-density lipoprotein (HDL) <40 mg/dL in men or <50 mg/dL in
women,
systolic blood pressure ≥130 mmHg or diastolic blood pressure
≥85,
fasting glucose ≥100 mg/dL.
A 10-year risk of a first CHD event of 16 to 18 percent,
which is as high as many individuals who have already had
an MI or stroke.
Considered to be a prediabetic condition linked to
increased risk of cardiovascular disease.
INTRODUCTION
RISK FACTORS AND MECHANISMS
INTERVENTIONS
SUMMARY AND RECOMMENDATIONS
INTERVENTIONS
Patients with an ischemic stroke or transient ischemic attack
(TIA) should be treated with all available risk reduction
strategies.
Currently viable strategies include:
blood pressure reduction,
statin therapy,
antithrombotic therapy,
lifestyle modification,
select patients with symptomatic carotid disease may benefit from
revascularization.
Treatment of all major stroke risk factors, compared with no
treatment, would reduce the risk of recurrent stroke by 80 %.
Antihypertensive therapy
In accordance with American Heart Association/American Stroke
Association (AHA/ASA) guidelines 2014:
resumption of antihypertensive therapy for previously treated patients with
known hypertension for both prevention of recurrent stroke and prevention
of other vascular events.
initiation of antihypertensive therapy for patients with any type of ischemic
stroke or TIA who have an established blood pressure ≥140 mmHg systolic or
≥90 mmHg diastolic.
Unlike the 2014 AHA/ASA guidelines, there is a suggestion (a weaker
recommendation) to initiateof antihypertensive therapy for previously
untreated patients with ischemic stroke or TIA of atherothrombotic, lacunar
(small vessel occlusive), or cryptogenic type, whose baseline blood pressure
is >120 mmHg systolic or >70 mmHg diastolic.
Do not give antihypertensive therapy for nonhypertensive patients (ie, blood
pressure <130/80 mmHg) who have had an ischemic stroke or TIA due to a
cardioembolic phenomenon (eg, atrial fibrillation).
Antihypertensive therapy…cont’d
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Lifestyle modification
A number of behavioral and lifestyle modifications may be
beneficial for reducing the risk of ischemic stroke and
cardiovascular disease.
These include:
smoking cessation,
limited alcohol consumption,
weight control,
regular aerobic physical activity,
moderate to vigorous intensity physical exercise most days of the week for
at least 40 minutes
moderate intensity exercise is defined as activity sufficient to break a sweat
or noticeably raise the heart rate
salt restriction, and
a Mediterranean diet
Diet
Patients with a history of stroke or TIA, are encouraged to
follow a Mediterranean-type diet that emphasizes the intake of
vegetables, fruits, whole grains, low-fat dairy products, poultry,
fish, legumes, nontropical vegetable oils, and nuts.
Limits the intake of sweets, sugar-sweetened beverages, and
red meats.
Calories from saturated fat should be limited to 5 to 6 percent
and calories from trans-fat should be reduced.
For patients who would benefit from blood pressure lowering,
a reduction in sodium (< 2400 mg per day) is also suggested.
The 2013 American Heart Association/American College of Cardiology (AHA/ACC) guideline on lifestyle management
to reduce cardiovascular risk;
The 2014 AHA/ASA guideline for stroke prevention in patients with stroke or TIA
Weight reduction
Weight reduction for obese patients is potentially
beneficial for improved control of other important
parameters, including blood pressure, blood glucose,
and serum lipid levels.
The 2014 AHA/ASA guidelines for stroke prevention
recommend screening all patients with stroke or TIA
for obesity with measurement of body mass index
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Revascularization
Revascularization of the cervical
internal carotid artery with
endarterectomy or stenting is
beneficial for patients with recently
symptomatic ICA atherosclerotic
disease
There is no proven benefit of
revascularization for patients with
large vessel atherothrombotic
disease in anterior and posterior
cerebral circulation sites other than
the cervical internal carotid artery.
Polypills
Contain various combinations of statins, antihypertensive
medications, and aspirin.
Potential advantages include increased compliance and decreased
costs.
May be useful as a population-based strategy in resource limited
settings.
Potential disadvantages include increased adverse effects, individual
patient variability concerning the optimal combination of
medications, and difficulty in titration.
Contained hydrochlorothiazide 12.5 mg, aspirin 81
mg, atorvastatin 20 mg, and enalapril 5 mg; participants who
developed a cough were switched to a polypill
containing valsartan 40 mg instead of enalapril.
The polypill demonstrated efficacy in both primary and secondary
prevention.
INTRODUCTION
RISK FACTORS AND MECHANISMS
INTERVENTIONS
SUMMARY AND RECOMMENDATIONS
SUMMARY AND RECOMMENDATIONS
1. The major treatable atherosclerotic stroke risk factors are hypertension, diabetes,
smoking, and dyslipidemia. Common causes of ischemic stroke amenable to treatment
include atrial fibrillation and carotid artery stenosis.
2. Most patients with an ischemic stroke or transient ischemic attack (TIA) should be
treated with all available risk reduction strategies.
3. Resumption of antihypertensive therapy is recommended for:
Previously treated patients with known hypertension who are beyond the first few days
after stroke onset.
Patients previously untreated with antihypertensive therapy who are beyond the first
few days after stroke onset, we make the following recommendations:
Patients with ischemic stroke or TIA of any type who have an established blood
pressure ≥140 mmHg systolic or ≥90 mmHg diastolic.
Patients with ischemic stroke or TIA of atherothrombotic, lacunar (small vessel
occlusive), or cryptogenic type, and an established blood pressure >120 mmHg
systolic or >70 mmHg diastolic.