AHA/ASA update stroke prevention guidelines
MedWire News: The latest stroke prevention guidelines from the American Heart/Stroke Association (AHA/ASA) outline treatment strategies for an extensive list of risk factors and emphasize the role of the emergency department (ED) in stroke prevention.
In contrast to the 2006 guidelines, the updated version includes recommendations for the prevention of hemorrhagic stroke, due to the overlapping risk and prevention strategies with ischemic stroke, and focus on "an individual patient-oriented approach" to stroke prevention.
"Between 1999 and 2006, there's been over a 30% reduction in stroke death rates in the USA and we think the majority of the reduction is coming from better prevention," said the Chair of the guideline writing committee Larry Goldstein (Duke Stroke Center, Durham, North Carolina, USA).
The guidelines, which appear in the journal Stroke, cover treatment recommendations for the "well-documented" modifiable risk factors hypertension, smoking, diabetes, dyslipidemia, atrial fibrillation (AF), other cardiac conditions, sickle cell disease, postmenopausal hormone therapy, oral contraceptions, diet and nutrition, physical inactivity, and obesity.
They also suggest that carotid revascularization may be considered in highly selected patients with asymptomatic carotid stenosis, with the evidence slightly stronger for surgery (Class IIa, Level A) than stenting (Class IIb, Level B).
However, Goldstein et al stress that recent advances in medical therapy have rendered the benefits of either procedure uncertain in asymptomatic patients.
Less well-documented risk factors covered in the guidelines include migraine, the metabolic syndrome, alcohol consumption, elevated homocysteine levels, and inflammation.
The writing committee also notes the value of nonmodifiable risk factors, such as age, gender, and genetic factors, for assessing people's risk for stroke.
The new guidelines highlight the role of the ED in primary stroke prevention. In particular, they cite evidence for the effectiveness of ED-based smoking cessation programs and the identification and treatment of AF. Screening for hypertension in the ED and referral of patients with drug or alcohol problems are also considered reasonable.
"With growing numbers of Americans using the ED for primary care, especially those in socioeconomically at-risk populations, the ED may present a unique opportunity to have an impact on the increasing burden of cerebrovascular and cardiovascular disease," say Goldstein et al.
However, they caution that this must be balanced against "the higher cost of obtaining care in this setting and suboptimal use of resources."
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By Eleanor McDermid