New AHA/ASA Stroke Guidelines Focus on Prevention, Pregnancy… : Neurology Today

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The American Heart Association and the American Stroke Association’s first update to guidelines for primary stroke prevention since 2014 emphasizes that the majority of strokes are preventable through lifestyle changes.

New guidelines for primary stroke prevention by the American Heart Association and the American Stroke Association (AHA/ASA)—the first update since 2014—include a new emphasis on increased risks for women, particularly those who have experienced hypertension and diabetes during pregnancy.

The guidelines, published in the Oct. 21 edition of the journal Stroke, underscored that 80 percent of strokes are preventable through lifestyle changes and addresses environmental, socioeconomic, and educational factors that increase the risk of stroke.

The authors noted that progress had been made in both stroke awareness in the general population and hospital approaches in treating stroke, but challenges remain for certain groups of people, particularly younger women.

Many of the suggestions for reducing stroke risk are familiar—regular doctor visits, physical exercise, and attention to high blood pressure—but new recommendations specifically include the Mediterranean Diet, screening for sedentary behavior, and paying particular attention to patients who had complications during pregnancy.

The guidelines also suggest the need for more research on the impact that glucagon-like protein-1 receptor agonists (GLP-1) treatments for those with diabetes and high cardiovascular risk might have on stroke prevention.

“The good news is a lot of these recommendations are really just good for your health in general, not just your brain health, but your health overall,” said Eliza C. Miller, MD, an associate professor of neurology at Columbia University and one of the study authors. While it’s important for people to think about their stroke risk, the goal is not to scare people, she said, but to get them thinking about their choices earlier on in life.

“It’s putting these ideas out there, that these are practices that can reduce the risk of having a first stroke, and so you should know about them,” she said. “A lot of people don’t know about the impact of sleep, for example. And I find that a lot of patients I talk to who have had a stroke don’t realize that smoking increases your risk of stroke. They know about lung cancer and COPD but don’t associate smoking with increasing the risk of stroke.”

Lead author Cheryl D. Bushnell, MD, MHS, FAHA, a professor of neurology at Wake Forest University School of Medicine in North Carolina, said that while diet, exercise, and salt intake are good guidelines overall, there’s a need for a personalized approach, rather than an all-or-nothing attitude. For example, she said, while it’s a good idea generally to reduce salt intake, the focus is on a dietary pattern overall, not on one single thing people eat or don’t eat.

The study specifically recommended the Mediterranean Diet, which focuses on fish, vegetables, and starches like quinoa and snacks like nuts and olives. But while that might be accessible to some populations, it’s out of reach—physically and financially for others, said Lauren H. Sansing, MD, MS, professor of neurology at Yale School of Medicine.

Dr. Sansing pointed out that in the United States, most people have easy access to meat, and when they are looking for a quick meal on the run, it’s hard to find one that would fit the Mediterranean diet guidelines. Then there’s the cost.

“Fatty fish, things like salmon, are expensive. Olive oil is expensive. Nuts are expensive. It can be a challenge in the United States to really adhere to the Mediterranean diet,” she said, but clinicians can tell patients there are things they can do when looking for a snack: “Grab a snack of walnuts, as opposed to a bag of chips. … It’s about trying to make some healthier choices when we can that will hopefully add up to long-term benefits.”

Dr. Bushnell said the guidelines were organized to include risks across a lifespan and addressed the large amount of new data since 2014 concerning women’s stroke risk both during and after pregnancy. The recommendations include screening women who have one of several multiple adverse pregnancy outcomes, including gestational diabetes and hypertensive disorders of pregnancy.

“The main thing that I learned as we were pulling all the data together is that these adverse pregnancy outcomes, lumped together, are actually quite common, with 1 in 10 women experiencing one of these adverse pregnancy outcomes,” she said, noting that while typically women remember their pregnancy complications, they don’t think about them as a risk factor for stroke or heart disease later in life.

“We are trying to elevate the level of awareness both from the clinician side and from the patient’s side so they can make the necessary lifestyle changes,” Dr. Bushnell said.

Monique Chireau Wubbenhorst, MD, MPH, a practicing obstetrician-gynecologist and research fellow at the University of Notre Dame, worked with Dr. Bushnell on a 2011 paper addressing the possible connection between preeclampsia and stroke risk, both before and after pregnancy. Back then, it was just a hypothesis, but there wasn’t enough literature to back up their theory. Now, as reinforced by the AHA/ASA stroke guidelines, women aren’t just at-risk during pregnancy but also later in life.

“Now we can counsel women about their stroke risk based on issues they had during their pregnancy,” she said. “Most women who get pregnant are young and don’t really engage in a lot of primary care after they give birth.”

The new emphasis is an alert both for patients and for obstetrician/gynecologists, who often do double duty as primary care physicians for their patients and may need to manage those risks post-pregnancy or refer them to primary care or specialists to improve stroke care and awareness, said Dr. Chireau Wubbenhorst.

“If you have a woman who has hypertension and markedly elevated lipids, you may feel more comfortable referring that woman to primary care, or if you had a woman who had a cardiac event in pregnancy, she had cardiomyopathy and still has some residual cardiac failure, that person should be seeing a cardiologist,” she said. “It is an excellent opportunity for us, as OB/GYNs, to engage women, encourage them, and say, ‘Hey, did you see your follow-up?’”

The study also noted an increased risk of stroke for those who have migraines, which disproportionately affect 20 to 30 percent of women ages 15 to 49. Those who have migraines with aura are particularly at risk, particularly for ischemic strokes and in younger women, the report stated, adding that “despite the large number of observational studies investigating the association between migraine and stroke, multiple areas of uncertainty remain in optimal stroke prevention in individuals with migraine.” Authors recommended studies to determine whether preventative treatment of migraine would reduce stroke risk.

The recommendations pair with the AHA/ASA “Get With The Guidelines” (GWTG) stroke program, which has improved stroke care significantly over 20 years thanks to a 75 percent participation rate among US hospitals and improvements in 41 of 44 quality measures. The improvements have led to reduced hospital mortality and better patient outcomes, according to a 20-year analysis of the program published in the Oct. 24 edition of Stroke. The analysis looked at outcomes from the GWTG program from April 2003 to December 2022, including 7,837,849 patients with a median age of 71, of whom 51 percent were female.

Gregg C. Fonarow, MD, professor of cardiovascular medicine at the University of California, Los Angeles, and an author of the analysis, said that, stroke treatment has seen large, rapid improvements in treatment development and patient outcomes.

“What’s so remarkable is that 41 of the 44 measures we were looking at showed these very significant improvements—for clinical outcomes, reductions in in hospital mortality, for ischemic stroke, for intracranial hemorrhage, for subarachnoid hemorrhage, progressively over time to where we’re talking about large and meaningful reductions, more patients able to be discharged home—so these are really meaningful, clinically relevant improvements.”

Dr. Sansing, from Yale, agreed, adding that the very act of paying attention to details such as time to treatment and patient discharge information—for at home, rehab, and hospice, for example—improved treatment across the board.

“I think we’ve made incredible strides in the acute treatment of stroke with reperfusion therapies and with a lot of attention on quality and quality of care through things like ‘GWTG,’” she said. “When hospitals are reporting and when these details will be reported, you pay a lot more attention to it, right? It’s not just the act of reporting, it’s that what happens behind the scenes that ensures quality care.”

While the data from the GWTG program is particularly insightful for the clinician and hospital side, it’s also important that patients have an idea of the treatment they should be getting—and the importance of getting that treatment quickly, Dr. Fonarow said.

“With stroke, time matters so much,” he said. “They want to be part of a community and system that knows which of the certified hospitals have with a true stroke system of care and to get them rapidly transported to the most qualified hospital that’s close to home.”

One of the things that has been a challenge is working with smaller and rural hospitals to provide stroke care, making sure they have a 24-hour CT scanner and clinicians trained in stroke care, Dr. Fonarow said. The next step to address that challenge is a program called the “Rural Health Accelerator,” which helps those hospitals participate in the GWTG standards.

He said that the two studies highlight the need for more stroke awareness and prevention, both on an individual basis, at the doctor’s office, and at the workplace, where wellness initiatives could focus on maintaining optimal blood pressure and physical activity to prevent strokes.

Disclosures

Dr. Miller had no disclosures.