Stroke Prevention in Primary Care

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1 Stroke Prevention in Primary Care ANNE LINDSTROM, APN, FNP-BC, SCRN Disclosures I have no disclosures. Objectives Describe tools available to estimate patient risk of stroke Review non-modifiable risk factors for stroke Understand current recommendations for management of modifiable stroke risk factors 1

2 Stroke by the Numbers Each year 795,000 people will experience a new or recurrent stroke On average every 40 seconds, someone in the United States today has a stroke Stroke is the 5 th leading cause of death in the united states Which translates to every 4 minutes, someone in the United States dies of a stoke Stroke is the leading cause of serious long-term disability The cost of direct and indirect stoke care per year is over $83.6 billion Types of Stroke Ischemic 87% all of strokes are ischemic Hemorrhagic 10% Intracranial Hemorrhage 3% Subarachnoid Hemorrhage Stroke symptoms are not associated with pain which decreases the likelihood of patients taking immediate action 5 million people per year fail to report stroke like symptoms to their health care provider 51.2% of the patient population surveyed by NHIS, could only describe one or more stroke like symptoms Levels of Evidence Determining Stroke Risk 2

3 Assessing Risk of Stroke AHA/ASA Recommendations An ideal stroke risk assessment tool that is simple, widely applicable and accepted, and takes into account multiple risk factors Caution in using tools as they do not include all risk factors Risk assessment tools should be used with care, as they do not include all the factors that contribute to disease risk. The use of a risk assessment tool such as the Framingham Stroke Profile and the AHA/ACC CV Risk Calculator is reasonable (Class IIa, Level of Evidence B) Kernan et al, 2014 AHA/ACC CV Risk Calculator Framingham Stroke Profile 3

4 Non-modifiable Risk Factors for Stroke Non-modifiable Risk Factors Age Gender Prevalence of stroke survivors is projected to increase, especially among elderly women , stroke rates declined significantly in those >60 but remained unchanged in those years old. Lifetime stroke risk at age 65 decreased to 14.5% in men and 16.1% in women from 19.5% and 18% respectively Each year 55,000 more women than men have a stroke, women have a higher lifetime risk 1 in 5 vs 1 in 6 in men Race By 2030, there is a projected 20.5% increase in stroke prevalence from 2012, the highest increase will be in Hispanic men Ethnic disparities persist in stroke rates Mozzafarian et al

5 Other Non-modifiable Factors Family history Early onset heart disease or stroke Personal history of previous stroke/tia Recurrence rates in a cohort of 10,399 patients discharged with a primary diagnosis of stroke in the state of South Carolina in % at 1 month 5% at 6 months 8% at 1 year 18.1% at 4 years 15% of all strokes have a first event that can be classified as a TIA Mozaffarian et al 2015 Modifiable Risk Factors for Stroke 5

6 Hypertension # 1 risk factor for stroke Treatment of hypertension is one of the most effective strategies for reducing stroke risk Hypertension Screening and treatment recommended including medication and lifestyle modification. (Class I, Level of Evidence A) Patients who have hypertension should be treated with to a target blood pressure of <140/90 mm Hg. (Class I, Level of Evidence A) Successful treatment of blood pressure is more important than the choice of a specific agent, treatment should be individualized. (Class I, Level of Evidence A) Self-monitoring of blood pressure is recommended. (Class I, Level of Evidence A). Dyslipidemia Leads to atherosclerosis and heart disease Should be aggressively treated following updated recommendations 6

7 Dyslipidemia Lifestyle changes and statin medications are recommended according to the ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk for primary prevention of ischemic stroke in patients estimated to have a high 10-year risk for cardiovascular events. (Class I, Level of Evidence A) Treatment with niacin, fibric acid derivatives, bile acid derivatives and ezetimibe may be considered if statin therapy not tolerated, efficacy is not established. (Class IIb, Level of Evidence B) Dyslipidemia Stone et al 2014 Intensive Statin Therapy Stone et al

8 Diabetes 22 Diabetes is an independent risk factor for stroke and doubles the risk 20% of people with diabetes will die of stroke People with diabetes have increased risk of vascular risk factors HTN DM Atherosclerosis Diabetes Blood pressure goal <140/90 (Class I, Level of Evidence A) Treatment with statin (Class I, Level of Evidence A) Adding a fibrate does not aid in decreasing stroke. (Class III, Level of Evidence B) The usefulness of aspirin to prevent stroke in people with diabetes but low 10 year risk of CV disease is unclear. (Class IIb, Level of Evidence B) Atrial Fibrillation Atrial fibrillation (AF) is a significant risk factor for stroke, associated with 4-5 fold increased risk of ischemic stroke About 2.3 million Americans have either sustained or paroxysmal AF. The mechanism for stroke is embolism of stasis-induced thrombi forming in the left atrial appendage (LAA). Anticoagulation remains underutilized especially in the elderly 8

9 Atrial Fibrillation Adults > 65 should be screened for afib by pulse assessment and EKG as indicated (Class IIa, Level of Evidence B) Patients with non-valvular AF and CHA2DS2-VASc score of 0, reasonable to not use antithrombotic therapy (Class IIa, Level of Evidence B) Patients with score of 1 and low risk of hemorrhagic complication it is reasonable to consider no antithrombotic therapy, aspirin therapy or anticoagulant therapy. (Class IIb, level of evidence C). If anticoagulation deemed unsuitable closure of LAA may be considered if it can be performed at a center with low rates of complication and patient can tolerate risk of 45 days post procedure anticoagulation.(class IIB, level of evidence B). Risk Stratification for Patients with Afib CHADS2 (Risk Score range = 0-6 points) Congestive heart failure (1 point) Hypertension (1 point) Age > 75 years (1 point) Diabetes mellitus (1 point) Stroke/TIA (2 points) CHA2DS-2VASc (Risk Score range = 0-9 points) Congestive heart failure (1 point) Hypertension (1 point) Age years (1 point), > 75 years (2 points) Diabetes mellitus (1 Point) Vascular disease (PAD, MI, aortic plaque) (1 point) Female sex (1 point) ACCP treatment guidelines Low risk: 0 points -none Moderate risk: 1 point -OAC High risk: > 2 points -OAC HAS-BLED (bleeding risk schema)(risk score range = 0-9 points) Hypertension (1 point) Abnormal renal function (1 point) Abnormal liver function (1 point) Prior stroke (1 point) Prior major bleeding or bleeding predisposition (1 point) INR in therapeutic range < 60% of time (1 point) Age > 65 years (1 point) Use of antiplatelet or non-steroidal drugs (1 point) Excessive alcohol use (1 point) Scores > 2 associated with clinically relevant and major bleeding. Other Cardiac Conditions MI Vitamin K antagonist therapy is reasonable for patients with STEMI and asymptomatic left ventricular mural thrombi. (Class IIa; Level of Evidence C). Anticoagulant therapy may be considered for patients in STEMI and anterior apical akinesis or dyskinesis (Class IIb; Level of Evidence C). Valvular Heart disease Anticoagulation may be considered for asymptomatic patients with severe mitral stenosis and left atrial dimension 55 mm by echocardiography. (Class IIb; Level of Evidence B). Anticoagulation may be considered for patients with severe mitral stenosis, an enlarged left atrium, and spontaneous contrast on echocardiography. (Class IIb; Level of Evidence C). Patent Foramen Ovale (PFO) Antithrombotic treatment and catheter-based closure are not recommended in patients with PFO for primary prevention of stroke. (Class III; Level of Evidence C). 9

10 Asymptomatic Carotid Stenosis Screening low risk populations is not recommended (Class III, Level of Evidence C). The USPSTF concludes with moderate certainty that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. High Risk individuals include: older age, male sex, hypertension, smoking, hypercholesterolemia, diabetes mellitus, and heart disease. Patients with asymptomatic carotid stenosis should be prescribed daily aspirin and a statin and screened for other stroke risk factors. (Class I, Level of Evidence C) Carotid Stenosis Treatment Endarterectomy In patients who are to undergo CEA, aspirin is recommended pre- and post-op because it was used in every major CEA trial. (Class I, Level of Evidence C) CEA in asymptomatic patients with >70% stenosis is reasonable provided risk of perioperative risk of stroke, MI and death is low. However, effectiveness compared to medical management is not well (Class IIa, Level of Evidence A). Stenting Prophylactic CAS might be considered in highly selected patients with asymptomatic carotid stenosis (60% by angiography, 70% ultrasound), however, effectiveness compared to medical therapy is not well established. (Class IIb, Level of Evidence B) 10

11 Obstructive Sleep Apnea Screening using a structured questionnaire such as Berlin or Epworth Sleepiness Scale, physical exam and polysomnography may be considered.(class IIb, Level of Evidence C) Treatment of sleep apnea to reduce stroke risk is reasonable although effectiveness is unknown. (Class IIb, Level of Evidence C) OSA Scales Lifestyle Changes Diet and Nutrition Reduce intake of sodium and increase intake of potassium to lower blood pressure. (Class I, Level of Evidence A) A DASH-style diet, low in saturated fat (Class I, Level of Evidence A) A diet that is rich in fruits and vegetables, and thereby high in potassium, is beneficial and may lower the risk of stroke. (Class I, Level of Evidence B) A Mediterranean diet supplemented with nuts may be considered in lowering the risk of stroke. (Class IIa, Level of Evidence B) Physical Inactivity Physical activity is recommended because it is associated with a reduction in the risk of stroke.(class I, Level of Evidence B) The 2008 Physical Activity Guidelines for Americans are endorsed and recommend that adults should do at least 150 minutes a week of moderate-intensity, or 75 minutes a week of vigorous-intensity aerobic physical activity. (Class I, Level of Evidence B) 11

12 Cigarette Smoking Counseling in combination with drug therapy is recommended (Class I, Level of Evidence A) Abstention from cigarette smoking is recommended for patients who have never smoked based on epidemiological studies showing a consistent and overwhelming relationship between smoking and both ischemic stroke and subarachnoid hemorrhage. (Class I, Level of Evidence B) Community-wide or statewide bans on smoking in public spaces are reasonable for reducing the risk of stroke and myocardial infarction. (Class IIa, Level of Evidence B) Alcohol and Drugs For individuals who choose to drink alcohol, consumption of 2 drinks per day for men and 1 drink per day for non-pregnant women might be reasonable. (Class IIb, Level of Evidence B). Referral to an appropriate therapeutic program is reasonable for patients who abuse drugs that have been associated with stroke, including cocaine and amphetamines. (Class IIa, Level of Evidence C) Other Stroke Risk Factors Migraine Smoking cessation strongly recommended due to increase risk of stroke in those with migraine with aura and smoking (Class I, Level of Evidence B) Consider alternative to oral contraceptives especially those with estrogen in women with migraines due to increase risk of stroke (Class IIb, Level of Evidence B) Hyperhomocystenemia The use of the B complex vitamins, cobalamin (B12), pyridoxine (B6) and folic acid might be considered but effectiveness is not well established. (Class IIb, Level of Evidence B) Hypercoagulable state The usefulness of genetic screening is not well established.(class IIb, Level of Evidence C) The usefulness of specific treatments for primary stroke prevention in asymptomatic patients with a hereditary or acquired thrombophilia is not well established. (Class IIb, Level of Evidence C) 12

13 Antiplatelet Recommendations Aspirin for cardiovascular risk prevention is reasonable for those with 10 year risk of >10% (Class IIa, Level of Evidence A) Aspirin can be useful in first stroke prevention among women including those with diabetes (Class IIa, Level of Evidence B) Aspirin is not useful for preventing a first stroke in low-risk people. (Class III, Level of Evidence A) Aspirin is not useful for preventing a first stroke in people with diabetes in the absence of other high-risk conditions. (Class III, Level of Evidence A) Summary Every visit is an opportunity to identify stroke risk factors Optimization of stroke prevention requires systems of care that identify and gain control of risk factors safely, efficiently and with cost-effectiveness. Access to care is necessary As health professionals, we must ensure that progress in preventing stroke does not lead to complacency. Questions? 13

14 References AHA/ACC CV Risk Calculator Framingham Stroke Profile January, CT et al AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation. Journal of the American College of Cardiology. 2014, downloaded from on 5/4/15. Kernan, WN et al. Guidelines for the Primary Prevention of Stroke A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association 2014 downloaded from Mozaffarian D et al. Heart disease and stroke statistics 2015 update: a report from the American Heart Association. Circulation ;e Stone, NJ et al ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, downloaded from USPSTF Recommendations: Carotid Artery Stenosis: Screening, July 2014, downloaded from 14

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