Primary Prevention

Aspirin

The use of ASA in patients with no history of stroke or ischemic heart disease reduced the incidence of nonfatal myocardial infarction (MI) but not of stroke. A meta-analysis of eight trials found that the risk of stroke, especially hemorrhagic stroke, was slightly

increased with ASA use. Major bleeding risk was also increased with ASA use. The

Women's Health Study evaluated over 38,000 women and found a benefit with ASA

use in high-risk women 65 years and older. A recent meta-analysis found a higher risk of hemorrhagic stroke in men and a greater risk of major bleeding in both men and

women. Primary prevention guidelines recommend ASA use in older women who are at high-risk for stroke; however, the benefit must be weighed against the risk of major bleeding. No benefit and potentially more risk of hemorrhagic stroke has been found in men, therefore, ASA is not recommended in this group.28

Statin Therapy

Dyslipidemia has not previously been identified as an independent risk factor for stroke; however, recent studies have found a relationship between total cholesterol

levels and stroke rate. Statin use may reduce the incidence of a first stroke in high-

risk patients (e.g., hypertension, coronary heart disease, or diabetes) including patients with normal lipid levels. Stroke risk was decreased by 27% to 32% overall in large 29 30

clinical trials. ' Patients with a history of MI, coronary artery disease (CAD), elev ated lipid levels, diabetes, and other risk factors benefit from treatment with a lipid-lowering agent including patients with normal lipid levels.

BP Management

Lowering BP in patients who are hypertensive has been shown to reduce the relative

risk of stroke, both ischemic and hemorrhagic, by 35% to 44%. All patients should have their BP monitored and controlled appropriately based on current guidelines for

BP management. Reduction in BP is the main goal as one agent has not been clearly shown to be more beneficial than any other for the primary prevention of stroke.

Smoking Cessation

The relationship between smoking and both ischemic and hemorrhagic stroke is clear. Patients should be assisted and encouraged in smoking cessation as the stroke risk after cessation has been shown to decline over time. Effective treatment options are available including counseling, nicotine replacement products, and oral agents.

Other Treatments

A number of other disease states and lifestyle factors should be addressed as primary prevention of stroke. Atrial fibrillation is an important and well documented risk for stroke. See Chapter 9 for information on stroke prevention in atrial fibrillation. Diabetes, carotid stenosis, cardiac disease, obesity, and physical inactivity are other risks that should be assessed and managed appropriately.

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