Updated guidelines offer new advice on how to prevent strokes

In the United States, someone has a stroke every 40 seconds. And every 3 minutes and 11 seconds, someone dies of a stroke. Overall, each year, about 610,000 people will have a stroke for the first time. And once you’ve had a stroke, you’re chances of having another one are a lot higher. But there is some good news: Up to 80 percent of strokes may be preventable.

For the first time in a decade, the American Stroke Association (ASA) issued new recommendations with the aim of preventing strokes among people who have never had one. The “2024 Guideline for the Primary Prevention of Stroke” offers new guidance, particularly on preventing strokes in women. The updated guidance also considers the role of weight-loss drugs known as GLP-1s in stroke prevention as well as social determinants of health—or the nonmedical factors that influence people’s health, such as where and how they grow up, live, work, and age.

“The most effective way to reduce the occurrence of a stroke and stroke-related death is to prevent the first stroke—referred to as primary prevention,” said Chair of the guideline writing group, Cheryl D. Bushnell, M.D., M.H.S., FAHA, professor and vice chair of research in the department of neurology at Wake Forest University School of Medicine in Winston-Salem, North Carolina in a news release. “This guideline is important because new discoveries have been made since the last update 10 years ago. Understanding which people are at increased risk of a first stroke and providing support to preserve heart and brain health can help prevent a first stroke.”

What is a stroke—and why do they happen?

There are two types of strokes—ischemic and hemorrhagic. An ischemic stroke occurs when blood flow to the brain is blocked. This deprives the brain of oxygen and essential nutrients. And within minutes, brain cells begin to die. About 90 percent of strokes are ischemic. The rest are hemorrhagic strokes. These occur when there is sudden bleeding in the brain. This puts pressure on brain cells, which damages them.

Both types of strokes share many risk factors, or things that make some people more likely to experience them. Some of these risk factors can’t be changed, such as:

Age: Anyone can have a stroke (even babies), but the risk increases as you get older.

Genetics: Your risk of having a stroke is higher if you have a close family member who had one.

Sex: Earlier in life, men are more likely than women to have a stroke. (But women’s lifetime risk is higher since they tend to live longer. Also, women who take birth control pills or use hormone replacement therapy have a higher risk of stroke. Stroke risk also increases during pregnancy and the postpartum period. High blood pressure during pregnancy also increases the lifetime risk for stroke.)

But there are several risk factors for stroke that can be controlled, including:

• High blood pressure
• Obesity
• Being inactive or sedentary
• Poor diet
• Smoking

These controllable factors account for 82 to 90 percent of all strokes, according to the National Heart, Lung, and Blood institute (NHLBI).

Updated recommendations to prevent new strokes

The updated ASA guidelines, which were published online on October 21 in Stroke, call for improved strategies to help prevent first-time strokes, including regular screenings, newer medications, and lifestyle changes.

The recommendations include reiterate proven strategies for the prevention of stroke, such as:

Not smoking: Smoking damages the heart and blood vessels, increasing the risk for stroke. It can also contribute to high blood pressure—a key risk factor for stroke. Just being around someone who smokes can make you more likely to have a stroke.

Getting regular physical activity: Being active can help you maintain a healthy weight, lower your blood pressure, and keep your blood sugar under control—all of which can reduce the risk of stroke. Adults should get at least 150 minutes per week of moderate-intensity aerobic activity, 75 minutes per week of vigorous aerobic activity, or a combination of both.

Prioritizing sleep: Most adults need 7 to 9 hours of quality sleep each night. Research shows that problems with sleep are linked to an increased risk of stroke.

But the guidelines also include some new recommendations for people who have never had a stroke to help reduce their risk, including:

Follow a Mediterranean diet: The Mediterranean eating plan focuses on fruit and vegetables, healthy fats, such as such as fatty fish or seafood, nuts, seeds, avocado, and extra-virgin olive oil, beans and other legumes, and whole grains. Meanwhile, it limits intake of red meat, salt, processed foods, sweets, and full-fat dairy. This style of eating can help support brain health and reduce strike risk. It is linked to better weight control, lower blood pressure, reduced inflammation, and other heart-healthy effects.

Screen for key stroke risk factors. The ASA urges primary care physicians to use physical exams and blood tests to help screen for high blood pressure, high blood sugar levels, and unhealthy cholesterol levels—all important but manageable risk factors for stoke.

Use medication to control risk factors. The ASA encourages the use of medication to improve blood pressure and cholesterol levels. The group pointed out that research has shown treatment with just one drug effectively controls high blood pressure in only about 30 percent of patients. Most people who need medication to manage high blood pressure need two to three drugs to keep their condition under control.

The ASA also issued a new recommendation, calling for the consideration of glucagon-like peptide-1 (GLP-1) receptor agonists, or GLP-1s, which are FDA-approved drugs used to not only help people lose weight, but also reduce the risk of heart disease and type 2 diabetes in people who are overweight or obese.

Take social determinants of health into account: In the U.S., the risk of stroke varies by race and ethnicity. Non-Hispanic Black adults and Pacific Islander adults have the highest rates of death from stroke. The ASA points out that strokes are more likely to affect people with lower incomes and less education who are living in areas with less access to healthy foods, quality healthcare, and other resources that support health and well-being.

Historically, Black, Hispanic, and other underserved communities are more likely to have lower incomes, to be unemployed, or earn less than their white counterparts despite having the same level of expertise. The ASA urges healthcare professionals (HCPs) to consider the effects of these social drivers of health as well as bias, discrimination, and racism on their patients’ health. The group says HCPs should focus on improve access to care, such as address language barriers, providing more patient education, and helping patients find treatment options that are both effective and affordable.

Special considerations for women, transgender women, and gender-diverse people: The ASA calls for HCPs to screen for health issues that could increase women’s risk for stroke, including use of oral contraceptives, high blood pressure during pregnancy, other pregnancy complications such as premature birth, endometriosis, premature ovarian failure, and early onset menopause. The group also recommends that high blood pressure be treated during pregnancy and within six weeks of delivery to reduce the risk intracerebral hemorrhage (a blood vessel bursts, causing bleeding inside brain), which is a leading cause of maternal morbidity and death.

Transgender women and gender-diverse people who are taking the hormone estrogen for gender-affirming care may also be more likely to have a stroke. The ASA calls for HCPs to assess and manage existing stroke risk factors to help offset this increased risk.

Spot the warning signs of stroke

Strokes are medical emergencies that require immediate medical attention. Every second counts. Delayed treatment can lead to lasting brain damage, long-term disability, or even death. Learning the signs of a stroke can help you ensure you or someone around you gets help as soon as possible.

Call 911 right away if you or someone else has the following symptoms:

• Sudden weakness
• Paralysis or numbness on one side of the face or body
• Face drooping
• Sudden and severe headache
• Trouble seeing
• Trouble speaking or understanding speech

Do not drive to the hospital or let someone else drive you. Call an ambulance. This can help ensure you start receiving treatment—even before you get to the hospital. Recovery from stroke depends on how quickly it is treated.