Stroke: Primary Prevention

Stroke is a leading cause of long-term disability in adults and the fifth leading cause of mortality in the United States. One of the main tasks related to stroke in the family medicine setting is assessment and management of modifiable risk factors. The American Heart Association/American Stroke Association (AHA/ASA) guidelines on primary prevention of stroke recommend that cigarette smoking, physical inactivity, overweight and obesity, dyslipidemia, hypertension, and diabetes be addressed and/or managed to decrease the risk of stroke. Obstructive sleep apnea (OSA) is an independent risk factor for stroke. Screening for OSA in patients at risk of stroke can be considered. Atrial fibrillation (AF) contributes to more than 20% of acute ischemic strokes. Guidelines recommend that some patients with AF be treated with warfarin or direct-acting oral anticoagulants for stroke prevention, as the clinical situation warrants. Other risk factors for stroke include carotid artery disease, migraine with aura, sickle cell disease, alcohol or drug use, hypercoagulable states (including COVID-19), and previous stroke or transient ischemic attack. Recent meta-analyses have found that aspirin may not be beneficial for primary prevention of stroke. Aspirin currently is not recommended for primary stroke prevention in low-risk individuals.