Dr. Klein-Ritter is an assistant professor of medicine, State University of New York (SUNY) Stony Brook School of Medicine, Stony Brook, New
York.
Disclosure: The author states that she has no outside funding,
Abstract
This article reviews and summarizes the American Heart Association/American Stroke Association guideline: Primary Prevention
of Ischemic Stroke. It focuses on recommendations applicable to the geriatric population that may decrease patient risk of
developing ischemic stroke. An approach focusing on assessing and treating modifiable risk factors is advised.Klein-Ritter D. An evidence-based review of the AMA/AHA guideline for the primary prevention of ischemic stroke. Geriatrics. 2009;64(9):16-20.
Key words: anticoagulation, atrial fibrillation, carotid stenosis, diabetes, hormone-replacement therapy, hyperlipidemia,
hypertension, ischemic stroke, platelet inhibitors, risk assessment, smoking
Drugs discussed: antihypertensives, aspirin, hormone replacement therapy, statins, warfarin
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Case scenario: Mr. A is a 78-year-old man with a history of hypertension, hyperlipidemia, diabetes, and atrial fibrillation. His home medications
were enalapril, metoprolol, simvastatin, baby aspirin, and metformin. He presented to the emergency room 6 hours after developing
a left facial droop and left-arm weakness. His physical exam was notable for a blood pressure of 145/95 mm Hg, an irregular
heart rate of 85 beats per minute, a II/VI systolic murmur in the axillary region, and the above-noted neurologic abnormalities.
Lab work revealed a total cholesterol of 200 mg/dL, with a high-density lipoprotein (HDL) value of 38 mg/dL; a low-density
lipoprotein (LDL) value of 110 mg/dL; and triglycerides of 180 mg/dL. An electrocardiogram showed atrial fibrillation, and
a magnetic resonance imaging scan revealed a new infarct in the right frontal and parietal regions. Carotid dopplers showed
50% stenoses in the internal carotid arteries bilaterally. An echocardiogram confirmed mild mitral valve regurgitation.
Was Mr. A's stroke avoidable? What could have been done before this patient's hospitalization to decrease his risk of stroke?
Ischemic stroke is a catastrophic event with significant morbidity and mortality. It can have profound effects on patients
and their families. Because of the multifactorial mechanisms involved, the approach to primary prevention needs to be individualized,
possibly using a risk-assessment tool. Modification of patient stroke risk factors must be made and consideration given to
antiplatelet and anticoagulant therapy, as well as referral for carotid endarterectomy and stenting.
The purpose of this article is to review and analyze the American Heart Associstion (AHA) guideline, Primary Prevention of
Ischemic Stroke1, developed by the AHA and the American Stroke Association (ASA) and funded by the AHA. The guideline is intended for use
by cardiologists, neurologists, internists, and family practitioners, as well as by midlevel practitioners.
Table 1: Rating scheme for the strength of evidence
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The guideline was formulated by a group nominated by Larry B. Goldstein, MD, FAAN, FAHA, the chairman of the committee. The
committee members were chosen on the basis of their previous work in relevant areas and were approved by the AHA Stroke Council's
Scientific Statement and Oversight Committee. The writers used systematic literature reviews of articles published from 2001
(after the last review) up to January 2005; referred to previously published guidelines, personal files, and expert opinions
to summarize existing evidence; indicated gaps in current knowledge; and formulated recommendations where appropriate. The
articles used were ranked according to a rating scheme that evaluated the strength of the evidence (Table 1),1 and recommendations were graded on the effectiveness of the treatment or procedure (Table 2).1 The guideline underwent extensive peer review and was approved by the AHA Science Advisory and Coordinating committees.
Table 2: Rating scheme for the strength of the of the recommendations
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It is estimated that there are more than 795,000 strokes per year in the United States and more than 140,000 stroke deaths.2 Despite advances in the treatment of certain patients with acute ischemic stroke, effective prevention remains the best
treatment for reducing the burden of stroke on patients and their families. The objectives of the AHA guideline were to review
the evidence on established and potential stroke risk factors and to provide recommendations to reduce stroke risk. The interventions
and practices considered included risk-assessment tools, screening measures, and risk-factor control.
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