Top 10 Things to Know About the 2024 Stroke Guideline

December 9, 2024|Lisa Maher

In the US, someone has a stroke every 40 seconds, and someone dies from stroke every 3 minutes and 11 seconds. Stroke is the leading cause of serious long-term disability,1 and the death rate for stroke has increased to 39.5 per 100,000 in 2022.1 Yet stroke is highly preventable, and what we do each day in clinical practice can decrease the risk. This article will focus on the 2024 stroke guideline updates and describe how to implement them into clinical practice to reduce the risk of stroke in our patients.

abstract graphic of the brain

10 Things to Know about the 2024 Stroke Guideline2

The 2024 Guideline for the Primary Prevention of Stroke,3 released in October 2024, updates the 2014 guideline and provides details about prevention strategies for people with no history of stroke.

As highlighted below, the new guidance aligns with the American Heart Association’s (AHA) Life’s Essential 8 to optimize cardiovascular and brain health, adds sex-specific suggestions for screening and prevention, and addresses lifestyle and pharmacotherapy options to reduce risk.

  1. At every age, everyone should have access to regular visits with a primary care health professional to identify and achieve opportunities to promote brain health.
  2. Screening for adverse social determinants of health in care settings with at-risk individuals is recommended, using evidence-based interventions.
  3. Adults with no prior cardiovascular disease (CVD) or at high or intermediate risk should adhere to the Mediterranean Diet to reduce stroke risk.
  4. New recommendation for screening for sedentary behavior and ongoing support for regular moderate-to-vigorous physical activity to support cardiovascular health and stroke reduction.
  5. New recommendation for the use of GLP-1 RAs in patients with diabetes and high cardiovascular risk or established CVD to lower risk for CVD and stroke.
  6. Blood pressure management to include 2+ antihypertensives recommended for primary stroke prevention in those who need pharmacologic treatment.
  7. Antiplatelet therapy for patients with antiphospholipid syndrome or systemic lupus erythematosus without stroke history or unprovoked venous thromboembolism (VTE). Those with antiphospholipid syndrome without unprovoked VTE likely benefit from vitamin K antagonist therapy (target INR 2-3) over direct OACs.
  8. Screening for and management of hypertension during pregnancy to reduce elevated stroke risk at present and in the future.
  9. Screening for endometriosis, ovarian failure before age 40, and menopause before age 45; all are associated with increased stroke risk.
  10. Understanding, evaluating, and managing transgender health issues that increase stroke risk, such as estrogens prescribed to transgender women.

The Stroke Prevention Gap

In the US, there continues to be a gap between potential and current control of stroke risk factors.3 As healthcare professionals, we have an opportunity—and an obligation—to help patients and their families better understand how to reduce their risk of stroke.

Through shared decision-making, we can identify and implement strategies such as lifestyle modification, medication, and other treatments.

Being aware of health literacy issues allows us to provide information in a way that helps patient understanding, such as using images, decision aids, and patient-centric language, as well as providing translations and/or translators.

We can also identify and link patients to resources to help address other non-medical factors, such as food and housing security and access to medications and health insurance. Being aware of our patients’ social and community context is also paramount. Prescribing exercise to a patient who lives in an area where it is unsafe to walk, for example, requires creative problem-solving to help the patient achieve their goal through different modalities.

Primary Prevention Screening

The 2024 includes the following class 1 (strong) recommendations. For further details and recommendations, refer to the AHA supporting materials for the 2024 stroke guidelines.

Risk Assessment

  • For those aged 40-79, risk estimations every 1-5 years to guide treatment decisions and lifestyle recommendations to reduce stroke risk
  • In individuals with AFib, utilization of the CHA2DS2-VASc score to assess the use of oral anticoagulation to reduce stroke risk
  • In ages 18+, periodic screening for social determinants of health to identify additional factors that contribute to stroke risk

Diet Quality

  • In adults without prior CVD and at high- or intermediate CVD risk, the Mediterranean diet is recommended

Physical Activity (Adults)

  • Screening for physical activity
  • Counseling patients to get at least 150 min. of moderate-intensity or 75 min. of vigorous activity weekly
  • Counseling to avoid excessive sedentary behavior

Blood Sugar

  • Asymptomatic adults ages 18+ with overweight, obesity, ASCVD: screening for diabetes
  • Those with diabetes and high cardiovascular risk or established CVD, GLP-1 receptor agonist treatment

Weight and Obesity

  • Adults 18+: screening for overweight/obesity

Lipids

  • Treatment with a statin for those who qualify for lipid-lowering therapy according to AHA guidelines

Blood Pressure (Adults)

  • Screening for hypertension
  • For those with stage 1 or 2 hypertension, lifestyle modification and drug treatment to achieve a blood pressure under 130/80
  • For those with hypertension, thiazide and thiazide-like diuretics, CCB, ACEI, and ARBs
  • In those with hypertension, drug therapy with 1+ medications to reach blood pressure control

Tobacco Use/Cessation Intervention

  • For active smokers: cessation medication with behavioral counseling
  • For active smokers of cigarettes and other tobacco products: assistance with cessation

Clinical Takeaways

  1. Stroke is highly preventable and requires clinician and patient action in a shared decision-making environment.
  2. Because strokes can occur at any age, screening and management should not be reserved for older patients.
  3. Counseling patients to adopt or maintain healthy lifestyle behaviors can reduce their stroke risk.
  4. Addressing risk factors, such as hypertension, hyperlipidemia, tobacco use, and others, can decrease the risk of stroke.
  5. Social determinants of health impact should be considered as they can increase an individual’s risk for stroke.

References

1. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics—2023 update: a report from the American Heart Association. Circulation. 2023;147:e93–e621.

2. American Heart Association. Top Things to Know: 2024 Guideline for the Primary Prevention of Stroke. Oct. 21, 2024. https://professional.heart.org/en/science-news/2024-guideline-for-the-primary-prevention-of-stroke/top-things-to-know. Accessed Nov. 25, 2024.

3. Bushnell C, Kernan WN, Sharrief AZ, Chaturvedi S, Cole JW, Cornwell WK 3rd, Cosby-Gaither C, Doyle S, Goldstein LB, Lennon O, Levine DA, Love M, Miller E, Nguyen-Huynh M, Rasmussen-Winkler J, Rexrode KM, Rosendale N, Sarma S, Shimbo D, Simpkins AN, Spatz ES, Sun LR, Tangpricha V, Turnage D; Velazquez G, Whelton P. 2024 Guideline for the primary prevention of stroke: a guideline from the American Heart Association/American Stroke Association. Stroke. Published online October 21, 2024. doi: 10.1161/STR.0000000000000475

Related Articles