Updated Stroke Prevention Guideline Has New Recs for Women, GLP-1 Drugs

The American Stroke Association and the American Heart Association have released a new guideline for the primary prevention of stroke, the first update since 2014. Like previous guidelines, this update, published October 21 in Stroke, urges physicians to screen for vascular risk factors and encourage healthy lifestyle changes to help their patients reduce the risk of a first stroke.

However, some things are new, including recommendations specifically for women, guidelines for the use of GLP-1 drugs, and an emphasis on lifelong care.

Take a Lifespan Approach

The framework of the new guideline is caring for the patient throughout their lifespan, said guideline committee chair Cheryl Bushnell, MD, clinical researcher and professor of neurology at Wake Forest University School of Medicine. And that, of course, is the purview of the primary care physician.

“These guidelines underscore the pivotal role that primary care physicians play in promoting and preserving cardiovascular and brain health,” said Erin DeLaney, MD, primary care physician and associate professor and vice chair of clinical affairs and quality at the University of Alabama at Birmingham School of Medicine. “Practicing medicine in the stroke belt of the US, it becomes increasingly clear that it is necessary to implement these recommendations early in a person’s life with the support and guidance of a PCP,” she added.

Deborah Levine, MD, MPH, professor of medicine at the University of Michigan Medical School and a co-author of the guideline, pointed to another reason for lifelong care. “Vascular risk factors are cumulative, and the prevalence of modifiable risk factors is increasing in teens and young adults,” she said. “Young adults with high blood pressure often are under-diagnosed and under-treated.”

Evaluate Sex-Specific Risk Factors

Notably, this guideline includes specific recommendations for women, calling for risk evaluation in patients with endometriosis, premature ovarian failure, or early menopause, as well as for those who use oral contraceptives. The guideline also has recommendations for pregnant individuals with hypertension or other complications of pregnancy, recommending that physicians treat elevated blood pressure during pregnancy and within 6 weeks of delivery.

The AHA/ASA update also urges physicians to be aware of potential risks in transgender women and gender-diverse individuals who are taking estrogen for gender affirmation. Dr. Bushnell pointed out that while there is not yet a lot of data on the risk of stroke in transgender women, it’s important to identify potential risk and mitigate it where possible. In addition, “There’s a tremendous amount of psychosocial stress and social determinants of health in these individuals, and that needs to be recognized,” she said.

Consider GLP-1 Drugs for Stroke Prevention

Recent evidence on GLP-1 receptor agonists was included in the analysis. “We have good evidence from randomized controlled trials that GLP-1 drugs reduce the risk of stroke in patients with diabetes,” said Dr. Levine. “We also have the new SELECT trial, published in the New England Journal of Medicine, showing that semaglutide reduces the risk of cardiovascular events in patients who have a BMI of 27 or higher and cardiovascular disease but no history of diabetes.”

The updated guideline gives GLP-1 receptor agonists a class 1a recommendation for use in patients with diabetes and high cardiovascular risk or established cardiovascular disease.

Provide Resources for Social Determinants of Health

An emphasis on the role of social determinants of health in stroke incidence and outcomes is also new to this guideline. Because stroke risk and poor outcomes can be increased by factors such as structural racism, poverty, housing and food insecurity, and lack of employment opportunity or educational attainment, the new guideline urges physicians to advocate for their patients. Choosing the least expensive medications is important, but the authors recommend that physicians go further and connect patients with resources and agencies that can help with these issues.

“Connecting patients to the right resources and navigating medication costs can be difficult and time-consuming, often requiring the expertise of a social worker or case manager,” Dr. DeLaney said. She also pointed out that not all primary care practices have access to these team members. In these cases, she suggested that physicians and other available team members familiarize themselves with resources such as GoodRx and drug manufacturers’ medication assistance programs, as well as available community resources.

Remember Lifestyle Basics

The one thing that wasn’t new in this guideline was the emphasis on lifestyle modifications. It suggests Life’s Essential 8 metrics for cardiac and brain health. This includes advising patients to eat well; get regular physical exercise; keep weight, blood sugar, blood pressure, and cholesterol within recommended levels; avoid tobacco; and get good quality sleep. While the Mediterranean diet is still recommended for primary prevention of stroke, the guideline authors noted that low-fat diets have little impact on stroke risk.

“We’re just trying to provide encouragement and simple things that people can do to reduce their risk and make some lifestyle changes,” Dr. Bushnell said.

Disclosures:

Dr. Bushnell reported an ownership interest in Care Directions which provides digital products for stroke care.

Drs. Levine and DeLaney reported no conflicts of interest.