Perspective:

The following are 10 points for healthcare professionals to remember about these guidelines for the primary prevention of stroke:

1. The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack.

2. The use of a risk assessment tool such as the American Heart Association (AHA)/American College of Cardiology (ACC) cardiovascular (CV) Risk Calculator (http://my.americanheart.org/cvriskcalculator) is reasonable because these tools can help identify individuals who could benefit from therapeutic interventions and who may not be treated on the basis of any single risk factor. These calculators are useful to alert clinicians and patients of possible risk, but basing treatment decisions on the results needs to be considered in the context of the overall risk profile of the patient (Class IIa; Level of Evidence B).

3. Physical activity is recommended because it is associated with a reduction in the risk of stroke (Class I; Level of Evidence B). Healthy adults should perform at least moderate- to vigorous-intensity aerobic physical activity at least 40 minutes/day 3 to 4 days/week (Class I; Level of Evidence B).

4. Reduced intake of sodium and increased intake of potassium as indicated in the US Dietary Guidelines for Americans are recommended to lower blood pressure (Class I; Level of Evidence A). A diet that is rich in fruits and vegetables and thereby high in potassium is beneficial and may lower the risk of stroke (Class I; Level of Evidence B). A Mediterranean diet supplemented with nuts may be considered in lowering the risk of stroke (Class IIa; Level of Evidence B).

5. Regular blood pressure screening and appropriate treatment of patients with hypertension, including lifestyle modification and pharmacological therapy, are recommended (Class I; Level of Evidence A). Patients who have hypertension should be treated with antihypertensive drugs to a target blood pressure of <140/90 mm Hg (Class I; Level of Evidence A).

6. Among overweight (body mass index [BMI] = 25-29 kg/m²) and obese (BMI >30 kg/m²) individuals, weight reduction is recommended for reducing the risk of stroke (Class I; Level of Evidence B).

7. In addition to therapeutic lifestyle changes, treatment with an HMG coenzyme-A reductase inhibitor (statin) medication is recommended for the primary prevention of ischemic stroke in patients estimated to have a high 10-year risk for CV events, as recommended in the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults (Class I; Level of Evidence A). Treatment of adults with diabetes mellitus with a statin, especially those with additional risk factors, is recommended to lower the risk of first stroke (Class I; Level of Evidence A).

8. Counseling, in combination with drug therapy using nicotine replacement, bupropion, or varenicline, is recommended for active smokers to assist in quitting smoking (Class I; Level of Evidence A). Abstention from cigarette smoking is recommended for patients who have never smoked, on the basis of epidemiological studies showing a consistent and overwhelming relationship between smoking and both ischemic stroke and subarachnoid hemorrhage (Class I; Level of Evidence B).

9. For patients with nonvalvular atrial fibrillation, a CHA₂DS₂-VASc score of ≥2, and acceptably low risk for hemorrhagic complications, oral anticoagulants are recommended (Class I). Options include warfarin (international normalized ratio [INR], 2.0-3.0) (Level of Evidence A), dabigatran (Level of Evidence B), apixaban (Level of Evidence B), and rivaroxaban (Level of Evidence B). The selection of antithrombotic agent should be individualized on the basis of patient risk factors (particularly risk for intracranial hemorrhage), cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including the time that the INR is in therapeutic range for patients taking warfarin.

10. Patients with asymptomatic carotid stenosis should be prescribed daily aspirin and a statin. Patients should also be screened for other treatable risk factors for stroke, and appropriate medical therapies and lifestyle changes should be instituted (Class I; Level of Evidence C).