Prevention and Treatment Measures

Understanding risk factors and how to minimize their likelihood is a necessary first step towards making significant impacts in stroke prevention. When blood pressure readings are 140/90 mmHg or higher, and 130/80 mmHg or higher in diabetics, yearly monitoring is recommended. Monitoring can occur every two years if normal levels of 120/80 mmHg exist. Cholesterol levels should be checked every five years using a fasting lipoprotein profile. According to the American Heart Association, women should maintain total cholesterol below 200 mg/dL; HDL above 50 mg/dL; LDL below 100 mg/dL; and triglyceride levels below 150 mg/dL. It is necessary to implement lifestyle changes including a healthy diet, reduction of salt intake, regular exercise, and weight reduction in order to reduce and maintain blood pressure and cholesterol levels. Fortunately, there are preventive treatment measures and lifestyle recommendations emphasizing healthy eating patterns low in saturated fats, and avoiding trans fats, each assisting in cardiovascular benefits. Suggestions for a healthy diet are listed in Table 2.

In addition to following a healthy diet, losing weight and regular exercise, medications, if necessary, have also been used to lower blood pressure, such as:

• Angiotensin-converting enzyme (ACE) inhibitors

• Diuretics

• Angiotensin-receptor blockers

• Beta blockers or alpha blockers

The formation of blood clots can occur from an abnormal heart rhythm, and with clot breakage, ischemic strokes potentially occur. Anticoagulants such as warfarin (Coumadin) or aspirin assist reducing the potential for blood platelets to form clots. Blood clotting medications have shown a 68% reduction of risk for ischemic strokes.

Total cholesterol, low-density lipoprotein cholesterol, the total cholesterol to high-density lipoprotein cholesterol ratio, and non-high-density lipoprotein cholesterol were significantly associated with increased risk of ischemic stroke.³⁸ Medications are often recommended if target cholesterol and triglyceride levels have not been achieved after three months of lifestyle changes, LDL cholesterol levels are 190 mg/dL+, and/or personal history identifies one or more risk factors (e.g., heart disease, diabetes, prior stroke, low HDL’s, and high triglycerides). Such options are:

• Statins, Niacin, and Fibrates all used to reduce triglyceride and LDL levels and raise HDL’s.

Statin medications are recommended beyond their cholesterol-lowering effects and are commonly prescribed for ischemic stroke patients upon discharge from the hospital.³⁷ Discontinuing statins can cause changes in platelet activity or inflammation increase their risk of cardiovascular events and dying.³⁹

Aspirin has been used as a preventive medication for cardiovascular diseases. Findings from randomized trials totaling >47,000 patients questioned the clinical benefits of aspirin in primary prevention for three key populations: patients with diabetes mellitus, community-dwelling elderly individuals, and patients without diabetes mellitus who are at intermediate risk for atherosclerotic events. At the present time, most patients without recognized atherosclerotic cardiovascular disease should not be prescribed aspirin. Instead, management of comorbidities customized to the expected cardiovascular risk should be implemented.⁴⁰ The guidelines for the prevention of stroke in patients with stroke and transient ischemic attack published in 2014 was updated in 2021, in a document entitled “The 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack”.^41,42 According to the 2005 Women’s Health Study, healthy women taking a low dose aspirin every other day showed a risk reduction for ischemic strokes by 24%, yet the risk for hemorrhagic strokes rose by 24%. The CVD benefits for women age 65+ taking daily aspirin demonstrated a 34% reduction in heart attacks and fewer ischemic strokes by 30%. The Women’s Health Study further reported that healthy women under age 65 may suffer greater side effects such as gastrointestinal bleeding, bruising, and increased risk for hemorrhagic strokes versus modest benefits from daily aspirin use. Furthermore, healthy women 65+, and younger women with family history of CVD should consult their physician regarding a low dose aspirin therapy (81 mg aspirin).⁴³

Cigarette smoking is an independent, powerful, and dose-respondent risk factor for first ischemic stroke⁴³, approximately doubling the risk of stroke.³⁷ Patients who have had a stroke or TIA should avoid smoking and second-hand smoke. Counseling with or without pharmaceutical intervention, such as nicotine replacement, is recommended. Research studies have indicated a five-step approach to quitting along with smoking cessation programs encompassing the following suggestions:⁴⁵

• Set a quit date. Make a commitment publicly to people who will support you on your path to quitting.

• Choose a method for quitting. Cold turkey, decreasing the number of cigarettes smoked, or decreasing how much of each cigarette you will smoke.

• Decide if you need pharmaceutical aid or other help to quit, (such as gum, spray, patch, inhaler) or prescription medicines such as bupropion hydrochloride or varenicline. Plan for your Quit Day.

• Stop smoking on your Quit Day.

Get at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity, or a combination of both, preferably spread throughout the week. Moderate-intensity exercise such as walking, swimming, and bicycling can assist in recovering from a stroke and reduce the risk for another CVA event. Add moderate- to high-intensity muscle-strengthening activity (such as resistance or weights) on at least 2 days per week. Utilize a physical therapist to design a tailored program if a stroke-related disability has occurred.⁴⁶