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. The role of aspirin for the primary prevention of cardiovascular disease was visited in 2019, and again in 2022. The decision to initiate low-dose aspirin use for the primary prevention of CVD in adults aged 40 to 59 years who have a 10% or greater 10-year CVD risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small. Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit. The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older.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.⁴⁴ 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.

Being physically active helps all people, no matter their age, lead healthier lives. Some physical activity is better than doing none. By being more active throughout the day in relatively simple ways, people can quite easily achieve the recommended activity levels. Children and adolescents aged 5-17 years:

• Should do at least 60 minutes of moderate to vigorous-intensity physical activity daily.

• Physical activity of amounts more than 60 minutes daily provides additional health benefits.

• Should include activities that strengthen muscle and bone, at least 3 times per week. Adults aged 18–64 years

• Should do at least 150 minutes of moderate-intensity physical activity throughout the week, or do at least 75 minutes of vigorous-intensity physical activity, or an equivalent combination of both.

• For additional health benefits, adults should increase their moderate-intensity physical activity to 300 minutes per week, or equivalent.

• Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.

  Adults aged 65 years and above

• Should do at least 150 minutes of moderate-intensity physical activity throughout the week, or at least 75 minutes of vigorous-intensity physical activity, or an equivalent combination of both.

• For additional health benefits, they should increase moderate-intensity physical activity to 300 minutes per week, or equivalent.

• Those with poor mobility should perform physical activity to enhance balance and prevent falls, 3 or more days per week.

• Muscle-strengthening activities should be done involving major muscle groups, 2 or more days a week.⁴⁶