New Primary Stroke Prevention Guideline: Interview With Cheryl D. Bushnell, MD, MHS, FAHA

© 2024 HMP Global. All Rights Reserved.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates.

Interview by Jodie Elrod

EP LAB DIGEST. 2024;24(11):ONLINE ONLY.

EP Lab Digest talks briefly with Cheryl D Bushnell, MD, MHS, FAHA, about the 2024 Guideline for the Primary Prevention of Stroke¹ from the American Heart Association/American Stroke Association, including key changes, emphasis on social determinants of health, and future directions.

This is the first update in a decade. What do you believe is the most significant change in this guideline compared to the 2014 version,² and why is it crucial for stroke prevention?

This guideline is an important and timely update from 2014 for multiple reasons. First, there have been groundbreaking clinical trials that have been published with new medications both to treat a specific disease (diabetes/obesity and high cholesterol), and to lower the risk of stroke and heart disease. For example, the glucagon-like peptide (GLP-1) receptor agonists have been shown to drastically reduce blood sugar in patients with Type 2 diabetes, and they also lead to significant weight loss in these patients, which has numerous downstream benefits that help reduce the risk of stroke and other complications of diabetes. Other new recommendations are to emphasize being physically active, and to avoid sedentary behavior. The guideline includes a new recommendation to screen for sedentary behavior and counsel patients to be more physically active. How to optimize women’s health and reduce their risk of stroke includes recommendations for managing high blood pressure during pregnancy, screening for pregnancy complications, and screening for premature ovarian failure (very early menopause before age 40), early-onset menopause (before age 45), and endometriosis (an inflammatory condition caused by endometrial tissue found outside the uterus). We also recommend screening for adverse social determinants of health (SDOH), which is a new addition since the 2014 guideline. 

The recommendations are key for primary stroke prevention because 80% of strokes are preventable, and there is currently a very wide prevention gap. In other words, providers generally know how to prevent stroke, however, this guideline broadens the population of individuals who should be screened for primary stroke risk. We believe implementation of these recommendations could save many lives, reduce disability, and promote brain health by preventing a first stroke.

The guideline places a strong emphasis on SDOH. How can electrophysiologists incorporate considerations of social and economic factors into their patient care strategies to improve stroke prevention outcomes?

There is abundant evidence that adverse SDOH can be barriers to prevention (inability to afford health insurance and medications, access to health care, etc.), therefore increasing stroke risk. Screening for these barriers prior to prescribing medications that individuals may not be able to afford is critical. In addition, knowing where a patient lives and health care access in their community (urban vs rural, distance from a medical facility) can help to tailor strategies to optimize cardiovascular health and reduce risk of a first stroke.

Given the evolving landscape of stroke prevention strategies, what do you see as the most critical areas for future research in primary stroke prevention, particularly regarding the intersection of electrophysiology and stroke risk management?

The main knowledge gaps and areas of research pertain to ways to strengthen routine health screening in primary care and other practices, which can be challenging when clinicians are already pushed to see as many patients as possible. Development of screening tools that could be easily incorporated into the clinic visit or the electronic health record, as well as additional personnel to provide counseling, are likely needed to help clinicians identify patients with the highest risk and support healthy lifestyle and stroke prevention strategies with patients.  

References

1.     Bushnell C, Kernan WN, Sharrief AZ, et al. 2024 Guideline for the primary prevention of stroke: a guideline from the American Heart Association/American Stroke Association. Stroke. 2024 Oct 21. Online ahead of print. doi:10.1161/STR.0000000000000475

2.     Meschia JF, Bushnell C, Boden-Albala B, et al; on behalf of the American Heart Association Stroke Council. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:3754-3832. doi:10.1161/STR.0000000000000046