Today, I review, link to, and excerpt from 2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Stroke. 2024 Dec;55(12):e344-e424. doi: 10.1161/STR.0000000000000475. Epub 2024 Oct 21.
The above article has been cited by 25 articles in PubMed.
All that follows is from the above article.
Abstract
Aim: The “2024 Guideline for the Primary Prevention of Stroke” replaces the 2014 “Guidelines for the Primary Prevention of Stroke.” This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.
Methods: A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.
Structure: Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association’s Life’s Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.
Keywords: AHA Scientific Statements; guideline; hemorrhagic stroke; ischemic stroke; stroke.
Contents [Refers To The PDF Link]
Abstract…e344Top 10 Take-Home Messages…e345Preamble…e3461. Introduction…e347
1.1 Methodology and Evidence Review…e3471.2. Organization of the Guideline Writing Group…e3471.3. Document Review and Approval…e3481.4. Scope of the Guideline…e3481.5 Class of Recommendations and Level of Evidence…e3501.6 Abbreviations…e3502. General Concepts…e351
2.1 Evaluation of Evidence for Primary Stroke Prevention…e3512.2 Emphasis on Groups with Elevated Stroke Risk…e3512.3 Social Determinants of Health…e3523. Patient Assessment…e3524. Management of Health Behaviors and Health Factors for Primary Prevention of Stroke: Life’s Essential 8…e355
4.1 Diet Quality…e3554.2 Physical Activity…e3574.3 Weight and Obesity…e3594.4 Sleep…e3604.5 Blood Sugar…e3614.6 Blood Pressure…e3634.7 Lipids…e3654.8 Tobacco Use…e3675. Atherosclerotic and Non-Atherosclerotic Risk Factors…e369
5.1 Asymptomatic Carotid Artery Stenosis…e3695.2 Asymptomatic Cerebral SVD, Including Silent Cerebral Infarcts…e3725.3 Migraine…e3736. Specific Populations…e374
6.1 Sickle Cell Disease…e3746.2 Genetic Stroke Syndromes…e3776.3 Coagulation and Inflammatory Disorders…e379
6.3.1 Inflammation in Atherosclerosis…e3796.3.2 Autoimmune Conditions…e3806.3.3 Malignancy…e3826.3.4 Infection…e3826.4 Substance Use and Substance Disorders…e3836.5 Sex- and Gender-Specific Factors…e385
6.5.1 Pregnancy…e3856.5.2 Endometriosis…e3906.5.3 Hormonal Contraception…e3916.5.4 Menopause…e3926.5.5 Transgender Health…e3946.5.6 Testosterone Use…e3957. Heart Disease…e396
7.1 Cardiomyopathy…e3968. Antiplatelet Use for Primary Prevention…e397Disclosures…e399References…e403
Top 10 Take-Home Messages
1. From birth to old age, every person should have access to and regular visits with a primary care health professional to identify and achieve opportunities to promote brain health.2. Screening for and addressing adverse social determinants of health are important in the approach to prevention of incident stroke. This updated guideline includes an orientation to social determinants of health, acknowledging its impact on access to care and treatment of stroke risk factors. Therefore, screening for social determinants of health is recommended in care settings where at-risk stroke patients may be evaluated, with the acknowledgment that evidence-based interventions to address adverse social determinants of health are evolving.3. The Mediterranean diet is a dietary pattern that has been shown to reduce the risk of stroke, especially when supplemented with nuts and olive oil. However, low-fat diets have had little impact on reducing the risk. This guideline recommends that adults with no prior cardiovascular disease and those with high or intermediate risk adhere to the Mediterranean diet.4. Physical activity is essential for cardiovascular health and stroke risk reduction. This guideline includes a summary of high-quality data showing that prolonged sedentary behavior during waking hours is associated with an increased risk of stroke. Therefore, we provide a new recommendation for screening for sedentary behavior and counseling patients to avoid being sedentary, as well as a call for new studies of interventions to disrupt sedentary behavior. This is in addition to the recommendation to engage in regular moderate to vigorous physical activity.5. Glucagon-like protein-1 receptor agonists have been shown to be effective not only for improving management of type 2 diabetes but also for weight loss and lowering the risk of cardiovascular disease and stroke. On the basis of these robust data, we provide a new recommendation for the use of these drugs in patients with diabetes and high cardiovascular risk or established cardiovascular disease.6. Blood pressure management is critical for stroke prevention. Randomized controlled trials have demonstrated that treatment with 1 antihypertensive medication is effective for reaching the blood pressure goal in only ≈30% of participants and that the majority of participants achieved the goal with 2 or 3 medications. Therefore, ≥2 antihypertensive medications are recommended for primary stroke prevention in most patients who require pharmacological treatment of hypertension.7. Antiplatelet therapy is recommended for patients with antiphospholipid syndrome or systemic lupus erythematosus without a history of stroke or unprovoked venous thromboembolism to prevent stroke. Patients with antiphospholipid syndrome who have had a prior unprovoked venous thrombosis likely benefit from vitamin K antagonist therapy (target international normalized ratio, 2–3) over direct oral anticoagulants.8. Prevention of pregnancy-related stroke can be achieved primarily through management of hypertension. Treatment of verified systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg during pregnancy and within 6 weeks postpartum is recommended to reduce the risk of fatal maternal intracerebral hemorrhage. In addition, adverse pregnancy outcomes are common and are associated with chronic hypertension and an elevated stroke risk later in life. Therefore, screening for these pregnancy outcomes is recommended to evaluate for and manage vascular risk factors, and a screening tool is included to assist with screening in clinical practice.9. Endometriosis, premature ovarian failure (before 40 years of age), and early-onset menopause (before 45 years of age) are all associated with an increased risk for stroke. Therefore, screening for all 3 of these conditions is a reasonable step in the evaluation and management of vascular risk factors in these individuals to reduce stroke risk.10. Understanding transgender health is essential to truly inclusive clinical practice. Transgender women taking estrogens for gender affirmation have been identified as having an increased risk of stroke. Therefore, evaluation and modification of risk factors could be beneficial for stroke risk reduction in this population.
Preamble
Beginning in 2017, numerous modifications to the AHA/ASA guidelines have been implemented to make guidelines shorter and enhance user friendliness. Guidelines are written and presented in a modular knowledge chunk format; each chunk includes a table of recommendations, a brief synopsis, recommendation-specific supportive text, and, when appropriate, flow diagrams or additional tables. Other modifications to the guidelines include the addition of Knowledge Gaps and Future Research segments in some sections and a web guideline supplement (Data Supplement) for useful but noncritical tables and figures.Jose Romano, MD, FAHAChair, AHA Stroke Council Scientific Statement Oversight Committee
1. Introduction
Adults in the United States can control their risk for stroke by optimizing a few behaviors and taking advantage of evidence-based preventive care. These simple behaviors and care strategies are included in the AHA’s Life’s Essential 8, which serves as an educational tool to help everyone know how to stay healthy and prevent all forms of cardiovascular disease (CVD).1 The 8 strategies are as follows: eat better, be more active, quit tobacco, get healthy sleep, manage weight, control cholesterol, manage blood sugar, and manage blood pressure (BP).
Stroke is also a leading cause of adult-onset disability; among individuals who survive 6 months, almost half are dependent in at least 1 activity of daily living.8 Beyond physical dependence and disability, stroke and the cumulative brain injury that results from recurrent events lead to cognitive decline.9 With better implementation of known strategies for risk factor control, more than half of stroke events could be prevented, along with the associated disability and cognitive decline.10,11 Over time, this would be expected to lower the proportion of US adults living with brain injury related to stroke, which is currently estimated to be 7% among adults ≥60 years of age.12
This 2024 guideline parallels the 2014 AHA/ASA “Guidelines for the Primary Prevention of Stroke”13 in addressing both ischemic and hemorrhagic strokes. . . . The aim of the present guideline is to provide clinicians with evidence-based recommendations for prevention of the first stroke.
• AF (covered in the 2019 American College of Cardiology [ACC]/AHA AF focused update)14;• Congenital heart disease (covered in the 2018 ACC/AHA guideline)15;• Valvular heart disease (covered in the 2020 ACC/AHA guideline)16;• Subarachnoid hemorrhage (covered in the 2023 AHA/ASA guideline)19;• Pediatric stroke, except as it pertains to sickle cell disease (SCD)20;• Secondary prevention of stroke (covered in the 2021 AHA/ASA guideline)21;• Pathways for the implementation and dissemination of guideline recommendations in clinical practice.This guideline is organized into topics that are inclusive of primary prevention of stroke across the life span of adults. When the topics overlap with the 2014 guideline, studies and clinical trials published since 2014 have been summarized to underpin the current recommendations. There are 6 clinical sections:
1. Patient assessment;2. Life’s Essential 81;3. Atherosclerotic and nonatherosclerotic risk factors (eg, migraine);4. Special populations, including trans health (a first for stroke primary prevention), SCD (the exception for including the pediatric population), genetic stroke syndromes, coagulation and inflammatory disorders, substance use, and sex-specific risk factors (pregnancy and pregnancy complications, endometriosis, hormonal contraception, menopause, and exogenous testosterone use);5. Heart disease, specifically atrial cardiopathy and left ventricular dysfunction; and6. Antiplatelet use for primary prevention.The current guideline includes recommendations for screening for stroke risk factors in the primary care setting in the Patient Assessment section, which incorporates social determinants of health (SDOH), a highly influential group of nonmedical factors that affect cardiovascular and stroke risk and prevention.24 In addition, in lieu of certain nonmodifiable risks such as age and genetic factors, we focused on prevention across the life span. The genetic factors that currently have treatments available that could potentially alter the risk of stroke also were the focus of this guideline. The modifiable risk factors are now organized and summarized according to a powerful new measure of cardiovascular health, Life’s Essential 8, which is a pattern of treatment targets and behaviors that can affect the risk of stroke.1 To reflect the stroke risk that increases with age, we included atherosclerotic risk factors, specifically asymptomatic carotid disease, asymptomatic small-vessel disease (SVD)/cerebral infarcts, and nonatherosclerotic risk that includes migraine.
Another modification to this update is the inclusion of special populations, or individuals with potentially enhanced risk (Figure 1) that may occur across the life span but affects primarily young and middle-aged adults. Hypertensive disorders of pregnancy (HDP) and other pregnancy complications associated with stroke during and later in life were described in the 2014 AHA/ASA “Guidelines for the Prevention of Stroke in Women,”25 but the recommendations in this current guideline are guided by the vast amount of literature published since 2014. Other sex-specific topics that have yet to be covered in other stroke prevention guidelines include endometriosis, menopause, and testosterone use. Trans health is also extremely important to discuss because these individuals are marginalized in some societies and may be skeptical of medical care but could have unique risks for stroke.Figure 1. Elements associated with elevated stroke risk. CADASIL indicates cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.We also discuss the evidence behind anticoagulation and cardiomyopathy, as well as anticoagulation for the primary prevention of stroke. The final section of the guideline is an update of antiplatelet use for primary prevention of stroke.In the process of developing this guideline, the writing group reviewed prior published AHA/ASA guidelines and scientific statements, listed in Supplemental Table 1. These are resources for readers and reduce the need for repetition of existing guideline recommendations.1.5. Class of Recommendations and Level of Evidence
Recommendations are designated with both a Class of Recommendation (COR) and a Level of Evidence (LOE). The COR indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The LOE rates the quality of scientific evidence supporting the intervention based on the type, quantity, and consistency of data from clinical trials and other sources (Table 1).Table 1. Applying the American College of Cardiology/American Heart Association Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)1.6. Abbreviations
Abbreviation Meaning ACC American College of Cardiology ACCORD Action to Control Cardiovascular Risk in Diabetes ACS asymptomatic carotid artery stenosis ACST Asymptomatic Carotid Surgery Trial AF atrial fibrillation AHA American Heart Association aPL antiphospholipid antibody APO adverse pregnancy outcome APS antiphospholipid syndrome ASA American Stroke Association ASPREE Aspirin in Reducing Events in the Elderly BMI body mass index BP blood pressure CADASIL cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy CEA carotid endarterectomy CHC combined hormonal contraceptive COR Class of Recommendation CPAP continuous positive airway pressure CRCT chronic red cell transfusion CREST 2 Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial CSVD cerebral small-vessel disease CVD cardiovascular disease DASH Dietary Approaches to Stop Hypertension DBP diastolic blood pressure e-cigarette electronic cigarette ERT enzyme replacement therapy GLP-1 glucagon-like protein-1 HDP hypertensive disorders of pregnancy HHT hemorrhagic telangiectasia HOPE-3 Heart Outcomes Prevention Evaluation–3 HR hazard ratio HT hormone therapy ICH intracerebral hemorrhage JPPP Japanese Primary Prevention Project LDL low-density lipoprotein LDL-C low-density lipoprotein cholesterol LOE Level of Evidence MI myocardial infarction MRI magnetic resonance imaging OSA obstructive sleep apnea PAVM pulmonary arteriovenous malformation PCSK9 proprotein convertase subtilisin/kexin 9 PD periodontal disease PFO patent foramen ovale RCT randomized controlled trial SBP systolic blood pressure SCD sickle cell disease SCI silent cerebral infarct/infarction SDOH social determinants of health SLE systemic lupus erythematosus SPRINT Systolic Blood Pressure Intervention Trial STOP Stroke Prevention Trial in Sickle Cell Anemia SVD small-vessel disease TCD transcranial Doppler TIA transient ischemic attack TRAVERSE Testosterone Replacement Therapy for Assessment of Long-Term Vascular Events and Efficacy Response in Hypogonadal Men USPSTF US Preventive Services Task Force VKA vitamin K antagonist WARCEF Warfarin Versus Aspirin in Reduced Cardiac Ejection Fraction WC waist circumference WHR waist-to-hip ratio Table 2. Supplemental Guidance on Level of Evidence
Table 3. Study Populations and Characteristics Included for Primary Prevention Evidence Review
Study populations Characteristics 1. General population without CVD Primary prevention 2. Population with CVD and no stroke Primary prevention 3. Population with CVD and stroke ≥50% without stroke is primary prevention CVD indicates cardiovascular disease.2.2. Emphasis on Groups With Elevated Stroke Risk
Certain patient populations have elevated risk for stroke. In these populations, elevated risk can be related to genetic factors in the case of inherited conditions, biological factors related to sex-specific risks or hormones, social factors that relate to health care access or other SDOH, or a combination of these factors (Figure 2). In this guideline, we introduce several new sections to highlight populations at higher risk for stroke and, in some cases, populations who may be less likely to receive routine screening for common vascular risk factors despite their elevated risk. For several of these populations, high-quality clinical trial data testing the effect of risk factor control on stroke risk do not exist. The lack of data to guide management for these patient populations is largely related to the following:Figure 2. Selected genetic, biological, and social factors affecting stroke risk. CADASIL indicates cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.• Lack of inclusion in stroke clinical trials;• Clinical trial feasibility given low prevalence; and• Failure to identify populations as important subgroups.We highlight research gaps for these higher-risk populations to encourage research that can be used to guide clinical management in the future. We acknowledge that there are many other populations with elevated stroke risk related to SDOH, including access to care, geographic location, educational attainment, economic stability, and structural racism. Because many of these underlying drivers of inequities operate at societal and systemic levels, they are not within the scope of this guideline, and we do not include recommendations for them here. However, in mentioning these drivers of inequities, we aim to highlight the critical need for future research to understand mechanisms by which they influence risk so that we can develop evidence-based interventions to target them.2.3. Social Determinants of Health
SDOH are nonmedical factors, including education, economic stability, health care access, neighborhood of residence, experiences of racism, and others, that contribute to inequities in care, health, and health care outcomes.3,26–453. Patient Assessment
58. Hong C, Pencina MJ, Wojdyla DM, Hall JL, Judd SE, Cary M, Engelhard MM, Berchuck S, Xian Y, D’Agostino R, et al. Predictive accuracy of stroke risk prediction models across Black and White race, sex, and age groups. JAMA. 2023;329:306–317. doi: 10.1001/jama.2022.2468359. Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost. 2012;107:1172–1179. doi: 10.1160/TH12-03-0175Synopsis
Prevention of stroke in office-based care begins by meeting with patients to identify behaviors and conditions that place them at risk. Prevention should begin early in life because unidentified and unmanaged risk causes damage to arteries, the brain, and the heart years before disease is manifest. The most common treatable behaviors and conditions that increase risk are the AHA’s Life’s Essential 8,1 but others include AF and substance use disorders.66 Talking with patients will identify modifiable behaviors (eg, cigarette smoking, physical inactivity, sleep problems, and poor-quality diet) and social, environmental, or economic factors that contribute to risk or affect remediation (Table 4). Physical findings that should prompt offers of treatment include high weight and high BP. Findings on testing include dyslipidemia and hyperglycemia. Estimation of 10-year risk for atherosclerotic CVD, as described in a special report by the ACC/AHA,73 can inform shared decision-making. Screening and risk remediation are usually achieved in the context of regular primary care. For women, their obstetrician-gynecologist may be this source of primary care; obstetrical complications (ie, preeclampsia) are associated with pregnancy-related stroke and risk for hypertension later in life.73. Lloyd-Jones DM, Braun LT, Ndumele CE, Smith SC, Sperling LS, Virani SS, Blumenthal RS. Use of risk assessment tools to guide decision-making in the primary prevention of atherosclerotic cardiovascular disease: a special report from the American Heart Association and American College of Cardiology [published correction appears in Circulation. 2019;139:e1133]. Circulation. 2019;139:e1162–e1177. doi: 10.1161/CIR.0000000000000638Table 4. Key Conditions Affecting Stroke Risk and Screening Methods to Classify Them as Emphasized in This Guideline for Primary Prevention of Stroke
Risk condition Screening method Comment BP Office measurement Elevated office measures should be confirmed with home or ambulatory monitoring per AHA guidance on BP classification.67 Cigarette smoking Interview Direct questioning helps classify individuals as never, past, or current cigarette smokers. It will identify whether a patient is ready to quit, which would be the clinician’s cue to offer treatment options. Diabetes Blood test Most convenient tests include fasting blood glucose and hemoglobin A1c. Diet quality Interview Direct questioning of patients can help determine whether their current eating pattern emphasizes healthy foods and minimizes less healthy foods.68 Instruments for clinical use include the Mediterranean Diet Adherence Screener and the Mediterranean Eating Pattern for Americans tool.69,70 Dyslipidemia Blood test Current guidelines offer nonfasting testing as convenient for patients with validity similar to that of fasting testing for key lipid fractions. Overweight Office measurement BMI is the most common measure of weight health, but additional measures of central adiposity such as the WC may refine risk. Physical inactivity Interview Direct inquiry can be used to determine whether a patient is meeting US Department of Health and Human Services guidelines for physical activity. Formal questionnaires are not accurate for clinical use. SDOH Interview/questionnaire SDOH include employment status, household income, education, food insecurity, health care access, housing, access to transportation, neighborhood and built environment, and internet access. Screening instruments are available.71 Sleep disorder Questionnaire Clinicians can ask patients about sleep hours. Questionnaires include the Epworth Sleepiness Index, Berlin Questionnaire, and Pittsburgh Sleep Quality index.72 Substance use disorders Interview/questionnaire Direct questioning or use of validated instruments can identify individuals with substance use disorders related to stroke risk (ie, alcohol, cocaine, intravenous drug injection). AHA indicates American Heart Association; BMI, body mass index; BP, blood pressure; SDOH, social determinants of health; and WC, waist circumference.Recommendation-Specific Supporting Text
1.An important application for stroke risk classification is to support primary prevention decision-making on initiation of antiplatelet therapy and therapy to lower BP or cholesterol. The relative risk (RR) reduction for these therapies is similar in patients at high and low risk for first stroke. The absolute risk reduction, however, is higher for those at higher risk. This means that fewer patients at high risk need to be treated to prevent a stroke compared with patients at low risk. Therefore, patients with higher absolute risk reduction may be more willing to incur the risk and inconvenience of preventive therapy than those at lower risk. Both the US Preventive Services Task Force (USPSTF) and the AHA endorse risk assessment for decision-making in primary prevention.67,68,74,75 Clinicians use risk prediction instruments that estimate risk for atherosclerotic CVD broadly rather than cerebrovascular disease alone for 3 reasons: (1) Risk factors and preventive therapy overlap for these 2 diseases; (2) the broader instruments perform as well as stroke-specific instruments for stroke risk58; and (3) in patient-centered care, both diseases are important. Among instruments,67,77–79 the Pooled Cohort Equation is widely used in the United States.58,80 However, the AHA has developed new equations, the Predicting Risk of CVD Events equations, that are expected to replace the Pooled Cohort Equation.772.Risk prediction instruments can facilitate patient-centered, preventive stroke care. The right instrument, however, needs to be selected for the right patient, and the resulting risk estimates need thoughtful interpretation and application. Prediction instruments are commonly applied to 2 groups of patients to guide stroke prevention therapy: those with nonvalvular AF and those with or without AF who are at risk for arterial disease. The CHA2DS2-VASc score is recommended by the AHA to inform risk-based anticoagulation of patients with nonvalvular AF of any duration.14,59 However, the CHA2DS2-VASc instrument is imperfect in that risk of stroke varies among populations with the same score. For this reason, the AHA recommends that a patient’s risk estimate may also consider other factors related to stroke risk such as burden of AF. With this understanding, oral anticoagulation is recommended for patients with an annual stroke risk ≥2% (generally a CHA2DS2-VASC score of ≥2 in men or ≥3 in women).14,82 Our recommendation to apply the CHA2DS2-VASc score for assessment of patients with AF is consistent with other AHA guidelines.82,83 These guidelines also recognize that risk estimation is just one factor in the decision for anticoagulation in patients with nonvalvular AF. Another is bleeding risk.84 We agree with the ACC and AHA that treatment decisions should be individualized in the context of shared decision-making.833.Several modifiable behaviors and medical conditions have been associated with increased stroke risk in observational research. Except for AF, no high-quality randomized trials have tested the effect of screening for these behaviors and conditions on stroke risk. Our recommendation to screen for modifiable behaviors and medical conditions is based on (1) randomized trials that demonstrate the benefit of treating risk factors, however identified, to reduce risk for stroke; (2) trials that demonstrate the benefits of treating risk factors to reduce the factors themselves; and (3) nonrandomized studies. In subsequent sections of this guideline that deal with specific behaviors and conditions, we summarize the evidence behind screening recommendations. For convenience, Table 4 lists modifiable behaviors or medical conditions for which we recommend screening. Some of these risk factors are associated. For example, hypertension, obesity, and obstructive sleep apnea (OSA) are risk factors for AF; modifying them could reduce risk for AF.85 Table 4 also includes a recommendation to screen for SDOH, discussed in the Synopsis. One consequence of few screening trials is that the optimal screening interval is uncertain. The USPSTF recommends screening for hypertension yearly for adults >40 years of age and every 3 to 5 years for adults 18 to 39 years of age.60 The AHA recommends screening for traditional risk factors every 4 to 6 years in adults 20 to 79 years of age.61 More frequent screening for modifiable behaviors and medical conditions may be warranted after a person is found to have borderline values on initial or subsequent testing.4.Economic, environmental, and social factors modify risk for atherosclerotic CVD62 and stroke specifically.35,63–65 Together, these nonclinical and nonbiological factors are referred to as SDOH.57 They include fundamental factors such as exposure to structural racism, income, wealth, employment opportunity, and educational attainment; intermediate factors such as neighborhood safety, social environment (including isolation), and access to care; and proximate factors such as access to transportation, access to communication technology, and health literacy. The result of exposure to adverse SDOH is decreased detection and control of stroke risk.26 In a recent scientific statement,26 the AHA pointed out that fundamental causes are best addressed by policy and social movements. Intermediate and proximate factors can be addressed by local and individual interventions. At the clinic level, these include assistance with housing, food access, transportation to medical care, special efforts to build trust with health care professionals, health education, and assistance with medication adherence. No trials have tested the effect of screening for SDOH on stroke incidence, but we recommend screening for actionable determinants (eg, transportation, health knowledge, access to healthy food, health insurance, housing, transportation, communication technology, access to safe walking space) as a logical prerequisite to helping patients overcome barriers to control of their stroke risk.
