Stroke Prevention

Amytis Towfighi, MD

Nine out of 10 strokes are due to modifiable factors. Yet, preventive strategies thus far have been relatively ineffective in curbing the global stroke burden. Although the pathophysiology and risk factors for stroke are well-characterized, our understanding of how to optimize healthcare systems and empower patients–to ensure prescription of evidence-based care for stroke prevention, access to care, adherence to medications, control of risk factors, and engagement in healthy lifestyles and self-management–is poor.

In the first article of this issue, Hill and Towfighi provide an overview of the global burden of stroke due to modifiable risk factors, a summary of the literature regarding key behavioral, metabolic, and environmental stroke risk factors, and strategies for primordial, primary, and complex secondary stroke prevention. The succeeding contributions review specific behavioral and metabolic risk factors for stroke: blood pressure (Dakay and Silver); nutrition (Spence); diabetes, obesity, and metabolic syndrome (Tang, Liebeskind. Towfighi), and hyperlipidemia (Barkas and Milionis). Lightbody et al provide a systematic review and meta-analysis of cohort and case-control studies delineating the association between psychosocial risk factors and stroke.

Subsequently, we approach stroke prevention strategies by pathophysiologic mechanism: intracranial and extracranial large artery atherosclerosis (Banerjee and Turan); small vessel disease (Smith); cardioembolism (Sacchetti, Furie, and Yaghi); cerebral arteriopathies, venous thrombosis, and migraine (Camargo and Singhal); genetic mechanisms (Majersik); and antiplatelets for noncardioembolic stroke (Krishnan et al).

The penultimate article addresses special considerations in women (Al-Rasheed and Jaigobin). The final manuscript provides an overview of strategies for organized outpatient care for transient ischemic attack or minor stroke (Joundi and Saposnik).

Our historical approach of targeting small high-risk populations for stroke prevention and focusing primarily on prescription of medications (with little attention to medication adherence or risk factor control) has been ineffective. To rein in the global burden of stroke, it is critical to understand how to promote health literacy, expand access to care, improve lifestyle behaviors, bolster self-management skills and adherence to stroke prevention medications, and ensure that providers follow evidence-based guidelines for stroke prevention.