What's new in stroke prevention guidelines? My Top 5

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The American Heart Association and American Stroke Association have just issued an updated guideline for prevention of stroke in people who have never had a stroke previously (primary prevention). The prior guideline was 10 years old, so this update is filled with a ton of new information.

The guideline kicks off with a Top 10 of key messages. Here are five that I found especially interesting, as a hormone/diabetes/obesity specialist!

GLP1 receptor agonist therapy is now recommended in people with diabetes and high cardiovascular risk or established cardiovascular disease. In particular, semaglutide (Ozempic) and dulaglutide (Trulicity) have been shown to reduce stroke risk in people with type 2 diabetes. A meta analysis of 12 trials found that GLP1 receptor agonists are associated with 27% lower stroke risk, with no evidence of heterogeneity across trials.

Endometriosis, premature ovarian failure (before age 40), and early onset menopause (before age 45) are all associated with an increased risk of stroke. Screening for all of these conditions is a reasonable step in the evaluation and management of vascular risk factors to reduce stroke risk.

They call out the importance of understanding transgender health. Transgender women taking estrogens have increased risk of stroke.

The Mediterranean diet is recommended for adults with no prior cardiovascular disease and those with medium or high risk of cardiovascular disease, because this diet has been shown to reduce risk of stroke, especially when supplemented with nuts and olive oils. I’m a little less excited by this one, because we know that one diet does not fit all. While it may be great for stroke prevention to follow the Mediterranean diet, this will not suit people who do not enjoy, or do not have access to, Mediterranean foods. Finding a individualized dietary stratety must take into account what fits a person’s tastes, cultural preferences, and what is affordable/accessible.

Physical activity is essential for cardiovascular health and for reducing risk of stroke. Prolonged sedentary behavior during waking hours is associated with an increased risk of stroke (think: sitting at a desk all day). So now, in addition to the existing recommendation to engage in regular moderate to vigourous physical activity, they recommend screening for sedentary behavior and counseling people to avoid sedentary lifestyles.

For many other important aspects of stroke prevention, be sure to check out the entire guideline!

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