Stroke

Stroke

• National Guidelines and Recommendations
• Professional Groups
• Advocacy Groups
• Other Resources

National Guidelines and Recommendations

U.S. Preventive Services Task Force (USPSTF) Guidelines

For patients at moderate risk for stroke due to family history: USPSTF strongly recommends that clinicians routinely screen men aged 35 years and older and women aged 45 years and older for lipid disorders and treat abnormal lipids in people who are at increased risk for coronary heart disease (CHD). Younger adults (men aged 20-35 and women aged 20-45) should be screened for lipid disorders if they have other risk factors for CHD.

U.S. Preventive Services Task Force (USPSTF) References for Stroke Guidelines:

• Screening for High Blood Pressure [uspreventiveservicestaskforce.org] (2007)
• Screening for Carotid Artery Stenosis [uspreventiveservicestaskforce.org] (2007)
• Screening for Coronary Heart Disease (2004): [uspreventiveservicestaskforce.org] (2004)
• Screening for Peripheral Arterial Disease [uspreventiveservicestaskforce.org] (2005)

U.S. Preventive Services Task Force (USPSTF Guidelines) Screening for Lipid Disorders in Adults

The USPSTF has found that there is good evidence that high levels of total cholesterol and low density lipoprotein-cholesterol (LDL-C) and low levels of high density lipoprotein-cholesterol (HDL-C) are important risk factors for coronary heart disease. The risk for coronary heart disease is highest in those with a combination of risk factors. The 10-year risk for coronary heart disease is lowest in young men and in women who do not have other risk factors, even in the presence of abnormal lipids.

The USPSTF also found good evidence that lipid measurement can identify asymptomatic men and women who are eligible for preventive therapy.

There is good evidence that lipid-lowering drug therapy substantially decreases the incidence of coronary heart disease in persons with abnormal lipids. The absolute benefits of lipid-lowering treatment depend on a person's underlying risk for coronary heart disease. Men over the age of 35 and women over the age of 45 who are at increased risk will realize a substantial benefit from treatment; younger adults with multiple risk factors for coronary disease, including dyslipidemia, will realize a moderate benefit from treatment; and younger men and women without risk factors for coronary heart disease will realize a small benefit from treatment, as seen in the risk reduction in 10-year CHD event rate.

Summary of Recommendations

Screening Men

• The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders.
  Rating: A recommendation
   
• The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease.
  Rating: B recommendation.

Screening Women at Increased Risk

• The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease.
  Rating: A recommendation
   
• The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease.
  Rating: B recommendation

Screening Young Men and All Women Not at Increased Risk

• The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease.
  Rating: C recommendation

Reference: Screening for Lipid Disorders in Adults, June 2008

U.S. Preventive Services Task Force (USPSTF Guidelines) Screening for Lipid Disorders in Children

Normal values for lipids for children and adolescents are currently defined according to population levels (percentiles). Tracking of lipid levels in children is variable, although evidence is stronger for TC and LDL than for HDL and TG. Screening using family history misses substantial numbers of children with elevated lipids. Most trials of drug interventions demonstrate improvement, but these trials were performed in selected groups of children. Several key questions could not be addressed because of lack of studies, including the effectiveness of screening on adult CHD or lipid outcomes, optimal ages and intervals for screening children, cost-effectiveness of screening, or the effects of treatment of lipids in childhood on adult CHD outcomes.

Reference: Screening for Lipid Disorders in Children and Adolescents: Systematic Evidence Review for the U.S. Preventive Services Task Force [uspreventiveservicestaskforce.org]
AHRQ Publication No. 07-0598-EF-1. July 2007.

Professional Organizations

American College of Radiology

Cerebrovascular disease

Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® cerebrovascular disease. [online publication]. Reston (VA): American College of Radiology (ACR); 2011. 23 p. [131 references]

This is the current release of the guideline.

The report cites:

Recommendations: Because of the cumulative long-term risk of morbidity and mortality from subarachnoid hemorrhage, especially with larger aneurysms (>25 mm in diameter) and the relatively low risk of clipping or coiling unruptured intracranial aneurysms, there may be a clinical role for prophylactic screening. Intra-arterial angiography carries the risk of thromboembolic complication and is relatively expensive; MRI and CTA provide less expensive, noninvasive alternative, although their sensitivity to lesions less than 5 mm in diameter is suspect. To date, individuals with a history of aneurysm or SAH in a first-degree relative have been considered candidates for screening. Nevertheless, significant gaps in knowledge of the natural history (and thus risk of rupture) of intracranial aneurysms remain. Hence, while screening with MRA or CTA may be appropriate in patients with a positive family history, its impact on patient outcome is questionable.

Reference: Cerebrovascular disease [guideline.gov]

• Risk factor for unruptured aneurysm. Positive family history.

Advocacy Groups

American Heart Association Guidelines - Stroke Guidelines

AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases

This 2002 update of the Primary Prevention Guide serves to integrate other guidelines and consensus statements developed since the initial Guide's approval. Although this Guide largely applies to adults, it does identify high-risk patients for whom screening and intervention in first-degree relatives (including children) would be an important aspect of primary prevention. However, this Guide will not provide specific recommendations for the reduction of cardiovascular risk in children and adolescents. This important issue will be the subject of a separate guide. However, a family-centered approach to primary prevention should be emphasized, inasmuch as it recognizes both the genetic and behavioral causes of the well-established familial aggregation of heart disease and stroke.

Reference: AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update [circ.ahajournals.org]
Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases

American Stroke Association

Stroke Risk Factors:

Heredity (family history) and Race

• An individual's stroke risk is greater if a parent, grandparent, sister or brother has had a stroke.
• African Americans have a much higher risk of death from a stroke than Caucasians do. This is partly because African Americans have higher risks of high blood pressure, diabetes and obesity.

Reference: Stroke Risk Factors [strokeassociation.org]

American Heart Association

Stroke Risk Often Runs in the Family

The American Heart Association (AHA) lists family history as an important non-modifiable stroke risk factor, along with advancing age, male sex, and prior history of heart attack or stroke.

It has long been believed that genes influence stroke risk, and now a large study from the U.K. offers some of the best evidence yet that this is so. Stroke patients in the study who were 65 or younger were almost three times as likely as non-stroke patients to have a parent or sibling who had an early stroke or heart attack.

Having a positive family history of stroke in a first-degree relative under the age of 65 should alert someone that they are probably at increased risk. For these people it is particularly important to make lifestyle changes that can decrease this risk.

Reference: Stroke Risk Often Runs in the Family [webmd.com]

Other Resources

Risk factors for stroke include personal or family history of stroke, transient ischemic attacks (TIA), or CHD.

There are nearly 35 single-gene disorders that feature stroke. Genetic tests for some of these disorders are now available. Information about diagnostic testing for genetic conditions that cause stroke can be found at GeneTests [nbci.nlm.nih.gov] and at Online Mendelian Inheritance in Man [omim.org].

Red flags suggestive of hereditary syndromes featuring stroke:

• Age at diagnosis of stroke or other cerebrovascular disease before age 65
• Several family members with stroke and/or stroke-related cardiac disease or vasculopathies.