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SPREAD V Ed. | |
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Primary prevention |
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| R 7.1 Grade D |
Counselling and promotion of correct life-styles are recommended to decrease stroke incidence and mortality, in the entire population but especially in subjects at high risk of vascular diseases. | ||||||||||
| R 7.2 Grade D |
Smoking cessation decreases the risk of stroke. It is recommended for all smokers independently of age and amount of smoking. | ||||||||||
| R
7.3 Grade B |
To prevent stroke, it is recommended to regularly perform physical activity. | ||||||||||
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®GPP |
A mild-to-moderate aerobic physical activity (a 30-minute walking at 10-12 minutes per kilometre) is recommended in most days of a week, preferably every day. | ||||||||||
| S7-1 | Based on the currently available evidence, an
alimentary pattern based on the Mediterranean diet and low in sodium
can be suggested to prevent stroke. Increased risk of stroke is associated in particular with excess sodium, alcohol and saturated fatty acids. On the contrary, for some foods a protective action was seen:
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| R 7.4 |
 In the general population
it is recommended to
achieve the following specific nutritional targets: |
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| 7.4 a. Grade C |
a healthy body weight (BMI=18.5-24.9). This can be achieved by progressively increasing the physical activity, controlling the intake of fats and sweets, increasing the amount of fruits and vegetables in the diet. | ||||||||||
| 7.4
b. Grade C |
salt intake ≤6 g/day (2.4 g of sodium). Salty food and adding salt to the food in cooking or at the table should be avoided. | ||||||||||
| 7.4
c. Grade D |
low consumption of dietary animal fats in favour of vegetable fats (in particular extra virgin olive oil). | ||||||||||
| 7.4
d. Grade C |
consumption of fish - e.g. salmon, swordfish, fresh tuna, mackerel, halibut, trout - at least 2 times per week (at least 400 g overall) as a source of polyunsaturated omega-3 fatty acids. | ||||||||||
| 7.4
e. Grade B |
two servings of vegetables
and 3 servings of fruit each day. NOTE: 1 serving of vegetables=250 g if cooked, 50 g if uncooked; 1 serving of fruit=150 g |
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| 7.4
f. Grade C |
regular consumption of whole grains and legumes (rich in energy, vegetable proteins, fibre, vitamins, folic acid and minerals: potassium and magnesium). | ||||||||||
| 7.4
g. Grade D |
regular consumption of milk and dairy products, choosing low-fat, low-sodium products. | ||||||||||
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7.4 h. |
limit the alcohol intake to not more than two glasses of wine (or an equivalent amount of alcohol) per day in men and to one in nonpregnant women, preferably with the main meals, in absence of metabolic contraindications. | ||||||||||
| R
7.5 a Grade A |
The treatment of arterial hypertension is recommended in all hypertensive subjects regardless of age and severity of hypertension, because it decreases the risk of stroke. The target indicated by the ESH-ECS guidelines for 2007 is a blood pressure <130 and <80 mm Hg in diabetic patients, and at least <140 and <90 mm Hg - or definitely lower if tolerated - in all other hypertensive subjects. | ||||||||||
| R
7.5 b Grade A |
In elderly subjects with isolated systolic hypertension, an antihypertensive treatment is recommended, preferring the use of diuretics or long-acting dihydropyridine Ca-antagonists. | ||||||||||
| R
7.5 c Grade B |
In hypertensive patients with left ventricular hypertrophy, the use of antihypertensive agents that block the renin-angiotensin system, such as losartan (demonstrated in one study to be superior to atenolol also for stroke prevention) is recommended. | ||||||||||
| R
7.5 d Grade B |
In patients with an high thrombotic risk (presence of coronary artery disease, peripheral artery disease, or diabetes mellitus associated with another vascular risk factor such as hypertension, hypercholesterolaemia, low HDL-cholesterol, cigarette smoking or microalbuminuria), for the primary prevention of stroke it is recommended to use ramipril at the 10 mg/day dosage. | ||||||||||
| R
7.6 Grade B |
Oral anticoagulants, maintaining the international normalised ratio (INR) in the 2 to 3 range, are recommended for patients with chronic and paroxysmal atrial fibrillation and valvular heart disease, independently of the presence of other risk factors. | ||||||||||
| R
7.7 a Grade D |
In patients with
chronic and paroxysmal non-valvular atrial fibrillation,
cardioversion is recommended as the first therapeutic approach. |
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| R
7.7 b Grade A |
In patients aged 65-75 years with chronic and paroxysmal non-valvular atrial fibrillation, oral anticoagulant therapy, maintaining the INR at 2-3, is recommended in absence of haemorrhagic risks. | ||||||||||
| R
7.7 c Grade A |
In patients with chronic and paroxysmal non-valvular atrial fibrillation, age over 75 years, and additional risk factors for thromboembolism (e.g. diabetes, arterial hypertension, heart failure, left atrial dilatation, left ventricular dysfunction), long term oral anticoagulation therapy (INR range 2-3) is recommended, evaluating carefully each individual case and taking into account the increased hemorrhagic risk - especially intracranial - of elderly people. | ||||||||||
| R
7.7 d Grade A |
Although less effective, aspirin (ASA) therapy (325
mg per day) is recommended as an alternative to anticoagulant
therapy in chronic and paroxysmal non-valvular atrial fibrillation for:
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| R
7.7 e Grade A |
In patients under 65 years of age with isolated chronic and paroxysmal non-valvular atrial fibrillation, no prophylactic treatment is recommended because the embolic risk is low. In presence of additional embolic risks, these must be evaluated in the individual case to decide between ASA and oral anticoagulant therapy | ||||||||||
| R
7.8 Grade C |
Long term oral anticoagulation therapy is recommended in patients with mechanical valvular prosthesis (INR range 2.5-3.5, and INR range 3-4 in case of ball valve or caged disk valve). | ||||||||||
| R
7.9 a Grade B |
In patients with coronary artery disease, the use of statins for the treatment of hypercholesterolemia is recommended for the primary prevention of stroke. | ||||||||||
| R
7.9 b Grade A |
In patients at high risk of vascular disease, therapy with simvastatin (40 mg per day) is recommended for the primary prevention of stroke. | ||||||||||
| R
7.9 c Grade D |
In hypertensive patients with at least three additional risk factors, therapy with atorvastatin (10 mg per day) is recommended for the primary prevention of stroke. | ||||||||||
| R
7.10 a Grade D |
The diagnosis and treatment of diabetes mellitus. along with the best control of fasting and post-prandial glycaemia, are recommended to decrease the risk of stroke. | ||||||||||
| R
7.10 b Grade A |
In diabetic patients >30 years old with at least one additional risk factor, therapy with aspirin is recommended for the primary prevention of stroke. | ||||||||||
| R
7.11 Grade C |
In patients with antiphospholipid antibodies, the anticoagulant therapy is recommended only for those with a history of thrombotic events. | ||||||||||
| R
7.12 ®GPP |
Although plaques of the aortic arch may be a risk factor for stroke, at present the treatment with anti-thrombotic agents is not recommended. | ||||||||||
| R
7.13 Grade A |
The hormonal replacement therapy with oestro-progestinic agents in postmenopausal women, aimed exclusively at preventing stroke, is not recommended. |
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