Risk Factor	Recommendation	Comment
Hypertension	BP <140/90 mm Hg	BP lowering is more important than choice of medication; diabetic patients may benefit from further BP reduction
Diabetes mellitus	Multifactor risk factor modification may be better than focusing on targeting glucose alone	Hb_A1c <7% has not been shown to reduce risk of stroke
Hyperlipidemia	Patients with elevated cholesterol, atherosclerosis anywhere: LDL <100 mg/dL Diabetics: LDL <70 mg/dL	First line: statins Second line: bile-acid sequestrants and niacin
Tobacco abuse	Combined pharmacologic and behavioral smoking-cessation therapy	Lack of direct evidence

BP, Blood pressure; Hb_A1c, hemoglobin A1c; LDL, low-density lipoprotein cholesterol.

Hypertension

Hypertension is related to stroke in a graded, continuous manner, and stroke risk is increased even when blood pressure levels are considered normal by current guidelines. Patients with prehypertension should be encouraged to control their pressure with nonpharmacologic lifestyle measures. The Joint National Committee (JNC) 7 guidelines for the classification and treatment of hypertension have been published (Table 2).

TABLE 2

Classification and Treatment of Blood Pressure

Classification	Systolic Blood Pressure (mm Hg)	Diastolic Blood Pressure (mm Hg)	No Compelling Indication^∗	With Compelling Indication^∗
Normal	<120	<80	No antihypertensive drug	No antihypertensive drug
Prehypertension	120–139	80–89	No antihypertensive drug	Drugs for compelling indication
Stage I hypertension	140–159	90–99	Thiazide-type diuretic for most; may consider ACEI, ARB, CCB, BB, or combination	Drugs for compelling indication, other drugs as needed
Stage II hypertension	≥160	≥100	Two-drug combination for most, usually a thiazide diuretic and a choice of ACEI, ARB, CCB, or BB	Drugs for compelling indication, other drugs as needed

ACEI, Angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; BB, β-blocker; CCB, calcium channel blocker.

^∗Lifestyle modifications are encouraged for all and include weight reduction for overweight patients, limitation of ethanol intake, increased aerobic physical activity (30–45 minutes daily), reduction of sodium intake (2.34 g), maintenance of adequate dietary potassium (120 mmol/day), smoking cessation, and DASH diet (rich in fruits, vegetables, and low-fat dairy products and reduced in saturated and total fat).

From Goldstein LB, Bushnell CD, Adams RJ, et al: Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association, Stroke 42:517–584, 2011. Used with permission. ©2011 American Heart Association, Inc.

A meta-analysis of 29 trials including 162,341 patients concluded that stroke risk is effectively reduced by lowering pressure (23%; 95% confidence interval [CI], 5%–37%). Most of the effect was not a direct result of the chosen pharmacologic regimen but rather was secondary to absolute reduction of blood pressure. Calcium channel blocker–based regimens showed a trend toward better efficacy when compared with β-blocker, diuretic-based (7%; CI, 1%–14%), or angiotensin converting enzyme (ACE) inhibitor–based regimens (12%; CI, 1%–25%). Current guidelines suggest that blood pressure should be maintained below 140/90 mm Hg in asymptomatic patients with extracranial carotid or vertebral artery atherosclerosis.