Prevention of Stroke

OBJECTIVE: This article provides an overview of the principles of stroke prevention, including the distinctions among primordial, primary, secondary, and tertiary prevention. The relationship between stroke prevention and preservation of brain health is considered, and recent guidelines for primary stroke prevention are emphasized. LATEST DEVELOPMENTS: The current standard for the reduction in risk of stroke focuses on public-facing educational tools and clinical risk prediction algorithms that incorporate demographic, lifestyle, and health factors. Newly developed and validated prediction algorithms include social determinants of health, remove racial biases, and include cardiometabolic and kidney disease. Secondary stroke prevention increasingly accounts for presumed causal mechanisms of stroke while managing risk factors. Long-term monitoring for atrial fibrillation, remote patient monitoring of blood pressure, and increased use of glucagon peptide-like protein-1 receptor agonists are recent developments that may reduce disparities in risk. Vascular risk factor control before and after stroke may help mitigate cognitive decline and dementia by preserving brain health. ESSENTIAL POINTS: Social and environmental determinants, or drivers, of health are increasingly recognized contributors to stroke risk, and they may be amenable to policy and population solutions. Primary stroke prevention usually falls to the primary care physician, but neurologists may be involved as well, particularly for patients who present for other reasons or who are incidentally discovered to have cerebral infarcts in the course of evaluation for other conditions. Efforts to prevent stroke will also improve brain health more broadly, including reducing risk of cognitive decline, dementia, and late-life depression.