Family History in Stroke Prevention: Contemporary Evidence and Nursing Implications

Stroke remains a leading (fourth) cause of death in the United States and a major cause of disability and dementia.1 Every year, an estimated 610,000 people in the United States experience their first stroke,1 but the number of people affected is substantially greater, as their first-degree family members’ risks for stroke increase by about 30%.2,3 Family history of stroke has also been associated with greater stroke-related mortality, particularly among younger adults2,4 and heightens the chances of a stroke survivor having a second stroke.2 Family history of disease is a common healthcare screening question that is used to guide clinical decision-making, treatment, and counseling. In a cartoon (Figure 1) by R. Cate, a healthcare provider asks a patient, “Does obesity run in your family?” and the patient responds, “No, nobody runs in my family.” The cartoon references 3 risk factors for stroke—obesity, physical inactivity, and family history. While the provider’s concern is about the family history of obesity, the patient brings to light a more important question: “Does physical inactivity run in your family?” Physical inactivity and other suboptimal lifestyle behaviors (eg, unhealthy diet) often precede obesity and stroke; therefore, should healthcare providers ask about family history of lifestyle behaviors instead, or in addition to stroke?FIGURE 1.: Family history of obesity versus physical inactivity? In ‘Toon with Cartoonist Ricardo Caté · Indian Pueblo Cultural Center. Nobody-Runs-in-the-Family.jpg (640 × 605). The cartoon was obtained from this site https://www.reddit.com/r/funny/comments/bpgvkv/does_obesity_run_in_your_family/ or https://i.pinimg.com/originals/ed/50/f9/ed50f928d15edff6d1c1c572a85d8671.jpg.Genetics and Family History of Stroke Stroke incidence, despite being largely preventable, is expected to rise in the coming decades,1,5 underscoring the need to strengthen preventative healthcare. While family history related to one’s genes plays a role in stroke risk, family habits and shared environmental factors are presumed to account for much of the risk.6,7 Thus, a healthy lifestyle for stroke prevention is essential. Even for adults aged 45 years with high polygenetic risk for stroke, researchers found that maintenance of optimal cardiovascular health, based on the American Heart Association’s Life’s Simple 7 (now Life’s Essential 8), could extend their lives without experiencing a stroke by 6 years.8 Polygenetic stroke risk scores are not currently used in clinical practice because further testing is needed, particularly among diverse populations.8 Genetic stroke research is ongoing, but complex, as described in the challenges outlined by Ekkert et al9 and Scott et al.10 Despite the challenges, genetics holds promise for transforming stroke prevention in the future with gene therapies and specialized screenings and treatment. Until then, “No, nobody runs in my family” demonstrates the importance of family behaviors and environments, beyond genetics. Lifestyle and Family History of Stroke Family history of disease should motivate individuals to engage in activities that lower their risk of the disease. However, people may not be aware of their family history or have inaccurate information about the condition a family member experienced (stroke vs. heart attack). Even with knowledge of a family history of disease, it is unclear whether knowledge translates into healthier behaviors.3,11,12 The focus of the question about family history of stroke should shift from genetics to lifestyle. Lifestyle behaviors, and the attitudes that accompany them, are typically initiated and reinforced through families. Family members may share activity levels and dietary habits that include the selection and preparation of foods, or the use of cigarettes and alcohol consumption. Additional shared family factors such as low health literacy levels,13 stressful lifestyles,14 and living in under-resourced settings can exacerbate unhealthy lifestyle behaviors.15 Stroke Guidelines and Family History of Stroke Opportunities exist to advance the progress of stroke prevention for individuals with a family history of stroke by addressing lifestyle behaviors from a family approach. The 2014 American Heart Association/American Stroke Association guidelines for primary stroke prevention,16 recommended that obtaining a family history can be useful in identifying people who may have increased stroke risk. However, the recommendation was not carried forward to the 2024 guidelines; instead, in lieu of genetic factors, the current recommendation is to screen individuals for risk factors based on the American Heart Association Life’s Essential 8, as well as screen for social determinants of health.17 The 2021 American Heart Association/American Stroke Association secondary prevention of stroke and transient ischemic attack guidelines provide recommendations aimed at changing individual patient behaviors and reference “family” by identifying that there is a gap in knowledge of the specific or allied role of family caregivers and dyads in the promotion and maintenance of health behaviors after stroke.18 In contrast, the 2020 Canadian Stroke Best Practice Guidelines for secondary stroke prevention recommend that persons at risk of stroke or transient ischemic attack and their family members should receive individualized information and counseling about possible strategies to modify their lifestyle and vascular risk factors.19 Recommendations for Nurses to Build Healthy Families for Stroke Prevention Considering families of stroke survivors as both caregivers and patients in whom to address shared stroke risk could be beneficial in preventing future strokes by promoting collective behavior change. In the acute care of stroke and rehabilitation, cardiovascular nurses can encourage the sharing of stroke risk reduction information (eg, Mediterranean diet) with family members. Theoretically driven, family-based interventions have been effective in improving health behaviors (eg, diet and physical activity) of families at risk of cardiometabolic disease20 and cardiovascular disease.21 No family-based intervention studies to our knowledge are specific to stroke, and while stroke shares similar risk factors for other cardiovascular diseases, the interest among families at risk of stroke and its impact could be greater with a focus on stroke. Boden-Albala et al22 found family/friend networks to be beneficial for blood pressure reduction in a clinical trial of discharge education following stroke, highlighting the network’s role in facilitating low salt intake and physical activity; however, outcomes of the network were not reported. As leaders in holistic care, nurses are ideally situated to reinforce family health history as a marker for stroke risk. In primary care, this includes routine assessment of family history of stroke, and if positive, assessment of lifestyle behaviors and challenges to achieving optimal cardiovascular health. When family history is unknown, the focus should shift to lifestyle, environment, and health indicators that reveal susceptibility to stroke. Nurses can also educate individuals at all ages about the importance of knowing their family history and its significance for stroke and lifestyle behaviors.23 Hickey et al24 detail additional opportunities nurses have to advance the assessment of family history to improve the health of all individuals. More cardiovascular nurses are needed to generate and apply evidence to prevent stroke, particularly through primordial and primary prevention efforts.25 This includes expanding research on family history with particular emphasis on stroke genetics and family-based stroke risk reduction interventions. Family history of stroke and lifestyle behaviors provide an open window for nurses to understand the risk of stroke among individuals and families, and family history should remain a valuable tool in advancing efforts to reduce stroke risk and stroke across the lifespan.