2024 Primary Stroke Prevention Guidelines: Key Takeaways and Clinical Implications

Since 1990, the American Heart Association (AHA)/American Stroke Association (ASA) have developed evidence-based clinical practice guidelines to translate scientific research into recommendations aimed at improving cerebrovascular health. Using systematic methods to evaluate and classify evidence, these guidelines serve as a framework for delivering quality stroke care to patients with, or at risk for, cerebrovascular disease. Although primarily intended for medical practice in the U.S., many recommendations have broader relevance. Overall, the guidelines are designed to support clinical decision-making and improve quality of care.¹

The AHS’s latest guideline for primary prevention of stroke, published in 2024, replaces the 2014 guidance and is intended to support clinicians in implementing evidence-based prevention strategies for individuals without a prior history of stroke.^2,3 The guideline was informed by a comprehensive review of research published since 2014, conducted between May and November 2023, as well as a review of related AHA scientific statements. Recognizing that both ischemic and hemorrhagic stroke are major causes of disability yet largely preventable, this updated guideline presents current, evidence-based recommendations for stroke prevention across the lifespan.

Co-vice chair of the writing group, Walter Kernan, MD, Emeritus Professor of Medicine and Senior Research Scientist at Yale University School of Medicine, recently spoke with NeurologyLive^® to outline key priorities from the updated primary stroke prevention guidelines. Throughout the conversation, Kernan outlined some of the most notable takeaways, including using the AHA’s “Life’s Essential 8” as a foundation for reducing stroke risk, while stressing the importance of regular access to primary care. In addition, Kernan underscored a lifespan approach to brain health, with early and repeated risk factor assessment, and detailed specific clinical considerations. He also identified major evidence gaps that warrant further research, including maternal stroke, sleep health, obesity, and health system–level primary care delivery.

NeurologyLive: What are the top takeaways from this guideline for primary stroke prevention?

Walter Kernan, MD: The bad news is that stroke is one of the leading causes of death and disability among Americans. The good news is that at least half of all stroke events can be prevented by improved control of common risk factors, most of which are listed among the American Heart Associations, “Life’s Essential 8:” diet, physical activity, nicotine exposure, sleep health, body mass index, blood lipids, blood glucose, and blood pressure.

It is not easy for Americans to get control of all these factors because our environment often steers us toward unhealthy lifestyles. For help with risk factors, however, this guideline takes a strong position that every person should have access to regular visits with a primary care health professional. In primary care, work should identify and remediate social determinants of health and assist patients in adopting healthy diets, engaging in more physical activity, and getting control of blood pressure, glucose, lipids, and weight.

What are the clinical implications of this guideline?

There are many, but a core concept throughout the guideline is the idea that brain health should be promoted across the lifespan. Risk factors should be aggressively identified for management at most primary care visit for adults of all ages and at least every 1-5 years after age 40.

A few specific implications of note include:

1) Clinicians should ask women about a history of endometriosis, premature ovarian failure, or early onset menopause as these are associated with increased risk for stroke. They should also ask about hypertensive disorders of pregnancy and other adverse pregnancy outcomes because these are associated with chronic hypertension and elevated stroke risk through other risk pathways.

2) GLP-1 receptor agonists are recommended for patients with diabetes and high cardiovascular risk or established cardiovascular disease.

3) Among the main risk factors for stroke, hypertension is critical.Most patients will require at least 2 antihypertensive medications. The most important advice is to help every eligible patient get to the goal of less than 130/80 mm Hg.

4) Recommend the Mediterranean diet for adults at high or intermediate CVD risk

5) To prevent pregnancy-associated stroke, institute treatment during pregnancy or in the early postpartum period for severe hypertension (SBP at least 160 or DBP at least 110) to reach a target less than 160/100 as soon as possible to reduce risk of fatal maternal ICH.

What are some unanswered questions that remain in this area?

Maternal Stroke: More research is needed to define the optimal blood pressure during pregnancy and the postpartum period.

Primary Care: On a national policy level, more work is needed to construct effective, disseminated, high quality, and easily accessible primary care.

Social Determinants of Health: Optimal strategies to screen for and remediate these determinants are needed.

Sleep: Sleep and sleep quality are emerging as important topics for brain health, yet we have few clinical trials to guide intervention for impaired sleep.

Obesity: Current and novel medications that promote weight loss should be tested to determine efficacy and safety for primary stroke potential. Epidemiologic and other data suggest that weight optimization could emerge as a very important strategy for brain health.

Transcript edited for clarity. Click here to view more of our coverage on stroke.

REFERENCES
1. Bushnell C, Kernan WN, Sharrief AZ, et al. 2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. Published online October 21, 2024. doi:10.1161/STR.0000000000000475
2. New guideline: Preventing a first stroke may be possible with screening, lifestyle changes. News Release. American Heart Association. Published October 21, 2024. Accessed December 15, 2025. https://newsroom.heart.org/news/new-guideline-preventing-a-first-stroke-may-be-possible-with-screening-lifestyle-changes
3. Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(12):3754-3832. doi:10.1161/STR.0000000000000046