1. Lower your blood pressure
High blood pressure damages arteries so they clog or burst more easily, escalating the risks of both types of stroke: ischemic, caused by blockage of a blood vessel that supplies part of the brain; and hemorrhagic, the less common but deadlier stroke that occurs when a blood vessel bursts inside the brain. Treatment to lower blood pressure, including lifestyle changes and medication, can reduce those risks by a third.
Recommendations: Have your blood pressure checked at least once every two years and more often if you're 50 or older. If your reading is high-normal—above 120/80 millimeters of mercury (mmHg) but below 140/90 mmHg, the cutoff for hypertension—try to lower it by adopting the lifestyle changes listed below. People with blood pressure below 120/80 mmHg have about half the lifetime stroke risk of those with hypertension. If your reading is 140/90 mmHg or higher, talk with your doctor about adding an antihypertensive drug.
Many people start with thiazide diuretics, which are safe, effective, and available as low-cost generics. People with certain health problems shouldn't take thiazide diuretics, so they might need different drugs to lower their blood pressure.
2. Improve cholesterol levels
LDL (bad) cholesterol, a fatty substance in the blood, builds up plaque on artery walls, causing arteries to narrow. If plaque ruptures, a blood clot can form and block a blood vessel to the brain, causing a stroke. In a 2004 analysis of trials including more than 90,000 people with heart disease or other risk factors like diabetes or high blood pressure, the reduction of LDL cholesterol with the use of statin drugs cut stroke risk by about 21 percent and reduced plaque buildup in the neck arteries that carry blood to the brain.
Recommendations: Men 35 and older should get a complete lipid profile—which measures LDL (low-density lipoprotein) and HDL (high-density lipoprotein) cholesterol levels, as well as triglycerides, an artery clogging fat—at least every five years. Women 45 and older should, too, if they're at high risk of heart disease because of other risk factors like being a smoker or having a diabetes. (To determine your risk, use our calculator.) People younger than that should also consider testing, though the benefits for them are less certain, especially if they are female or are otherwise healthy and at low risk of heart disease.
To lower cholesterol, start with exercise, weight control, and a diet minimizing saturated fat and cholesterol. Avoid trans fats in processed foods containing partially hydrogenated oils. If those measures aren't sufficient, ask your doctor about adding a statin medication.
3. Rein in diabetes
High blood sugar levels damage blood vessels over time. In addition, people with diabetes are likely to have hypertension, high cholesterol, and excess weight. All told, diabetes increases the risk of ischemic strokes from 1.8-fold to nearly six-fold. While improved blood sugar control reduces diabetes-related complications of the eyes, nerves, and kidneys, it hasn't been shown to lower stroke risk. But aggressive lowering of blood pressure and the use of statins, when needed, by people with diabetes can reduce risk. Evidence has shown that strict blood-pressure control reduced the chance of a stroke by 44 percent. And statin use has been shown to reduce stroke risk by 48 percent among type 2 diabetics.
Recommendations: Adults who are at high risk for diabetes should have their blood sugar level measured at least every three to five years. That includes people with a personal history of heart attack, stroke, or heart disease, as well as those with any of these coronary-risk factors: blood pressure over 135/80 mmHg; obesity (with a body mass index of 30 or over); or an LDL level over 130 mg/dL. Adults without those risks should also consider screening, though the benefits for them are less certain.
If you have diabetes, keep your blood pressure below 130/80 mmHg with lifestyle approaches and medication if needed. An ACE inhibitor or angiotensin receptor blocker (ARB) is useful because those antihypertensive drugs slow the progression of kidney disease in people with diabetes. In addition, try lowering your LDL cholesterol to below 100 mg/dL. The use of a statin is recommended, especially if you have additional risk factors.
4. Consider low-dose aspirin
Aspirin wards off heart attack and stroke by preventing artery-blocking blood clots. But it's not for everyone, mainly because it can cause dangerous gastrointestinal bleeding. Still, research suggests that only 20 percent of the women and 14 percent of the men who should be taking it are.
Recommendations: People of any age who are at very high risk of a stroke should almost always take aspirin to protect their heart. That includes those who have already had a stroke or ministroke and those who have heart disease or diabetes.
Aspirin can also help prevent first strokes in women between 55 and 79 without that history, if they're at increased stroke risk based on such factors as blood pressure and cholesterol levels and smoking status. (Men are also often candidates for low-dose aspirin, based on the same factors, but to prevent heart attacks, not strokes.) To help determine your risk, talk with a doctor and use our heart attack and stroke risk calculator. Regardless of gender, the therapy should be limited to those who are not at increased risk of gastrointestinal bleeding. For men and women 80 and older, there's still not enough evidence to know for certain whether aspirin helps or not, so talk with a doctor to see if it might make sense in your case. See our other tips on taking low-dose aspirin.
5. Have your pulse checked
Atrial fibrillation, a heart-rhythm disorder, can lead to blood clots that can travel to the brain, amplifying the risk of an ischemic stroke. The blood thinner warfarin (Coumadin and generic) reduces that risk by 64 percent yet might be underprescribed. Seniors often benefit substantially from the drug, according to the stroke prevention guidelines. A new blood thinner, dabigatran (Pradaxa), at a dose of 150 mg twice daily was associated with fewer strokes than warfarin but had a similar risk of major bleeding and a higher rate of gastrointestinal bleeding and heart attacks, according to a trial published in 2009 and supported by the drugmaker. Its long-term safety is unknown. It costs about $230 a month vs. up to $70 a month for Coumadin or the cheaper generic plus the cost of regular testing to monitor the drug's effects.
Recommendations: Your doctor should check your pulse for irregular rhythms at every visit and follow up with an electrocardiogram or other heart monitoring if necessary. People over age 65 are at heightened risk for atrial fibrillation and should be carefully checked. People with atrial fibrillation and a low stroke risk should talk with their doctor about taking aspirin, and those at moderate risk should weigh the risks and benefits of warfarin vs. aspirin. Those with atrial fibrillation plus multiple risk factors usually require warfarin; dabigatran could now be a reasonable alternative.
6. Neck surgery: Think twice
If either of the two carotid arteries, located on each side of the neck, becomes clogged, a stroke can result. People with severe carotid narrowing that has caused a stroke or transient ischemic attack (TIA)—a strokelike episode that doesn't cause permanent damage—are at high risk for a second stroke, and surgery to scrape out the blockage significantly reduces that risk. But those with a narrowed carotid artery that hasn't triggered symptoms are at much lower risk, and the benefit of surgery is small. "With advances in medical treatment—including lifestyle changes and medication—the risk of stroke in those patients has fallen to one-half to 1 percent a year or less," Goldstein says. "By adding surgery, you're maybe making a tiny number tinier. That has to be balanced against the risks of the procedure." Risks include strokes or death at a rate of 3 percent and higher.
Recommendations: Screening for clogged neck arteries is not recommended for people without stroke risk factors because it generates many false-positive test results that can lead to further testing with angiography, which carries a small risk of triggering a stroke, or to unnecessary surgery. You should be screened and treated for other stroke risk factors. Surgery might be considered for certain people without symptoms who have significant carotid narrowing depending on their life expectancy and other overall health problems. For those who are unable to undergo surgery, doctors can insert a tiny balloon to crush the blockage and a stent to prop the artery open.