CEimpact Podcast

AHA/ASA 2024 Guideline for the Primary Prevention of Stroke

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Stay ahead in stroke prevention with insights from the updated AHA/ASA guidelines, designed to optimize care for at-risk patients. This episode highlights key changes, actionable strategies, and the pharmacist’s role in reducing stroke incidence through evidence-based interventions. Tune in to stay informed and enhance patient outcomes in stroke prevention.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Justinne Guyton, PharmD, BCACP
Associate Professor of Pharmacy Practice
University of Health Sciences and Pharmacy

Reference
2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association
https://www.ahajournals.org/doi/10.1161/STR.0000000000000475

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Identify three key updates in the AHA/ASA 2024 Stroke Prevention Guideline.
2. Explain the pharmacists role in applying evidence-based strategies for stroke prevention.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-022-H01-P
Initial release date: 1/27/2025
Expiration date: 1/27/2026
Additional CPE details can be found here.

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Speaker 1:

Hey CE Impact subscribers. Welcome to the Game Changers Clinical Conversations podcast. I'm your host, Josh Kinsey, and as always, I'm super excited about our conversation today. Stroke remains one of the leading causes of death and disability. The new AHA-ASA Stroke Prevention Guideline provides critical updates to enhance prevention efforts. Today, we'll explore these key updates and discuss how pharmacists can play a pivotal role in implementing evidence-based stroke prevention practices. It's so great to have Justine Guyton as our guest expert for this episode. Welcome, Justine. Thanks for joining us.

Speaker 2:

Thanks so much for having me.

Speaker 1:

Yeah, so before we jump in, in case our learners are not familiar with you, give us a little bit about your background, maybe a little bit about your practice site and why you're passionate about this topic today.

Speaker 2:

Yeah, thank you. So I practice in ambulatory care, so I am in a primary care clinic at a department of public health, so I get to work with a lot of patients that are underinsured and have a lot of different factors impacting their access to healthcare. So it's a really kind of interesting place to be a pharmacist trying to apply guidelines, kind of, with another layer of patient care in there.

Speaker 1:

Yeah, that's great, that's awesome. Yeah, I appreciate your service in that realm and also again appreciate you joining us today. So, thank you. Let's jump into just kind of laying I always like to lay the groundwork. My listeners have gotten used to me kind of making sure the foundation is laying. We're all on the same page before we start talking. So just again, review for us the prevalence of stroke, like how impactful is it on public health? It's probably more common than we realize. So let's just kind of lay that field first and talk a little bit about the prevalence of stroke and maybe you know like the history of the guidelines and where they came from and that kind of thing.

Speaker 2:

Yeah, so just wanted to reiterate these guidelines are the primary prevention guidelines. So the whole kind of focus of these guidelines is about preventing stroke, preventing a first stroke. So there's going to be a different set of guidelines for patients that have already had a stroke. So really prevention is kind of the key word in this conversation. Today. There's hundreds of thousands of patients that are having a first stroke each year and I even heard a stat that at least half of those are thought to be preventable. So I think that's really kind of the impetus for this guideline is just how impactful stroke can be with morbidity, mortality and kind of like impact on somebody's life.

Speaker 2:

And then knowing that half of those could have been prevented. It's obviously really important that we have recommendations that are available to help people kind of understand how to prevent them.

Speaker 1:

Wow, yeah, yeah, that's a wild stat to know that so many could have been prevented. So, again, it's why education is key and that we're making sure that our pharmacists out there are on the front lines trying to prevent these. So you mentioned the stroke prevention guidelines and tell us about the significance of them. You and I talked previously and you reminded me that they only come out once every 10 years or so, so clearly this is a big deal that we're talking about the updates. So maybe what informs those updates? And just a little history about the guidelines in general.

Speaker 2:

Yeah, so you're right, this is the first time these prevention guidelines have been updated in 10 years, so obviously there's been a lot of information that's come out in the meantime, so that's a big impetus for this change. I'd say, when I was looking through the guidelines I saw kind of two big areas that I think are noteworthy. So one I think one of the ways that they kind of really focus the guidelines and are kind of discussing them, if you will, has been kind of simplified. So there's a term called AHA, so American Heart Association's Life's Essential Eight, and so that's kind of a new way of thinking about, or maybe organizing it in your brain, a lot of these things that we'll talk about as far as what the recommendations are. And then I think the other big thing that I noticed was a couple new risk factors had been identified maybe in the past 10 years and had been included in these guidelines. So those are kind of the two big areas that I saw being updated.

Speaker 1:

Yeah, and that's a key one in my opinion the risk factors, because again, that's something else for us to be on the lookout for, since we are often the first and most common healthcare provider that our patients see.

Speaker 1:

Because you know it's often that they see us, and opposed to an annual physical or whatnot. So right, yeah, okay, that's great. So let's jump into a little bit about what are some of the opportunities. So we always like to try to provide our listeners and our learners with opportunities that they can employ at their practice site. So what can we do as pharmacists? How can we expand our roles? What are some of the areas and things that we can do to help prevent strokes?

Speaker 2:

Yeah. So I think, kind of thinking about this, there's just so many ways I could I could tackle this question, or pharmacists could be involved, going back to the AHA like life's essential aid it's really the American Heart Association kind of discussing eight different facets of like everyday life that we should be paying attention to. That impact stroke. So that, right, there is eight different ways. So those areas are going to be blood sugar, blood pressure, weight management, lifestyle. So food choices, exercise choices, sleep a lot of different areas, and so those are all smoking cessation, so those are all the different ways that we know somebody is going to be.

Speaker 2:

Day-to-day life, lifestyle or risk factors are implementing or impacting their stroke risk. So simple things. I mean, I don't know how many patients fully realize that their blood pressure needs to be controlled, not just for the sake of the number of their blood pressure, but what that blood pressure has an effect on, so things like increasing stroke risk. So I think people know if stroke is bad, want to get my blood pressure controlled, but they don't necessarily always connect those and so just even letting patients know why it's important that they take their blood pressure medicines every day, not just to get that number down, even if they feel okay, but because that's impacting their stroke risk. It's kind of one way that I think about that.

Speaker 1:

Yeah, absolutely so. Adherence is key for medications that your patients are already taking. So, again, that would be a light bulb for you as a pharmacist when you see a patient who is on a blood pressure medication. Okay, this is a patient who is at risk for stroke.

Speaker 2:

And so that's where I need to be preventing.

Speaker 1:

So, again, educating the patient that adherence is key, making sure that they I love your comment of take it, even if you feel. Well, you know, because it's so many, so many patients that just, oh, I felt I felt fine this morning. I didn't feel like my blood pressure was high or my sugar was fine this morning or whatever. Well, it probably is because you've been taking your medicine, so let's continue, you know. But yeah, so that's that's really important as well. What are some of the other? So you mentioned glucose control and weight management.

Speaker 1:

So, like, what are some of the things that we can look for? Obviously, we can look for a patient who's on a diabetic medication diabetes medication. But like, what are some of the other things that we can kind of just keep our eyes open for and be like, oh, that's an at-risk patient for a stroke? Yeah.

Speaker 2:

Yeah, so you're right, diabetes is one. Another one that maybe would take a little bit more digging would be looking at patients to see if they're candidates for cholesterol medicine so statins essentially. So we know that increased cholesterol, especially LDL, increases stroke risk. Many different sets of guidelines are going to assess patients and their statin risk and if they would benefit from a statin. And we definitely know that those high risk patients so the really high LDL is like 190 and above or when we use the 10-year ASCVD risk calculator if anybody has that app it's what I often use to calculate it really fast but those with elevated risk or elevated risk and risk factors are going to be patients that need to be on a statin and kind of like blood pressure, but maybe a little bit different. I think cholesterol is even more confusing for patients because sometimes like their number looks OK but really we're looking kind of more globally with those risk factors and what that percent 10 year risk is to determine if they benefit from the statin.

Speaker 2:

And so I think that one doesn't always like strike patients as like why they need to take cholesterol medicine, or if they're even a candidate for one.

Speaker 1:

The guidelines are pretty straightforward about who should be initiated on one, so I think that's another one that if you have access to checking lipids, you'll be able to determine if a patient would benefit from the statin pretty quickly, yeah, and I know from experience I'm assuming it still is the case but a lot of MTM opportunities are out there about statins and making sure that everyone is available. Everyone that's eligible for a statin has at least been introduced to it or it's been discussed with them. So, yeah, that's a great call out as well, somewhere that we can start with prevention. And you mentioned weight and exercise. So let's talk a little bit about those, how they impact and maybe how, as a pharmacist, we can kind of call those out too.

Speaker 2:

Yeah, I think big picture, the lifestyle recommendations that are in these guidelines are for prevention. So if you're thinking about it from that perspective, they're really recommendations for everybody. I try to remind my patients of that. This is not just for you because you have diabetes or because you have a stroke risk. Really it's for everybody for risk reduction. So exercise recommendations are 150 minutes of moderate intensity activity, which might not really sound very specific, but that's kind of a brisk walk where you're kind of walking pretty quickly, you can still talk and everything, but you're putting some effort into it. Um, or 75 minutes of, uh, vigorous activity in a week. So that'd be something like jogging or anything more intense than that. But those recommendations are really for everybody and so that's something that any you could talk to any adult about in terms of like lifestyle, like food intake. Um, one of the big recommendations for many different prevention guidelines is the Mediterranean style of diet.

Speaker 1:

Got it, Got it. That's great, Super helpful. So what are the guidelines? Again, their prevention. So is there anything that we need to be like integrating or implementing into, or is it? Or is it strictly just because their prevention and pretty much all of our patients are going to have one of those things? If your patient is in your pharmacy, they're probably there for blood pressure, diabetes, obesity, you know they're probably there for something right? So is there any other thing that we need to kind of keep in mind as far as, like picking out who we should be targeting to talk to about the preventive therapies, or have we covered all you think?

Speaker 2:

I really think that you know everybody should be having these conversations. I think that's a big part of the push of the guidelines is making sure that patients understand their risk factors factors so not every single one of them can be fixed, but patients can understand kind of what their baseline risk is and that they are at risk for a stroke and why maybe some of the things that are modifiable are important. So I do think that the conversation is worthwhile. In adults, obviously there's some patients that might have a bigger magnitude of benefit than others. But I think that this is something that you can pick maybe one or two of those life's essential eights and see if that doesn't like make more sense for you to implement into your practice. I definitely can agree that talking to every patient about eight different factors of change could be really cumbersome.

Speaker 2:

Take your whole day. You know not leave a lot of time for other things, but maybe picking like one or two. That makes sense for your site.

Speaker 1:

Yeah, that's great and I love that you called out to the modifiable ones. I think that that's really important to kind of explain to patients and, in a sense of like, here's what I mean. Here's what we mean by modifiable. It's things that you can actually proactively make a change for. So yeah that's key.

Speaker 1:

Um, okay, great, so let's move into then some of the challenges. So we talked you briefly, just touched on a challenge, which is time. Right In the pharmacy practice setting. We all know that if we could all wish for one thing, it would be more time or more assistance, more staff to help with that. Give us more time. So obviously that's a barrier. What are some of the other challenges and barriers that you think are going to impede us from helping to carry out and to kind of target these patients and kind of implement the guidelines along the way, like you mentioned?

Speaker 2:

Yeah, I mean, you're definitely right, time is going to be a challenge. So I think that, like kind of starting strategically and figuring out maybe who your highest risk patients are you know, looking by blood pressure medicine or statin or whatever it might be might be a way to kind of target that. I think the other thing that can be a challenge is making sure that pharmacists have some sort of way to implement change. So ideally, you know, we would identify a change that needs to be made and also be able to implement that, whether it's through an MTM or having a relationship with a provider or some sort of useful way to kind of contact a prescribing healthcare provider. If you're not able to do, that are going to be some of the ways to be able to have a big impact. If you're kind of in the community setting, yeah, that's great a big impact if you're kind of in the community setting.

Speaker 1:

Yeah, that's great. A lot of patients who as we've touched on, a lot of patients who are at risk for a stroke, have a lot of comorbid conditions, so they're going to be complex patients. What are some of the other key things that we can attack with these patients? What are some of the things that we can spend time on and that we can put our effort into?

Speaker 2:

Yeah, the way that I like to approach that is kind of almost from the flip side of I'll often talk to patients about. Like you know, there's lots of recommendations in this area, this area and this area. Is there something that you've been thinking about that you'd like more information on, or is there one of these areas that you're interested in targeting that I can kind of help you make a specific plan with and I'll kind of try to work with where they already kind of maybe have that intrinsic motivation and they're maybe excited about something or had been thinking about something?

Speaker 2:

and try to run with that first, versus coming at a patient, kind of cold, saying you really need to quit smoking, you know, and that's just not what they're ready to do, but maybe they are willing to, you know, work on their diet and change something different about the way that they're eating and their eating habits yeah, absolutely, absolutely.

Speaker 1:

what are some of the opportunities for us as um healthcare providers? Are there any opportunities for us to collaborate with other healthcare providers, like what you? You mentioned weight nutrition, so that kind of made me think about that. Is there anybody else that we could be collaborating with and to make sure that our patients have access to everything they need?

Speaker 2:

Yeah, I think it really just depends on the patient. But you're right, there are some patients who would benefit from a little bit of lifestyle education and like what a Mediterranean diet is, but some that would really benefit from and are eager to learn more and might having a relationship with a nutritionist might be the best thing for them. Same thing with physical therapy. I've definitely have some patients that maybe have a bad back or a bad knee or something and they want to exercise or get more active and get more movement into their life. But they're really just not sure how. Those are great kind of sparks to kind of like be able to refer out or have them talk to their provider about getting a referral to something like physical therapy and thinking about what would be safe and effective movement for them, kind of in the place that they're at.

Speaker 1:

Yeah, that's good, that's great. So you had mentioned, obviously, your background in the public health kind of sector and you have a lot of patients who are underinsured and don't have great access to care, so let's talk about that. That's obviously a challenge as well. What?

Speaker 1:

are some of the tips and tricks you can share with our listeners about ways to overcome the access to care, the cost of medications. We all know that both of those things can affect adherence in patients, and if a patient has bad blood pressure and they're not adhering on their med, then they're at risk for you know. So like it all boils down, it boils back to this. So anything you can kind of share with us there that you've learned in your.

Speaker 2:

yeah, this might be kind of old news to some people, but kind of the things that I think about is just any of the generic combination medicines where I can lower the copay by just having one copay instead of two is something I jump to kind of right away.

Speaker 2:

We use a lot of copay cards for brand name medicines, trying to get them down a little bit for patients, especially beginning of the year, if they have higher copays or if their insurance has them at the higher tier. We use things like, even like GoodRx, just to look quickly at different pharmacies, at what maybe a comparison might be for the cash price of a medication at a couple different places. And then we have enough patients that don't have any insurance at all that we do pretty routinely use the manufacturer's coupons, so kind of the patient assistance programs through the manufacturers directly. That's definitely a more cumbersome process. It includes, you know, the provider, the prescriber's signature, the patient's signature, their financial information. But for some people you know it's a really necessary step for them and they're willing to do the work of bringing it back. Yeah.

Speaker 1:

Yeah, and because it could be game changing for especially if it's, you know, if they failed on other therapies and this is the one that actually is finally working and you know they're willing to go through that. So, and you know one thing that you mentioned there even you didn't mention it, but I'll throw it in. You kind of touched on it. You know we have training for community health workers. Know we have training for community health workers.

Speaker 1:

Yeah, they are really training technicians in that space to be kind of the right hand. They're already the right hand people in our pharmacies and so now they're, you know, being trained in that public health space to identify these opportunities. And so you'd mentioned that that was the work could be cumbersome sometimes, but, but you know, if you have a CHW or if you have a technician, that was the work could be cumbersome sometimes, but but you know, if you have a CHW or if you have a technician that's willing to go through that training, that's also something they can do. And they can also help identify other solutions for food insecurities and transportation insecurities and other things that we see. Because, let's be honest, if you have a patient who's underinsured and they're seeing you at a clinic. You know, at a public access clinic they probably have other insecurities and issues.

Speaker 1:

Yeah for sure. Okay, so let's talk through a little bit then, too, about I know myself, as when I practiced it's been a while, but when I practiced and when I actually practiced pharmacy, it was oftentimes in the community space, and so you know we do a lot of medication dispensing and education about things new medications, making sure they're inherent and everything but we don't always get to or do we should, but we don't always stay up to date with the guidelines. So why is it important for all pharmacists to stay up to date with this? Why is you know if you can just stress the importance that like it's impactful and it really makes a difference and just kind of shed?

Speaker 1:

some light for us.

Speaker 2:

Yeah, I would say big picture. I think cardiovascular health is definitely one of the ones that we're just seeing a lot in live more and more new trials coming out and data coming out and, obviously, guideline updates. So to me it definitely stands out as a space where we're seeing a lot of change and seeing a lot of data and newer medications that can be helpful. Maybe not anything that specifically hits like the AHA, asa, stroke prevention guidelines specifically, but I think when we think about that space, especially with patients with diabetes, we're definitely seeing like an explosion of medication classes that have glucose lowering benefit and then the GLPs as a class are linked to stroke lowering benefit. So when I'm talking to patients about why I want them to start an injection for the first time, the fact that I know that it helps lower their blood sugars but it also helps lower their cardiovascular risk, is a selling point that I can kind of help them with to better understand why this medicine is important versus maybe increasing their metformin dose today.

Speaker 1:

Absolutely. Yeah, that's important. So are there any other challenges that you've seen with? You know, pharmacists on the front line of trying to implement these prevention guidelines, anything else that you can be like, you wouldn't be the only one. Here's the way around it. Anything that we've missed today that you want to share?

Speaker 2:

I can't think of anything big. I think probably just like one of the biggest challenges is just how many opportunities there are here. So figuring out, like which one you want to do, or all eight of them, like you know, implementing them into a practice can be challenging.

Speaker 1:

Yeah for sure.

Speaker 2:

And then I think, just the time some of these it's not like as straightforward as like treatment guidelines are. So just to kind of flip that like if you have a, a stroke and you go to the hospital, you know, you know you're getting X, Y and Z medicine for that stroke, you know what just happened, it was uncomfortable, You're probably scared, You're getting discharged soon and the length of medication to like what its goal is, is very clear. I think when we're talking about prevention it becomes a little bit less clear, it's a little more nebulous. It's like, oh, my future self in five to 10 years. So anytime that you have a relationship with a patient and you already know them and you can kind of explain these things, I think that it makes it more impactful versus just somebody yakking at you with you should lose weight or you should eat healthy For sure, and connecting those dots for the patients.

Speaker 1:

I think that's a great point. Like sometimes even with us telling them like your weight and you know your weight is a factor in your risk for a stroke like, but, but why and and? Okay, so my blood pressure is a factor, but like why and why does me taking my medicine for blood pressure make that decrease? You know, so that risk factor decrease. So I think it's important, again, connect those dots. So to me it sounds like one of our biggest roles as a pharmacist is education, patient education, yeah, and just making sure that we are up to date on the most important information so that we can share it with our patients appropriately.

Speaker 2:

Yeah, and I would also challenge listeners to kind of think about the fact that I like to practice what I preach, if you will. So these are things that all of us should also be doing, and I think, the more that you kind of remember that these also apply to you, you should be thinking about these in your own life, and then I think that makes for more meaningful conversations with patients when you're like yeah, I love to eat cookies too.

Speaker 2:

Like goodness, it's Girl Scout season right now and the cookies are coming out and I'm going to have a hard time, but what I'm going to do instead is X, Y or Z, and this is what's helped me. I think sometimes that can help you in practice kind of connect with patients a little bit better and kind of remember this is really something for everybody.

Speaker 1:

Yeah, that's great. Well, so, as kind of just like a summary, I just want to reiterate again because we've given a lot of information out there for our listeners. It's not anything new to them. They're used to me throwing tons of stuff at them, stuff at them. So let's just kind of I always like to do a summary and kind of wrap it back up with, like I think and correct me if I'm wrong but what I'm hearing you say is pick a few, like there's no way that we can possibly do everything that the guidelines suggest, right, the prevention guidelines.

Speaker 1:

But to pick a few, and I think that some of that low hanging fruit is looking for patients who are on a blood pressure medication. I think that some of the that low hanging fruit is looking for patients who are on a blood pressure medication. Like that's, that's a first, that's a first step Patients who are on diabetic medications, patients who we know to be obese or have struggled with weight or nutrition in the past. And then you know that can, that can go down many routes, because that can bring in your, your exercise and all that kind of stuff as well, um, and really focus on adherence, right. So that's, that's a key, key one as well, um, adherence and education and targeting maybe those patients that we know to be diagnosed with something or have a comorbid condition or something.

Speaker 2:

Yeah, yeah, absolutely Okay great, all right.

Speaker 1:

Well, I learned. I learned stuff as well. That's great. Okay, so, like, what I always like to do at the end is give you a chance to tell us what the game changer is. So, summarizing kind of everything. I did a summary here, but, like, what is the game changer? Why do listeners need to walk away from this episode and do this? Why do they need to implement this? Why do they need to target those patients?

Speaker 2:

So tell us what the game changer is.

Speaker 2:

I think, if I was going to summarize, I would just remind everybody that half of strokes are preventable and there are at least eight different ways that we can help patients reduce their risk of stroke through the AHA's Life's Essential Eight. These are things that patients can do with lifestyle, so education can be implemented, and then medication and adherence all play a factor in that. So knowing that there is such room for improvement in population health and knowing that we see patients every day, it just means that there's so much room for a pharmacist to be involved.

Speaker 1:

Yeah, that's great, that's great. I just had this wild thought. I'm not wild, I'm sure many people thought of it before and they've probably done it but another way to simply do it, because you're saying that half are preventable. Again, that's such an impactful statement. But even if you did something as simple as putting a flyer at your register if you're in a community practice or, you know, maybe it's a flyer on a stand in your waiting area if you're in an amcare clinic or something, but that saying did you know that half of all strokes are preventable, are you at risk? You know, ask the pharmacist for more information, or something. So I think that, um, just really kind of putting yourself out there as that expert, um, because we are and just really kind of owning that. So, yeah, okay, great, this was great. Justine, thank you so much for joining us today. I appreciate it.

Speaker 2:

Yeah, thanks for having me. This is great.

Speaker 1:

Absolutely. If you're a CE plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at ceimpactcom and, as always, have a great week and keep learning. I can't wait to dig into another game changing topic with you all again next week.