Table 5.

New and Revised Recommendations for 2014^*

Section	2014 Recommendation	Description of Change from 2011
Assessing the risk of first stroke	The use of a risk assessment tool such as the AHA/ACC CV Risk Calculator (http://my.americanheart.org/cvriskcalculator) is reasonable because these tools can help identify individuals who could benefit from therapeutic interventions and who may not be treated on the basis of any single risk factor. These calculators are useful to alert clinicians and patients of possible risk, but basing treatment decisions on the results needs to be considered in the context of the overall risk profile of the patient (Class IIa; Level of Evidence B).	Reworded to add AHA/ACC CV Risk Calculator and link
Genetic factors	Treatment of Fabry disease with enzyme replacement therapy might be considered but has not been shown to reduce the risk of stroke, and its effectiveness is unknown (Class IIb; Level of Evidence C).	Slightly reworded; no change in class or level of evidence
	Screening for intracranial aneurysms in every carrier of autosomal-dominant polycystic kidney disease or Ehlers-Danlos type 4 mutations is not recommended (Class III; Level of Evidence C).	Previous statement was worded with less specificity, referring to “mendelian disorders associated with aneurysms”
	Pharmacogenetic dosing of vitamin K antagonists may be considered when therapy is initiated (Class IIb; Level of Evidence C).	Changed from Class III (is not recommended) to Class IIb (may be considered)
Physical inactivity	Healthy adults should perform at least moderate- to vigorous-intensity aerobic physical activity at least 40 min a day 3 to 4 d/wk (Class I; Level of Evidence B).	Changed wording to match new AHA lifestyle guideline
Dyslipidemia	In addition to therapeutic lifestyle changes, treatment with an HMG coenzyme-A reductase inhibitor (statin) medication is recommended for primary prevention of ischemic stroke in patients estimated to have a high 10-y risk for cardiovascular events as recommended in the 2013 “ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults” (Class I; Level of Evidence A).	Reworded to incorporate ACC/AHA guidelines (instead of NCEP); no change in class/LOE. Focusing on estimated cardiovascular risk as the determinant for initiating therapy is new.
	Niacin may be considered for patients with low high-density lipoprotein cholesterol or elevated lipoprotein(a), but its efficacy in preventing ischemic stroke in patients with these conditions is not established. Caution should be used with niacin because it increases the risk of myopathy (Class IIb; Level of Evidence B).	Changed from LOE C to LOE B; the risk of myopathy is highlighted
	Treatment with nonstatin lipid-lowering therapies such as fibric acid derivatives, bile acid sequestrants, niacin, and ezetimibe may be considered in patients who cannot tolerate statins, but their efficacy in preventing stroke is not established (Class IIb; Level of Evidence C).	Reworded from “other” to “nonstatin” (no change in class or LOE). Reference is no longer made to an low-density lipoprotein target for statin therapy because the decision to use moderate or intensive statin therapy depends on estimated risk of future cardiovascular events.
Diet and nutrition	A Mediterranean diet supplemented with nuts may be considered in lowering the risk of stroke (Class IIb; Level of Evidence B).	New recommendation
Hypertension	Regular blood pressure screening and appropriate treatment of patients with hypertension, including lifestyle modification and pharmacological therapy, are recommended (Class I; Level of Evidence A). Annual blood pressure screening for high blood pressure and health-promoting lifestyle modification are recommended for patients with prehypertension (systolic blood pressure of 120–139 mm Hg or diastolic blood pressure of 80–89 mm Hg) (Class I; Level of Evidence A).	New recommendations
	Annual blood pressure screening for high blood pressure and health-promoting lifestyle modification are recommended for patients with prehypertension (systolic blood pressure of 120–139 mm Hg or diastolic blood pressure of 80–89 mm Hg) (Class I; Level of Evidence A).
	Successful reduction of blood pressure is more important in reducing stroke risk than the choice of a specific agent, and treatment should be individualized on the basis of other patient characteristics and medication tolerance (Class I; Level of Evidence A).	New recommendation
	Self-measured blood pressure monitoring is recommended to improve blood pressure control (Class I; Level of Evidence A)	New recommendation
Obesity and body fat distribution	Among overweight (body mass index=25 to 29 kg/m2) and obese (body mass index >30 kg/m2) individuals, weight reduction is recommended for lowering blood pressure (Class I; Level of Evidence A).	Overweight and obesity have now been defined on the basis of body mass index
Obesity and body fat distribution cont’d	Among overweight (body mass index=25 to 29 kg/m2) and obese (body mass index >30 kg/m2) individuals, weight reduction is recommended for reducing the risk of stroke (Class I; Level of Evidence B).	Overweight and obesity have now been defined on the basis of body mass index, and the recommendation has been upgraded from IIa to I
Diabetes mellitus	Control of blood pressure in accordance with an AHA/ACC/CDC advisory to a target of <140/90 mm Hg is recommended in patients with type 1 or type 2 diabetes mellitus (Class I; Level of Evidence A).	Reworded to reference AHA/ACC/CDC advisory
	The usefulness of aspirin for primary stroke prevention for patients with diabetes mellitus but low 10-y risk of cardiovascular disease is unclear (Class IIb; Level of Evidence B).	Deleted the phrase “however, administering aspirin may be reasonable”
Cigarette smoking	Counseling in combination with drug therapy using nicotine replacement, bupropion, or varenicline is recommended for active smokers to assist in quitting smoking (Class I; Level of Evidence A).	Reworded and LOE changed from B to A
	Community-wide or statewide bans on smoking in public spaces are reasonable for reducing the risk of stroke and myocardial infarction (Class IIa; Level of Evidence B).	New recommendation
Atrial fibrillation	For patients with valvular atrial fibrillation at high risk for stroke, defined as a CHA2DS2-VASc score of ≥2, and acceptably low risk for hemorrhagic complications, chronic oral anticoagulant therapy with warfarin at a target INR of 2.0 to 3.0 is recommended (Class I; Level of Evidence A).	New recommendation
	For patients with nonvalvular atrial fibrillation, a CHA2DS2-VASc score of ≥2, and acceptably low risk for hemorrhagic complications, oral anticoagulants are recommended (Class I). Options include warfarin (INR, 2.0 to 3.0) (Level of Evidence A), dabigatran (Level of Evidence B), apixaban (Level of Evidence B), and rivaroxaban (Level of Evidence B). The selection of antithrombotic agent should be individualized on the basis of patient risk factors (particularly risk for intracranial hemorrhage), cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time INR is in therapeutic range for patients taking warfarin.	New recommendation
	For patients with nonvalvular atrial fibrillation and CHA2DS2-VASc score of 0, it is reasonable to omit antithrombotic therapy (Class IIa; Level of Evidence B).	New recommendation
	For patients with nonvalvular atrial fibrillation, a CHA2DS2-VASc score of 1, and acceptably low risk for hemorrhagic complication, no antithrombotic therapy, anticoagulant therapy, or aspirin therapy may be considered (Class IIb; Level of Evidence C). The selection of antithrombotic agent should be individualized on the basis of patient risk factors (particularly risk for intracranial hemorrhage), cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time INR is in therapeutic range for patients taking warfarin.	New recommendation
	Closure of the left atrial appendage may be considered for high-risk patients with atrial fibrillation who are deemed unsuitable for anticoagulation if performed at a center with low rates of periprocedural complications and the patient can tolerate the risk of at least 45 d of postprocedural anticoagulation (Class IIb; Level of Evidence B).	New recommendation
Other cardiac conditions	Anticoagulation is indicated in patients with mitral stenosis and a prior embolic event, even in sinus rhythm (Class I; Level of Evidence B).	New recommendation
	Anticoagulation is indicated in patients with mitral stenosis and left atrial thrombus (Class I; Level of Evidence B).	New recommendation
	Warfarin (target INR, 2.0–3.0) and low-dose aspirin are indicated after aortic valve replacement with bileaflet mechanical or current-generation, single-tilting-disk prostheses in patients with no risk factors* (Class I; Level of Evidence B); warfarin (target INR, 2.5–3.5) and low-dose aspirin are indicated in patients with mechanical aortic valve replacement and risk factors* (Class I; Level of Evidence B); and warfarin (target INR, 2.5–3.5) and low-dose aspirin are indicated after mitral valve replacement with any mechanical valve (Class I; Level of Evidence B).	New recommendations
	Surgical excision is recommended for treatment of atrial myxomas (Class I; Level of Evidence C).	New recommendation
Other cardiac conditions cont’d	Surgical intervention is recommended for symptomatic fibroelastomas and for fibroelastomas that are >1 cm or appear mobile, even if asymptomatic (Class I; Level of Evidence C)	New recommendation
	Aspirin is reasonable after aortic or mitral valve replacement with a bioprosthesis (Class IIa; Level of Evidence C).	New recommendation
	It is reasonable to give warfarin to achieve an INR of 2.0–3.0 during the first 3 mo after aortic or mitral valve replacement with a bioprosthesis (Class IIa; Level of Evidence C).	New recommendation
	Anticoagulants or antiplatelet agents are reasonable for patients with heart failure who do not have atrial fibrillation or a previous thromboembolic event (Class IIa; Level of Evidence A).	New recommendation
	Vitamin K antagonist therapy is reasonable for patients with ST-segment–elevation myocardial infarction and asymptomatic left ventricular mural thrombi (Class IIa; Level of Evidence C).	The level of evidence has been downgraded from A to C, but the recommendation grade is the same
	Anticoagulation may be considered for asymptomatic patients with severe mitral stenosis and left atrial dimension ≥55 mm by echocardiography (Class IIb; Level of Evidence B).	New recommendation
	Anticoagulation may be considered for patients with severe mitral stenosis, an enlarged left atrium, and spontaneous contrast on echocardiography (Class IIb; Level of Evidence C).	New recommendation
	Anticoagulant therapy may be considered for patients with ST-segment–elevation myocardial infarction and anterior apical akinesis or dyskinesis (Class IIb; Level of Evidence C).	New recommendation
	Antithrombotic treatment and catheter-based closure are not recommended in patients with patent foramen ovale for primary prevention of stroke (Class III; Level of Evidence C).	New recommendation
Asymptomatic carotid stenosis	Patients with asymptomatic carotid stenosis should be prescribed daily aspirin and a statin. Patients should also be screened for other treatable risk factors for stroke, and appropriate medical therapies and lifestyle changes should be instituted (Class I; Level of Evidence C).	New recommendation. The use of aspirin and statin therapy was implied but not explicitly stated except in the perioperative and postoperative context in the prior guidelines.
	It is reasonable to consider performing carotid endarterectomy in asymptomatic patients who have >70% stenosis of the internal carotid artery if the risk of perioperative stroke, myocardial infarction, and death is low (<3%). However, its effectiveness compared with contemporary best medical management alone is not well established (Class IIa; Level of Evidence A).	New recommendation
	It is reasonable to repeat duplex ultrasonography annually by a qualified technologist in a certified laboratory to assess the progression or regression of disease and response to therapeutic interventions in patients with atherosclerotic stenosis >50% (Class IIa; Level of Evidence C).	New recommendation
	Prophylactic carotid angioplasty and stenting might be considered in highly selected patients with asymptomatic carotid stenosis (minimum, 60% by angiography, 70% by validated Doppler ultrasound), but its effectiveness compared with medical therapy alone in this situation is not well established (Class IIb; Level of Evidence B).	New recommendation
	In asymptomatic patients at high risk of complications for carotid revascularization by either carotid endarterectomy or carotid angioplasty and stenting, the effectiveness of revascularization versus medical therapy alone is not well established (Class IIb; Level of Evidence B).	New recommendation
Sickle cell disease	Transcranial Doppler screening for children with sickle cell disease is indicated starting at 2 y of age and continuing annually to 16 y of age (Class I; Level of Evidence B).	Slightly reworded to include up to 16 y (no change in class or LOE)
	In children at high risk for stroke who are unable or unwilling to be treated with periodic red cell transfusion, it might be reasonable to consider hydroxyurea or bone marrow transplantation (Class IIb; Level of Evidence B).	Changed from LOE C to LOE B
Migraine	Smoking cessation should be strongly recommended in women with migraine headaches with aura (Class I; Level of Evidence B).	New recommendation
	Alternatives to oral contraceptives, especially those containing estrogen, might be considered in women with active migraine headaches with aura (Class IIb; Level of Evidence B).	New recommendation
Migraine cont’d	Closure of patent foramen ovale is not indicated for preventing stroke in patients with migraine (Class III; Level of Evidence B).	New recommendation
Drug abuse	Referral to an appropriate therapeutic program is reasonable for patients who abuse drugs that have been associated with stroke, including cocaine, khat, and amphetamines (Class IIa; Level of Evidence C).	Wording slightly revised to specifically list drugs associated with stroke
Sleep-disordered breathing	Because of its association with stroke risk, screening for sleep apnea through a detailed history, including structured questionnaires such as the Epworth Sleepiness Scale and Berlin Questionnaire, physical examination, and, if indicated, polysomnography may be considered (Class IIb; Level of Evidence C).	Wording slightly revised to include polysomnography and use of specific questionnaires. Recommendation class and LOE have been downgraded.
Elevated lipoprotein(a)	The clinical benefit of using lipoprotein(a) in stroke risk prediction is not well established (Class IIb; Level of Evidence B).	New recommendation
Inflammation and infection	Treatment of patients with high-sensitivity C-reactive protein >2.0 mg/dL with a statin to decrease stroke risk might be considered (Class IIb; Level of Evidence B).	The revised recommendation now defines elevated high-sensitivity C-reactive protein as >2.0 mg/dL in the context of considering statin initiation
Antiplatelet agents and aspirin	The use of aspirin for cardiovascular (including but not specific to stroke) prophylaxis is reasonable for people whose risk is sufficiently high (10-y risk >10%) for the benefits to outweigh the risks associated with treatment. A cardiovascular risk calculator to assist in estimating 10-y risk can be found online at http://my.americanheart.org/cvriskcalculator (Class IIa; Level of Evidence A).	Reworded to include cardiovascular risk calculator and link; changed from Class I to IIa
	Aspirin might be considered for the prevention of a first stroke in people with chronic kidney disease (ie, estimated glomerular filtration rate <45 mL·min−1·1.73 m−2) (Class IIb; Level of Evidence C). This recommendation does not apply to severe kidney disease (stage 4 or 5; estimated glomerular filtration rate <30 mL·min−1·1.73 m−2).	New recommendation
	Cilostazol may be reasonable for the prevention of a first stroke in people with peripheral arterial disease (Class IIb; Level of Evidence B).	New recommendation
	As a result of a lack of relevant clinical trials, antiplatelet regimens other than aspirin and cilostazol are not recommended for the prevention of a first stroke (Class III; Level of Evidence C).	New recommendation

ACC indicates American College of Cardiology; AHA, American Heart Association; CDC, Centers for Disease Control and Prevention; CV, cardiovascular; INR, international normalized ratio; LOE, level of evidence; and NCEP, National Cholesterol Education Program.

^*This table does not include recommendations that have been removed.