Stroke: an emphasis on guidelines.

2014 was notable for several advances in stroke, and particularly for the development of prevention guidelines. Prior guidance in stroke prevention, although comprehensive for stroke, was more narrowly focused and less well integrated with the overall theme of cardiovascular health. 1–3 The defi nition of stroke has undergone a transformation in recent years, 4 and the importance of control of cardiovascular risk factors to reduce stroke mortality and the value of inclusion of stroke in cardiovascular risk prediction instruments are increasingly recognised as part of the outcome cluster (ie, stroke is now regarded as a key outcome). 4–6 Thus, stroke is now more closely joined to other cardiovascular diseases, such as coronary artery disease and its sequelae, myocardial infarction, and heart failure. Here, we describe several key stroke guidelines from 2014 that have substantial practical implications, beginning with major new cardiovascular disease prevention guides that serve as important precedents to understand the new stroke guidance statements. The 2014 evidenced-based guidelines for the management of high blood pressure in adults (Eighth Joint National Committee or JNC 8) 7 and the American College of Cardiology/American Heart Association (ACC/AHA) statement on the treatment of blood cholesterol 8 provoked controversy. The JNC 8 guidance altered the blood pressure treatment goal to less than 150/90 mm Hg for people aged 60 years or older, a departure from the traditional goal of less than 140/90 mm Hg. 7 The new increased goal raised concern of heightened risk of stroke and could lead to confusion because other guidelines adhere to a target of less than 140/90 mm Hg. 9 In the guidelines for lipid management, four main sets of criteria indicate that people are eligible for statin therapy: clinical atherosclerotic cardiovascular disease; LDL cholesterol 190 mg/dL or more; age from 40 to 75 years, LDL cholesterol 70–189 mg/dL, and a history of diabetes mellitus; and a 10-year atherosclerotic cardiovascular disease risk of 7·5% or more. 7 The new ACC/AHA guidelines are valuable because they emphasise a risk-based approach; a new risk calculator to establish which patients qualify for statin therapy, overall, simplifi es the approach to lipid management in the community, and includes both heart disease and stroke prediction. The risk calculator has been criticised, however, because it might overestimate risk and lead to unnecessary statin treatment. 9 The AHA recurrent stroke prevention guidance statement recommends a blood pressure goal of less than 140/90 mm Hg; however, …