What is the 8+2 screening for people at high risk of stroke?

Stroke, also known as apoplexy, has become the leading cause of death in my country and the single disease with the highest disability rate. In my country, there is a new stroke patient every 12 seconds.

Stroke is a preventable and treatable disease. Active and effective intervention in the risk factors of stroke can significantly reduce the incidence of stroke, thereby reducing the disease burden of stroke.

Currently, the "8 + 2" stroke risk factors are used for screening of high-risk groups for stroke, including: 8 risk factors: hypertension, atrial fibrillation or valvular heart disease, smoking, dyslipidemia, diabetes, little physical exercise, obesity, and family history of stroke; as well as 2 past histories: personal history of stroke and history of TIA.

1. Hypertension

1) Diagnostic criteria

Without the use of antihypertensive drugs, the systolic blood pressure (SBP) was ≥ 140 mmHg and/or the diastolic blood pressure (DBP) was ≥ 90 mmHg when the office blood pressure was measured three times on different days.

Patients with a history of hypertension who are currently taking antihypertensive drugs should be diagnosed with hypertension even if their blood pressure is lower than 140/90 mmHg; SBP ≥ 140 mmHg and DBP < 90 mmHg are defined as isolated systolic hypertension.

Blood pressure outside the clinic is repeatable. Hypertension can be diagnosed if self-measured blood pressure at home is ≥ 135/85 mmHg and 24-hour dynamic blood pressure is ≥ 130/80 mmHg.

2) Intervention measures

Nonpharmacological treatments include weight loss, a heart-healthy diet, reduced sodium intake, dietary potassium supplementation, increased exercise as part of a training program, and limiting alcohol intake.

Antihypertensive drug treatment is recommended for people with a 10-year cardiovascular disease risk ≥ 10% and an average systolic blood pressure ≥ 130 mmHg or an average diastolic blood pressure ≥ 80 mmHg, and for people with a 10-year cardiovascular disease risk < 10% and an average systolic blood pressure ≥ 140 mmHg or an average diastolic blood pressure ≥ 90 mmHg.

All types of antihypertensive drugs can be used if they can effectively lower blood pressure. Those who need antihypertensive treatment should receive individualized treatment based on patient characteristics and drug tolerance.

3) Intervention goals

Patients with general hypertension should lower their blood pressure to

2. Abnormal glucose metabolism

1) Diagnostic criteria

Typical symptoms of diabetes (polydipsia, polyuria, polyphagia, weight loss) plus random blood glucose test ≥ 11.1 mmol/L, or fasting blood glucose test ≥ 7.0 mmol/L, or blood glucose ≥ 11.1 mmol/L 2 hours after glucose load.

2) Intervention measures

Comprehensive treatment includes improving lifestyle, nutritional therapy, exercise therapy, and drug therapy. First of all, the lifestyle of diabetic patients should be improved, including diet and physical exercise. If lifestyle alone cannot control blood sugar to the target, oral hypoglycemic drugs or insulin therapy should be started.

Diabetic patients should use statins in combination with strict control of blood sugar, blood pressure and lifestyle intervention, which can effectively reduce the risk of stroke.

Patients with diabetes and simple hypertriglyceridemia (＞5.6 mmol/L) should use phenoxy acid drugs.

3) Intervention goals

The recommended control target is fasting blood glucose 4.4-7.0 mmol/L and postprandial blood glucose < 10.0 mmol/L. For most non-pregnant adult patients with type 2 diabetes, the reasonable HbA1c control target is < 7.0%.

Under the premise of no hypoglycemia or other adverse reactions, the HbA1c control target is < 6.5% for patients with type 2 diabetes with a short course of disease, long life expectancy, no complications, and no cardiovascular disease;

An HbA1c target of < 8.0% is recommended for patients with a history of severe hypoglycemia, a short life expectancy, significant microvascular or macrovascular complications, severe comorbidities, or difficulty achieving conventional treatment goals.

3. Dyslipidemia

1) Diagnostic criteria

Table 1. Appropriate blood lipid levels and abnormal stratification criteria for primary prevention of ASCVD in China

2) Intervention measures

Diet therapy and lifestyle improvement are the basic measures for the treatment of dyslipidemia. Control the total energy on the basis of meeting the daily nutritional needs; reasonably choose the composition ratio of each nutritional element; control weight, quit smoking, limit alcohol; and insist on regular moderate-intensity metabolic exercise.

Statins are the first choice for drug treatment. Moderate-strength statins should be used initially, and the dose should be adjusted appropriately based on individual lipid-lowering efficacy and tolerance.

Patients who are intolerant to statins, whose cholesterol levels do not meet the standard, and those with severe mixed hyperlipidemia should consider using it in combination with other lipid-lowering drugs.

3) Intervention goals

Those diagnosed with ASCVD are directly classified as a very high-risk group;

Those who meet any of the following conditions are directly classified as high-risk groups:

①LDL-C ≥ 4.9 mmol/L (190 mg/dL);

② Diabetic patients with LDL-C 1.8 mmol/L (70 mg/dL) ~ 4.9 mmol/L (190 mg/dL) and aged 40 years and above.

For individuals who do not meet the above conditions, the average 10-year risk of ASCVD is defined as low risk, intermediate risk, and high risk according to the LDL-C or TC level, the presence or absence of hypertension, and the number of other ASCVD risk factors: < 5%, 5%-9%, and ≥ 10%, respectively.

For patients at very high risk of ASCVD, the LDL-C target value for statin therapy should be < 1.8 mmol/L or reduced by ≥ 50%;

The LDL-C target value for high-risk patients should be < 2.6 mmol/L or reduced by 50%;

The LDL-C target value for intermediate-risk and low-risk patients should be < 3.4 mmol/L.

4. Atrial fibrillation or valvular heart disease

1) Patients with valvular atrial fibrillation

For patients with rheumatic mitral stenosis and mechanical valve combined with atrial fibrillation, oral warfarin (INR 2.0-3.0) is recommended for anticoagulation therapy; for patients with atrial fibrillation combined with bioprosthetic valve replacement within 3 months or mitral valve repair within 3 months, oral warfarin (INR 2.0-3.0) is recommended for anticoagulation therapy.

2) According to CHA2DS2-VASc score:

Table 2. CHADS2 score and CHADS2-VASC score

① For patients with non-valvular atrial fibrillation with a CHA2DS2-VASc score of ≥ 2 for males and ≥ 3 for females, oral anticoagulant therapy is recommended. New oral anticoagulants (dabigatran, rivaroxaban, apixaban, edoxaban, etc.) or warfarin (INR 2.0-3.0) can be used.

② For patients with non-valvular atrial fibrillation whose CHA2DS2-VASc score is 1 for males and 2 for females, oral anticoagulants can be considered based on the benefit-risk balance, and the type of anticoagulant drug to be selected needs to be determined based on the principle of root cause.

③ Anticoagulation therapy is not recommended for patients with non-valvular atrial fibrillation with a CHA2DS2-VASc score of 0 for males and 1 for females.

3) For patients with atrial fibrillation (CHA2DS2-VASc score ≥ 2 points) combined with end-stage renal disease (creatinine clearance < 15 mL/min) or dialysis, warfarin is recommended for anticoagulation therapy.

4) Patients with indications for anticoagulant therapy but not suitable for long-term standardized anticoagulant therapy, or patients who still experience stroke or embolism despite long-term standardized anticoagulant therapy, may be considered for left atrial appendage occlusion in medical institutions with the necessary conditions.

5. Smoking

It is clear that smoking increases the risk of stroke.

Mobilize the participation of the whole society and adopt comprehensive tobacco control measures to intervene in smokers among the community population, including: psychological counseling, nicotine replacement therapy, oral smoking cessation drugs, etc.

6. Drinking

Drinkers should reduce their drinking as much as possible or quit drinking.

The daily alcohol content for men should not exceed 25 g, and for women no more than 12.5 g.

7. Lack of exercise

Individualized selection of physical activities suitable for oneself can reduce the risk of cerebrovascular disease. Healthy adults should engage in aerobic exercise 3 to 4 times a week, each time lasting about 40 minutes of moderate or higher intensity aerobic exercise (such as brisk walking, jogging, cycling or other aerobic exercise, etc.).

For people who mainly sit in meditation during their daily work, they should stand up and move around for 2 to 3 minutes for every hour of sitting.

8. Overweight and obesity

Overweight and obese people can lose weight through a healthy lifestyle, good eating habits, increased physical activity and other measures, which is beneficial for controlling blood pressure and reducing the risk of stroke.

9. History of stroke or TIA

On the basis of controlling the above-mentioned risk factors, oral antiplatelet drugs are recommended to prevent stroke recurrence in patients with non-cardioembolic ischemic stroke or TIA.

Aspirin 50-325 mg/d or clopidogrel 75 mg/d is the preferred drug; aspirin 25 mg + sustained-release dipyridamole 200 mg, 2 times/d or cilostazol 100 mg, 2 times/d can be used as an alternative.

Understand the specific content and target management of the above 8+2 risk factors and be your own health manager.