Objective
To establish, in a single resource, up-to-date
recommendations for primary care physicians regarding prevention
strategies for a first stroke.
Participants
Members of the National Stroke Association's
(NSA's) Stroke Prevention Advisory Board and Cedars-Sinai Health
System Department of Health Services Research convened on April 9,
1998, in an open meeting. The conference attendees, selected to
participate by the NSA, were recognized experts in neurology (9),
cardiology (2), family practice (1), nursing (1), physician assistant
practices (1), and health services research (2).
Evidence
A literature review was carried out by the Department of
Health Services Research, Cedars-Sinai Health System, Los Angeles,
Calif, using the MEDLINE database search for 1990 through April 1998
and updated in November 1998. English-language guidelines, statements,
meta-analyses, and overviews on prevention of a first stroke were
reviewed.
Consensus Process
At the meeting, members of the advisory board
identified 6 important stroke risk factors (hypertension, myocardial
infarction [MI], atrial fibrillation, diabetes mellitus, blood
lipids, asymptomatic carotid artery stenosis), and 4 lifestyle factors
(cigarette smoking, alcohol use, physical activity, diet).
Conclusions
Several interventions that modify well-documented and
treatable cardiovascular and cerebrovascular risk factors can reduce
the risk of a first stroke. Good evidence for direct stroke reduction
exists for hypertension treatment; using warfarin for patients after MI
who have atrial fibrillation, decreased left ventricular ejection
fraction, or left ventricular thrombus; using 3-hydroxy-3
methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors for patients
after MI; using warfarin for patients with atrial fibrillation and
specific risk factors; and performing carotid endarterectomy for
patients with stenosis of at least 60%. Observational studies support
the role of modifying lifestyle-related risk factors (eg, smoking,
alcohol use, physical activity, diet) in stroke prevention. Measures to
help patients improve adherence are an important component of a stroke
prevention plan.