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Consensus Statement |

Prevention of a First Stroke A Review of Guidelines and a Multidisciplinary Consensus Statement From the National Stroke Association

Philip B. Gorelick, MD, MPH; Ralph L. Sacco, MD; Don B. Smith, MD; Mark Alberts, MD; Lisa Mustone-Alexander, MPH, PA; Dan Rader, MD; Joyce L. Ross, MSN; Eric Raps, MD; Mark N. Ozer, MD; Lawrence M. Brass, MD; Mary E. Malone, MA, MSN; Sheldon Goldberg, MD; John Booss, MD; Daniel F. Hanley, MD; James F. Toole, MD; Nancy L. Greengold, MD, MBA; David C. Rhew, MD
JAMA. 1999;281(12):1112-1120. doi:10.1001/jama.281.12.1112.
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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.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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