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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;281:1112-1120.

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.

Author Affiliations: National Stroke Association: Department of Neurological Science, Rush Medical College, Chicago, Ill (Dr Gorelick); Department of Neurology, Columbia Presbyterian Medical Center, New York, NY (Dr Sacco); Colorado Neurological Institute, Englewood, Colo (Dr Smith); Division of Neurology, Department of Medicine, Duke University Medical Center, Durham, NC (Dr Alberts); Health Care Sciences, George Washington University School of Medicine and Health Sciences, Washington, DC (Ms Mustone-Alexander); Departments of Cardiology (Dr Rader and Ms Ross) and Neurology (Dr Raps), University of Pennsylvania Health System, Philadelphia; Department of Neurology, Georgetown University Medical School, Washington, DC (Dr Ozer); Department of Neurology, Yale University School of Medicine, New Haven, Conn (Dr Brass); Department of Nursing, Allied Health Division, Jefferson Community College, Louisville, Ky (Ms Malone); Department of Rehabilitation Medicine, University of Colorado Health Sciences Center, Denver (Dr Goldberg); Neurology Service, Department of Veterans Affairs, West Haven, Conn (Dr Booss); Division of Neuroscience Critical Care, Johns Hopkins Hospital, Baltimore, Md (Dr Hanley); Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC (Dr Toole); and in collaboration with Department of Health Services Research, Cedars-Sinai Health System, University of California, Los Angeles School of Medicine, Los Angeles (Drs Greengold and Rhew). Dr Raps died on December 9, 1998.

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