Prevention of a first stroke - A review of guidelines and a multidisciplinary consensus statement from the National Stroke Association

Objective To establish, in a single resource, up-to-date recommendations fo r primary care physicians regarding prevention strategies for a first strok e. Participants Members of the National Stroke Association's (NSA's) Stroke Pr evention Advisory Board and Cedars-Sinai Health System Department of Health Services Research convened on April 9, 1998, in an open meeting. The confe rence attendees, selected to participate by the NSA, were recognized expert s in neurology (9), cardiology (2), family practice (1), nursing (1), physi cian assistant practices (1), and health services research (2). Evidence A literature review was carried out by the Department of Health Se rvices 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 overview s 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 f irst stroke. Good evidence for direct stroke reduction exists for hypertens ion treatment; using warfarin for patients after MI who have atrial fibrill ation, decreased left ventricular ejection fraction, or left ventricular th rombus; using 3-hydroxy3 methylglutaryl coenzyme A (HMG-CoA) reductase inhi bitors for patients after MI; using warfarin for patients with atrial fibri llation and specific risk factors; and performing carotid endarterectomy fo r patients with stenosis of at least 60%. Observational studies support the role of modifying lifestyle-related risk factors leg, smoking, alcohol use , physical activity, diet) in stroke prevention. Measures to help patients improve adherence are an important component of-a stroke prevention plan.