The American Journal of Medicine
Volume 122, Issue 4, Supplement 2 , Pages S1-S6, April 2009

Introduction

  • Elizabeth A. Bower, MD, MPH

      Affiliations

    • Corresponding Author InformationRequests for reprints should be addressed to Elizabeth A. Bower, MD, MPH, Department of Medicine, Division of General Internal Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-602, Portland, Oregon 97239-3098
    • ,
  • Donald E. Girard, MD

Department of Medicine, Division of General Internal Medicine, Oregon Health and Science University, Portland, Oregon, USA

Article Outline

 

Stroke is a disease that can result in profound disability. Moreover, individuals with a history of stroke are at increased risk for recurrent stroke. Improvements in stroke survival rates and the aging demographic of the US population highlight the need for effective and timely treatment strategies aimed at reducing risk of any stroke. Primary care physicians typically see patients before they have a first stroke and thus are uniquely situated to assess stroke risk and initiate the best preventive strategies. For patients with a history of stroke, primary care physicians are often in the position of coordinating multifaceted and comprehensive care. This supplement to The American Journal of Medicine focuses on strategies for reducing secondary stroke risk in primary care practice.

In this introductory article, we provide an overview of stroke prevention from the perspective of primary care clinicians. The second article, by Dr. Mitchell S. V. Elkind, reviews the epidemiology of secondary stroke and its associated risk factors. In the third article, Dr. Dara G. Jamieson, includes a detailed discussion of diagnostic tools useful for evaluating patients with stroke. Finally, Dr. Helmi L. Lutsep, discusses treatment strategies useful for reducing risk for secondary stroke.

Back to Article Outline

Overview 

In the United States, stroke occurs in 780,000 people annually; for 600,000, it is the first event in the disease history.1 The large majority of strokes (87%) are ischemic in nature; the remainder are hemorrhagic events.1 Stroke survivors are at greatly increased risk for a recurrent stroke. Studies show that within the first 12 months after an initial stroke, between 8% and 12% of survivors are estimated to experience a second stroke2, 3; within 5 years this rate rises to 16.6%.2 The risk increases with age; in one analysis, 22% of individuals ≥65 years (n = 546) experienced a second stroke during 3.2 years of follow-up.2, 4

A trend toward increased stroke survival rates has been observed in recent years. Between 1994 and 2004, the stroke death rate decreased by 6.8%.1 Such decreases are in part related to improvements in stroke treatment. Financial costs are significant: estimated direct and indirect costs of all strokes were US$65.5 billion in 2008.1

Shifts in stroke survival rates and the aging demographic of the US population make the issue of secondary stroke prevention even more vital than it was just 10 years ago. Such statistics highlight the need for effective and timely treatment strategies aimed at reducing risk of stroke. Primary care physicians typically see patients before they have a first stroke, and thus are uniquely situated to assess stroke risk and initiate the best preventive strategies. For patients with a history of stroke, primary care physicians are in an ideal position to coordinate multifaceted and comprehensive care, beyond that typically achievable under the care of a single specialist.5 In addition, there are not nearly enough neurologists to provide this care, a situation that will worsen as the population ages.

Back to Article Outline

Preventing Stroke: The Significance of Risk Factor Reduction 

Recent guidelines for prevention of primary ischemic stroke provide a roadmap for assessing level of stroke risk in individual patients.6 Estimating this level of risk helps in selecting treatments and formulating an overarching individualized strategy for risk reduction.6 Those patients with the highest stroke risk are often those who present with nonmodifiable risk factors, such as increased age, male sex, family history of stroke, and Hispanic or African American ethnicity.6 The presence of such risks signals the need for rigorous treatment of modifiable risk factors, such as hypertension, dyslipidemia, diabetes mellitus, and certain lifestyle variables, such as frequent, heavy alcohol consumption, smoking, and physical inactivity.6 Modification of these risks is integral to primary and secondary stroke prevention.

Hypertension 

A clear, direct relation between blood pressure and stroke risk has been described in a number of important prospective investigations.7, 8, 9 Analysis from the Systolic Hypertension in the Elderly Program (SHEP) showed that in elderly persons with isolated systolic hypertension, but no history of stroke, risk of stroke or transient ischemic attack (TIA) was significantly elevated.7 Similarly, in a United Kingdom Prospective Diabetes Study (UKPDS-36) report, in patients with type 2 diabetes, higher systolic blood pressure levels were directly related to increased stroke incidence.9 Moreover, both the SHEP and UKPDS trials showed that blood pressure reduction was associated with significant decreases in stroke risk. In the UKPDS trial, tight blood pressure control (defined as pressures <150/<85 mm Hg) was linked to a 44% decrease in stroke risk for every 10-mm Hg decrement in systolic blood pressure.9 Based on these and other findings, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7)10 continues to define target blood pressure as <140/<80 mm Hg, but redefined optimal systolic blood pressure as <120 mm Hg (down from <130 mm Hg in JNC-6)11; moreover, blood pressure of 120 to 139/80 to 89 mm Hg is now considered “prehypertension,” warranting interventions aimed at lifestyle modification.10 In addition to lowering the threshold for “optimal” blood pressure, the JNC-7 guidelines encouraged more aggressive treatment to reach targets. Although diuretics are still recommended as first-line therapy, other medications should be considered early in treatment if target blood pressure levels are not achieved with a single agent.10

Serum Lipid Concentrations 

A positive relation between serum lipid concentrations and risk of stroke has been described in recent analyses and randomized trials.12, 13, 14, 15 Although one study from the United Kingdom failed to detect a relation between serum total cholesterol concentration and stroke risk,12 analysis from the Asia Pacific Studies Cohort Collaboration revealed a positive relation between serum lipid levels and ischemic stroke rate. A 25% increase in ischemic stroke rate was identified for every 1-mmol/L increase in total cholesterol concentration.13 Similarly, a prospective cohort study of 24,343 women in the United States showed that the risk for fatal ischemic stroke among those <55 years of age increased by 23% with every 1-mmol/L increase in serum total cholesterol.16 Moreover, lowering cholesterol with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statin) decreases the risk of both incident and recurrent stroke.15, 17

Current guidelines on primary ischemic stroke prevention state that an aggressive cholesterol-lowering regimen, including lifestyle modification and a statin, should be implemented for patients with known coronary artery disease and for high-risk patients with hypertension, including those with normal low-density lipoprotein (LDL) cholesterol concentrations.6 The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) provides comprehensive guidelines on lowering serum cholesterol for stroke prevention.18 In high-risk patients, such as those with coronary artery disease or diabetes, the recommended target LDL cholesterol level is <100 mg/dL (1 mg/dL = 0.02586 mmol/L).

Diabetes 

Individuals with diabetes are at greatly increased risk for stroke, compared with nondiabetic persons.19, 20 In the Nurses' Health Study, the adjusted relative risk of any type of stroke was 4.7-fold greater in those with comorbid type 1 diabetes and 1.8-fold greater in those with type 2 diabetes, compared with no diabetes.20 Similarly, another analysis showed that over 5 years of follow-up, patients with newly diagnosed type 2 diabetes were 2 times more likely to experience a stroke than were patients without diabetes.19

Because of the additional risk of cardiovascular and cerebrovascular disease imposed by diabetes, more stringent control of hypertension and dyslipidemia are recommended for patients with diabetes. Until quite recently, tight glucose control was also thought to be essential. This belief was based on the results of the Diabetes Control and Complications Trial (DCCT), which demonstrated that over a 10-year follow-up period intensive diabetes therapy in patients with type 1 diabetes resulted in a 57% decrease in cardiovascular events, including nonfatal stroke, compared with conventional therapy.21 In contrast, in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) and Action to Control Cardiovascular Risk in Diabetes (ACCORD) trials, tighter glucose control in patients with type 2 diabetes was not associated with reduction in macrovascular events, including stroke.22, 23

Lifestyle Risk Factors 

A variety of lifestyle behaviors are clearly linked to increased risk for stroke. Cigarette smoking,24, 25 excessive alcohol consumption,26, 27 physical inactivity,28, 29 and a diet low in fruits, vegetables, and whole grains30, 31, 32, 33 are all associated with increased stroke risk. Data from the Framingham Heart Study cohort revealed that smokers were roughly 2 times more likely than nonsmokers to experience a stroke.24 In men, heavy regular alcohol consumption (defined as ≥3 drinks on 3 to 4 days per week) is associated with a 47% increased risk for ischemic stroke.26, 27 Those who drink lightly, those who drink red wine, and women are at comparatively lower risk.26, 27 Obesity (body mass index >30 in men)34 and physical inactivity28, 29, 35 have also been linked to an elevated risk for stroke. One meta-analysis indicates that regular moderate exercise decreases stroke risk by 27%.35 Although no study has shown that losing weight decreases risk for stroke, obesity contributes to other stroke risk factors, such as hypertension, elevated fasting blood glucose levels, and serum lipids, and consequently, should be a priority for stroke risk reduction. Finally, diet has recently been examined as a contributing factor to stroke risk.30, 31, 32, 33 Diets high in fruits, vegetables, and whole grains have been linked to lower stroke risk, even when controlling for possible confounding factors.30, 31 This literature underscores the importance of lifestyle factors in stroke risk (and therefore prevention) and challenges physicians to implement strategies for lifestyle improvement.

Aspirin for Stroke Prevention 

The role of aspirin therapy for primary stroke prevention in the general patient population with no apparent history of cardiovascular disease is unclear. Although a recent meta-analysis of several large, prospective trials indicates primary cardiovascular event protection, it did not reveal a significant primary stroke preventive benefit of aspirin.36 Aspirin therapy, however, is recommended for individuals whose 10-year stroke risk is 6% to 10%; for these patients, the potential benefits of aspirin or other types of platelet antiaggregant therapy may outweigh potential risks and complications, most often gastrointestinal bleeding.6

Relatively few women were enrolled in the primary prevention trials with the exception of the Women's Health Study, which randomized 39,876 healthy women (≥45 years of age) with no history of stroke to low-dose aspirin therapy (100 mg on alternate days) or placebo.37 This study showed a 17% reduction in the overall risk for any type of stroke over a 10-year follow-up period. Subgroup analyses also showed that women with a history of other known stroke risks, such as hypertension, hyperlipidemia, and diabetes, as well as those with an estimated 10-year coronary heart disease risk of ≥10%, experienced significant primary stroke prevention benefits (based on relative risk versus placebo; all P ≤0.04) when given low-dose aspirin therapy. For these women, reductions in the occurrence of a first stroke during follow-up ranged from 24% to 54%.37

Based on these findings, low-dose aspirin therapy may be useful for primary stroke prevention in women with a high stroke risk, for whom there is evidence of the potential benefits outweighing the risks.6 It may also be useful in other specific patient populations, such as those with atrial fibrillation, asymptomatic carotid stenosis, and noncerebrovascular atherosclerosis.6 During the next several years, primary prevention trials should provide more definitive data regarding the use of aspirin therapy for primary prevention of stroke.38, 39

Back to Article Outline

Risk of Recurrent Stroke 

Because risk factors for secondary stroke are largely the same as those for primary stroke,40 secondary prevention targets the same well-recognized stroke risk factors. More than 17% of patients who have had a TIA or minor stroke will have another stroke event within 3 months, indicating the importance of early and aggressive intervention for secondary stroke prevention.41 A number of investigations have shown that targeting blood pressure, serum lipid levels, and diabetes control can help prevent secondary stroke.40 Platelet antiaggregant therapy, including aspirin, is appropriate for secondary stroke prevention. Management of these risk factors is discussed at length by Elkind elsewhere in this supplement.42

Back to Article Outline

Programmed Strategies for Stroke Prevention 

To address the need for early secondary interventions, the Stroke PROTECT (Preventing Recurrence of Thromboembolic Events Through Coordinated Treatment) Program was developed as an inhospital program composed of 8 medical and behavioral interventions (Table 1) aimed at secondary stroke prevention, to be initiated prior to hospital discharge after TIA or ischemic stroke.43, 44 Initial efficacy analyses are promising; at the time of hospital discharge from participating institutions, utilization of medical therapies was high (83% to 100% for those with no contraindications),43 and 100% of patients had received instruction and counseling for each of the behavioral targets.44 At 90 days postdischarge, adherence to medication therapy remained high (64% to 100% overall and 80% to 100% in patients with no contraindications), as did adherence to behavioral modifications (i.e., exercise, diet modifications, and tobacco cessation; range 70% to 97%).43 All smokers who quit during inpatient treatment remained smoke-free at follow-up, and 83% met the LDL cholesterol target of <100 mg/dL.43 Importantly, the 90-day rate of recurrent stroke or TIA (12.3%) was lower than in other investigations (18.5%).41

Table 1. Preventing recurrence of thromboembolic events through coordinated treatment (PROTECT) program interventions for secondary stroke prevention
Medical⁎

•Antithrombotic agent

•Statin

•Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker

•Thiazide diuretic

Behavioral

•Smoking-cessation advice, referral to a formal cessation program

•Implementation of the American Heart Association diet

•Exercise counseling

•Stroke education

•Stroke warning signs

•The need to call 911

•Knowledge of personal risk factors

Statin = 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor.

Adapted from Clinical Trials.gov39 and Circulation.40

⁎For patients with no specific contraindications.

Although PROTECT has shown that systems-based strategies are successful in the inpatient setting, the maintenance of a treatment regimen and sustained behavioral change must take place in the outpatient setting. A recent report evaluated the effectiveness of a systems-based program for stroke prevention designed for the office setting in the United Kingdom. The findings demonstrated that primary care practices that participated in the program training and practice audits assessing their adherence to treatment guidelines for management of atrial fibrillation and TIA were significantly more likely to correctly diagnose atrial fibrillation and adhere to the guidelines for treatment of TIAs.45 In the United States, initiatives to establish regional stroke care systems are underway.46 Major goals of such programs include patient and physician education about stroke risks, signs, and symptoms; advocating healthy lifestyle choices; and developing systems-based, standardized, acute stroke care strategies.46 As part of a stroke care system, the primary care physician will surely play a large role in patient education about stroke risk factors and treatment regimens for their modification.

Back to Article Outline

Challenges and Strategies for Effecting Patient Behavior Change 

The care-management role of primary care physicians creates an opportunity to develop individualized strategies for preventing primary and secondary stroke, which should include multiple therapeutic targets and interventions.5, 45 One well-recognized challenge is maintaining treatment adherence and initiating lasting lifestyle changes aimed at stroke prevention. Regular follow-up and patient contact may help initiate and maintain positive changes over time, with physicians then able to identify problems with treatment adherence or flagging commitment to lifestyle modifications. Physicians can actively take steps to address these challenges that go beyond reminders or referring patients for exercise and nutritional counseling. Specifically, physicians can use relatively brief outpatient encounters to implement behavioral strategies, such as motivational interviewing, which has been proven to facilitate client behavioral change (summarized in Table 2).47, 48, 49 The motivational interviewing technique has shown success with weight loss, physical activity, alcohol abuse, smoking cessation, treatment adherence, and management of diabetes and asthma. With this approach, the physician-patient relationship is recast as a partnership rather than the typical expert-recipient dynamic in which physicians mainly give medications and advice. This change in dynamic allows patients to examine and resolve ambivalence about making behavioral changes. The physician's role is to listen and persuade rather than instruct and lecture. This patient-physician partnership, which is unique to primary care physicians, best facilitates implementation of a comprehensive poststroke treatment program.

Table 2. Traditional versus motivational interviewing approaches toward eliciting patient behavior change
TraditionalMotivational
Physician/patient relationship:
Expert/recipientPartnership
Physician communication:
Characterized by:
Advice-givingElicit patient's ambivalence about change (indulgence vs. restraint)
Facts regarding consequences of behaviorClarify patient's underlying values and goals
Attempt to persuade patient to changeDiscuss patient motivation to change
Physician style:
Detached, factualQuiet, eliciting
Confrontational, aggressiveOpen to listening
Respectful
Patient perspective:
Feel pushed into changeFeel able to discuss behavior more openly; resolve ambivalence
Deny or attempt to hide problem behaviorDevelop belief in ability to change own behavior
Resist attempts to find solutions or initiate changeEmpowered to devise and carry out a change strategy

Adapted from Neurology,44 Qual Saf Health Care,45 and Circulation.46

Back to Article Outline

Summary 

The risk of stroke is high in the general population, and strokes place a heavy financial and personal burden on patients and their caregivers. The incidence of stroke in the United States is expected to increase over the next several decades as the population ages, making primary and secondary stroke prevention more critical. Primary care physicians can effect important improvements in the management of patients with strokes by implementing comprehensive treatment plans that address multiple risk factors and maximize the likelihood of effective patient lifestyle change.

Back to Article Outline

Author Disclosures 

The authors who contributed to this article have disclosed the following industry relationships:

Elizabeth A. Bower, MD, MPH, reports no relationships to disclose with any manufacturer of a product or device discussed in this article.

Donald E. Girard, MD, reports no relationships to disclose with any manufacturer of a product or device discussed in this article.

Back to Article Outline

References 

  1. Rosamond W, Flegal K, Furie K, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee Heart disease and stroke statistics—2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117:e25–e146
  2. Hillen T, Coshall C, Tilling K, Rudd AG, McGovern R, Wolfe CD South London Stroke Register. Cause of stroke recurrence is multifactorial: patterns, risk factors, and outcomes of stroke recurrence in the South London Stroke Register. Stroke. 2003;34:1457–1463
  3. Hankey GJ. Long-term outcome after ischaemic stroke/transient ischaemic attack. Cerebrovasc Dis. 2003;16(suppl 1):14–19
  4. Kaplan RC, Tirschwell DL, Longstreth WT, et al. Heart Protection Study Collaborative Group Vascular events, mortality, and preventive therapy following ischemic stroke in the elderly. Neurology. 2005;65:835–842
  5. Cuffe M. Preventing vascular events in high-risk patients: primary care on the front line. Clin Cardiol. 2006;29(suppl):II2–II3
  6. Goldstein LB, Adams R, Alberts MJ, et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council. Stroke. 2006;37:1583–1633
  7. Davis BR, Vogt T, Frost PH, et al. Systolic Hypertension in the Elderly Program Cooperative Research Group Risk factors for stroke and type of stroke in persons with isolated systolic hypertension. Stroke. 1998;29:1333–1340
  8. Eastern Stroke and Coronary Heart Disease Collaborative Research Group. Blood pressure, cholesterol, and stroke in eastern Asia. Lancet. 1998;352:1801–1807
  9. Adler AI, Stratton IM, Neil HA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ. 2000;321:412–419
  10. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure National High Blood Pressure Education Program Coordinating Committee The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–2572
  11. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;157:2413–2446
  12. Prospective Studies Collaboration. Cholesterol, diastolic blood pressure, and stroke: 13,000 strokes in 450,000 people in 45 prospective cohorts. Lancet. 1995;346:1647–1653
  13. Zhang X, Patel A, Horibe H, et al. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol. 2003;32:563–572
  14. Collins R, Armitage J, Parish S, Sleight P, Peto R Heart Protection Study Collaborative Group. Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet. 2004;363:757–767
  15. Amarenco P, Bogousslavsky J, Callahan A, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006;355:549–559
  16. Horenstein RB, Smith DE, Mosca L. Cholesterol predicts stroke mortality in the Women's Pooling Project. Stroke. 2002;33:1863–1868
  17. Amarenco P, Labreuche J, Lavallée P, Touboul PJ. Statins in stroke prevention and carotid atherosclerosis: systematic review and up-to-date meta-analysis. Stroke. 2004;35:2902–2909
  18. Grundy SM, Cleeman JI, Merz CN, et al. National Heart, Lung, and Blood Institute, the American College of Cardiology Foundation, and the American Heart Association Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227–239
  19. Jeerakathil T, Johnson JA, Simpson SH, Majumdar SR. Short-term risk for stroke is doubled in persons with newly treated type 2 diabetes compared with persons without diabetes: a population-based cohort study. Stroke. 2007;38:1739–1743
  20. Janghorbani M, Hu FB, Willett WC, et al. Prospective study of type 1 and type 2 diabetes and risk of stroke subtypes: the Nurses' Health Study. Diabetes Care. 2007;30:1730–1735
  21. Nathan DM, Cleary PA, Backlund JY, et al. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353:2643–2653
  22. Advance Collaborative GroupPatel A, MacMahon S, Chalmers J, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560–2572
  23. Action to Control Cardiovascular Risk in Diabetes Study GroupGerstein HC, Miller ME, Byington RP, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358:2545–2559
  24. Wolf PA, D'Agostino RB, Kannel WB, Bonita R, Belanger AJ. Cigarette smoking as a risk factor for stroke: the Framingham Study. JAMA. 1988;259:1025–1029
  25. Freund KM, Belanger AJ, D'Agostino RB, Kannel WB. The health risks of smoking (The Framingham Study: 34 years of follow-up). Ann Epidemiol. 1993;3:417–424
  26. Djousse L, Ellison RC, Beiser A, Scaramucci A, D'Agostino RB, Wolf PA. Alcohol consumption and risk of ischemic stroke: the Framingham Study. Stroke. 2002;33:907–912
  27. Mukamal KJ, Ascherio A, Mittleman MA, et al. Alcohol and risk for ischemic stroke in men: the role of drinking patterns and usual beverage. Ann Intern Med. 2005;142:11–19
  28. Gillum RF, Mussolino ME, Ingram DD. Physical activity and stroke incidence in women and men (The NHANES I Epidemiologic Follow-up Study). Am J Epidemiol. 1996;143:860–869
  29. Hu FB, Stampfer MJ, Colditz GA, et al. Physical activity and risk of stroke in women. JAMA. 2000;283:2961–2967
  30. Liu S, Manson JE, Lee IM, et al. Fruit and vegetable intake and risk of cardiovascular disease: the Women's Health Study. Am J Clin Nutr. 2000;72:922–928
  31. Liu S, Manson JE, Stampfer MJ, et al. Whole grain consumption and risk of ischemic stroke in women: a prospective study. JAMA. 2000;284:1534–1540
  32. FOOD Trial Collaboration. Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial. Stroke. 2003;34:1450–1456
  33. Mink PJ, Scrafford CG, Barraj LM, et al. Flavonoid intake and cardiovascular disease mortality: a prospective study in postmenopausal women. Am J Clin Nutr. 2007;85:895–909
  34. Kurth T, Gaziano JM, Berger K, et al. Body mass index and the risk of stroke in men. Arch Intern Med. 2002;162:2557–2562
  35. Lee CD, Folsom AR, Blair SN. Physical activity and stroke risk: a meta-analysis. Stroke. 2003;34:2475–2481
  36. Bartolucci AA, Howard G. Meta-analysis of data from the six primary prevention trials of cardiovascular events using aspirin. Am J Cardiol. 2006;98:746–750
  37. Ridker PM, Cook NR, Lee IM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med. 2005;352:1293–1304
  38. Brigham and Women's Hospital, Bayer Clinical Trials. A study to assess the efficacy and safety of 100 mg acetylsalicylic acid in patients at moderate risk of cardiovascular disease (ARRIVE). http://clinicaltrials.gov/ct2/show/NCT00501059Accessed March 5, 2009
  39. Japanese Ministry of Health, Labour and Welfare, Japan Heart Foundation, Bayer HealthCare. Japanese Primary Prevention Project With Aspirin. http://clinicaltrials.gov/show/NCT00225849Accessed July 7, 2008. ClinicalTrials.gov Identifier NCT00225849
  40. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: cosponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline. Circulation. 2006;113:e409–e449
  41. Coull AJ, Lovett JK, Rothwell PM Oxford Vascular Study. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ. 2004;328:326
  42. Elkind MSV. Outcomes after stroke: risk of recurrent ischemic stroke and other events. Am J Med. 2009;122(Suppl):S7–S13
  43. Ovbiagele B, Saver JL, Fredieu A, et al. In-hospital initiation of secondary stroke prevention therapies yields high rates of adherence at follow-up. Stroke. 2004;35:2879–2883
  44. Ovbiagele B, Saver JL, Fredieu A, et al. PROTECT: a coordinated stroke treatment program to prevent recurrent thromboembolic events. Neurology. 2004;63:1217–1222
  45. Wright J, Bibby J, Eastham J, et al. Multifaceted implementation of stroke prevention guidelines in primary care: cluster-randomised evaluation of clinical and cost effectiveness. Qual Saf Health Care. 2007;16:51–59
  46. Schwamm LH, Pancioli A, Acker JE, et al. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association's Task Force on the Development of Stroke Systems. Circulation. 2005;111:1078–1091
  47. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed.. New York: Guilford Press; 2002;
  48. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55:305–312
  49. Prochaska JO, Norcross JC, DiClemente CC. Changing for Good. New York: Avon Books; 1995;

 Statement of author disclosure: Please see the Author Disclosures section at the end of this article.

PII: S0002-9343(09)00138-7

doi:10.1016/j.amjmed.2009.02.004

The American Journal of Medicine
Volume 122, Issue 4, Supplement 2 , Pages S1-S6, April 2009

Article Tools