(Stroke. 1999;30:16-20.)
© 1999 American Heart Association, Inc.
Original Contributions |
Risk Factor Modification in Stroke Prevention
The Experience of a Stroke Clinic
From the Departments of Neurology, Boston University School of Medicine and Boston Veterans Administration Medical Center (L.N.J., V.L.B., N.C.A.) and the School of Public Health (M.R.W.), Boston University, Boston, Mass.
Correspondence to Viken L. Babikian, MD, Department of Neurology, Boston VA Medical Center, 150 S Huntington Ave, Boston, MA 02130.
 |
Abstract |
|---|
 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Background and Purpose—We reviewed Stroke Clinic data to determine the extent of risk factor modification achieved in patients with cerebrovascular disease over 2 years.
Methods—Visits to the Stroke Clinic of a tertiary medical center
from July 1, 1994, through June 30, 1996, were reviewed. Obesity,
smoking, hypertension, hyperlipidemia, hyperglycemia,
and lifestyle changes were noted in patients with 
2 visits (n=61) and
measures (number varied) of these parameters.
Results—Fifty-six patients (92%) had primary care
physicians. In the 49 patients with 2 weight measurements, 33 (67%)
were moderately or severely overweight by weight-height correlation.
Forty-four patients (90%) remained in the same weight category. Of the
60 patients with available blood pressure data, 50 (83%) were
hypertensive. At their last visits, 43 of the 50 (86%) were receiving
medications, and 22 of the 43 treated (51%) were controlled. Serum
glucose remained elevated in 14 of 47 patients (30%) and in 11 of 16
diabetic patients (69%). Thirty-six of 47 patients (55%) had elevated
lipid measurements. None of the 21 smokers quit during the study
period. Few patients modified dietary and exercise practices. Of 61
patients, 29 (48%) sustained vascular events during the study, with 17
of these 29 patients (59%) having strokes or transient
ischemic attacks.
Conclusions—Although most patients were asked to quit smoking, received advice regarding diet and exercise, and were medicated for hypertension, elevated glucose, and cholesterol levels, their risk factor profiles showed little improvement during the 2-year period. More effective methods of controlling stroke risk factors are needed.
Key Words: lifestyle • risk factors • stroke prevention
|
Introduction |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Recent advances in the treatment of acute ischemic stroke offer hope in reducing its devastating effects.1 2 3 4 However, these therapies are limited in availability because of poor public knowledge of or access to them and may help only a small fraction of stroke patients.5 Prevention remains an important approach to substantially reducing the incidence, recurrence, disability, and mortality of stroke. Potent modifiable stroke risk factors have been identified for several years.6 7 8 9 10 11 12 13 Modest weight loss in the obese can bring hypertension and hyperglycemia under much improved control.14 15 Relatively mild reductions in systolic and diastolic blood pressures can significantly reduce stroke risk across all levels of hypertension, whether mild, moderate, or severe.7 Furthermore, there is a growing imperative to control even mildly elevated blood pressure, which has been implicated in a large proportion of strokes.6 16 Smoking cessation also causes the risk of stroke to decrease rapidly, becoming that of a nonsmoker between 2 to 5 years after cessation.9 Aggressive treatment of these factors can therefore help to reduce the risk of stroke and recurrent stroke.
In the Stroke Clinic at a tertiary referral medical center, we reviewed how well the preceding and other stroke risk factors were being modified in patients at high risk for stroke, a large percentage of whom had already had a stroke. We aimed to determine whether there were positive changes in behavior and therapy that might reduce the risk of stroke in these patients.
|
Subjects and Methods |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Eighty-two patients were seen between July 1, 1994, and June 30, 1996, in the weekly Stroke Clinic of the Boston Veterans Administration Medcal Center. With each visit, histories and examinations were performed to determine whether new cerebrovascular events had occurred, and special note was made of the symptoms of peripheral vascular and cardiovascular disease, gastrointestinal bleeding, other hemorrhagic events, and other systemic illnesses or complications of medications. The patients' heights were recorded, and they were questioned regarding smoking, diet, and exercise. Pulse, weight, and blood pressures in both arms were routinely measured. Medications were reviewed, with special attention paid to anticoagulants, antiplatelet agents, or in some instances, study medications. Pertinent laboratory results (for example, the last international normalization ratio performed) were recorded, and answers to questions regarding hemorrhagic complications of hematologically active medications were noted. Glucose and lipid profiles were periodically monitored to further assess cerebrovascular disease risk. Referrals to a nutritionist and the Cholesterol Clinic were made when these parameters were found to be abnormal. When indicated, further imaging studies were obtained. Discharge summaries from recent hospitalizations and imaging studies were obtained for review as needed.
We retrieved data from the clinic charts of these patients in the year
after the study period. Of the 82 patients seen over the 2-year period,
61 had 2 visits. These 61 patients became the focus group of our
analysis (Table 1
). The
basis for enrollment in the Stroke Clinic—sometimes predating the
study period—was noted for each patient.
|
The presence of hypertension was based on blood pressure measurements
and the use of antihypertensive medications during the study period.
Only 1 patient had isolated diastolic blood pressure
elevation with repeated visits, and 1 other patient taking
antihypertensive medications had a single episode of isolated high
diastolic blood pressure. Other patients with
diastolic hypertension also had systolic
hypertension. For the uniformity of comparisons over time, therefore,
we analyzed systolic blood pressures (SBPs) only. SBP
was categorized according to the National Institutes of Health Fifth
Joint National Committee standards.17 We further grouped
the 6 Fifth Joint National Committee SBP categories into 3 categories
designated normal/high-normal SBP, mild/moderate hypertension, and
severe/very severe hypertension (Table 2).
|
The height and weight of patients according to US Department of Agriculture guidelines18 determined obesity. Designations of healthy weight or moderate or severe overweight were made accordingly. Total cholesterol, triglycerides, HDL, LDL, and the total cholesterol/HDL ratio (were determined to be elevated according to parameters described elsewhere.19 20 21 Elevated serum glucose levels were determined on the basis of the normal distribution of glucose levels for the population of that institution; a level >7.6 mmol/L (137 mg/dL) was designated abnormally high.
For purposes of communication, we noted whether each patient had a primary physician. A Stroke Clinic visit note was routinely added to each patient's medical record, and primary care physicians were occasionally contacted directly regarding vascular risk factors or other pertinent medical problems.
We determined whether patients were compliant with behavior and pharmaceutical modification and whether improved lifestyle habits and the use of medications improved stroke risk profiles.
|
Results |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Sixty-one patients were seen
2 times over the course of 24
months for a total of 341 visits. The average number of visits per
patient was 5.6 (range, 2 to 17), and the average time between visits
was 13.1 months (range, 0.5 to 24 months). (The patient with 17 visits
was on a study medication requiring almost monthly follow-up visits.
The patient seen next most frequently, 14 visits, was also in the same
study. Other patients had visits more in keeping with the mean number
of visits [5.6±2.88, mean±SD].) The mean age was 67 years (range,
43 to 84 years), and 59 of the 61 patients were men. Fifty-six patients
(92%) were under the care of a primary physician. Fifty-four (89%)
had sustained a prior stroke or transient ischemic attack (TIA)
(Table 1
).
Blood Pressure Control
Fifty (83%) of 60 patients with available blood pressure data
were known hypertensives (see Subjects and Methods). Forty-five of the
50 (90%) and 43 of the 50 (86%) were receiving antihypertensive
medications at the first and last visits, respectively. The remaining
hypertensive patients were not taking such medications. Of those
treated, 17 of 45 (38%) and 22 of 43 (51%) had controlled blood
pressure at these respective visits.
Regardless of an established diagnosis of hypertension, 35 of 60 (58%)
and 30 of 60 (50%) had elevated blood pressure at the first and last
visits (Table 2).
Weight Control
Thirty-three (67%) of the 49 patients with 2 documented weight
measurements were overweight at both their first and last visits.
Forty-four patients (90%) did not change weight categories during the
study period. With little variation from the first visit, 13 (27%)
were moderately overweight and 20 (41%) were severely overweight at
the last visit. The charts of 20 overweight patients (61%) had written
documentation of advice given to help them improve diet, exercise, and
weight control. Only 1 of these 20 patients lost weight substantially,
improving from severely to moderately overweight. Of the 61 patients in
this study group, 16 (26%) indicated that they had modified at least 1
lifestyle practice in an attempt to achieve weight control during the
2-year period.
Glucose Control
Forty-seven of 61 patients had >1 serum glucose measurement
during the study period. Of these 47 patients, the level was elevated
in 15 (32%) and 14 (30%) at the first and last measurements,
respectively.
Of the 61 patients, 21 (34%) were known diabetics, 17 (76%) of whom
were taking insulin, an oral hypoglycemic agent, or both. Four were not
taking any hypoglycemic agents. The lowest measured serum glucose at
any point in these 21 diabetic patients was >7.6 mmol/L (137
mg/dL) in 9 individuals (43%), and the range of serum glucose levels
was 3.9 to 16.1 mmol/L (70 to 289 mg/dL). Of the 16 diabetics with
2 glucose measurements, 10 (63%) and 11 (69%) had levels >7.6
mmol/L (137 mg/dL) at the first and last visits, respectively (Table 3).
|
Smoking
Various details about smoking were available for 60 of the 61
patients. The majority, 39 of 60 (65%), were nonsmokers. Only 3 of
these 39 nonsmokers (8%) quit smoking during enrollment in the Stroke
Clinic, doing so before the study period, however. Of the 21 current
smokers (35%), 15 (for whom we had pack-year histories) had an average
61.7 pack-year history of smoking. All smokers were advised to
discontinue smoking, and this was documented in writing in the
records of 14 of the 21 (67%). None of the 21 stopped smoking
during the study period.
Cholesterol Control
We obtained 2 cholesterol measurements in 47
patients during the study period. Of the 47, 20 had 2 full lipid
profiles. Table 4 shows that fewer than
half of these patients had target cholesterol levels at
their first and last visits. Of these 47 patients, 36 (77%) met the
criteria for hyperlipidemia. Of these 36 patients, 15
(42%) were treated with lipid-lowering agents at some point in the
study.
|
Of these 15 patients treated with lipid-lowering drugs, 7 (47%) had cholesterol levels >5.2 mmol/L (200 mg/dL), and 6 (40%) had LDL levels >3.4 mmol/L (130 mg/dL) for >50% of the measurements.
Patient Events
In the 24-month follow-up period, 2 patients (3%) had strokes,
and 15 patients (25%) had TIAs. One patient sustained a retinal artery
occlusion. Eight patients (13%) had manifest heart disease that
included ongoing/episodic congestive heart failure, angina,
coronary artery bypass surgery, or development of atrial
fibrillation. There were no documented myocardial infarctions. Of the 3
patients with peripheral vascular disease, 2 had recurrent
claudication, and 1 had a nonhealing foot ulcer.
During the study, 56 of 61 patients (92%) were receiving antiplatelet or anticoagulant medication. Fifteen (25%) were taking warfarin at the beginning of the study, and 12 (20%) were on warfarin at its end. Two patients had gastrointestinal hemorrhages. The first occurred in a patient who was taking warfarin, had an excessively prolonged international normalization ratio while hospitalized for hip surgery, and required a blood transfusion. The second hemorrhage occurred in a patient taking 81 mg/d aspirin. There were also minor hemorrhagic events such as epistaxis in 2 patients and trace genitourinary bleeding in 1 other patient. There were no fatalities in the 61-patient focus group.
|
Discussion |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
During 2 years of follow-up in the Stroke Clinic, the control of hypertension, obesity, diabetes, hypercholesterolemia, and smoking was not notably improved. This was observed even though 43 of 50 patients (86%) with hypertension were on antihypertensive medications, 20 of 33 overweight patients (61%) received documented recommendations regarding healthier diets and exercise, 14 of 21 smokers (67%) had documented advice to stop smoking, 15 of 36 hyperlipidemic patients (42%) were taking cholesterol-lowering agents, and 56 of 61 patients (92%) had a primary care physician with whom the Stroke Clinic was in touch. Furthermore, nondocumented recommendations regarding dietary changes, exercise, and smoking were routinely made to all patients. Despite these efforts to control vascular risk factors and the use of anticoagulant and antiplatelet medications in 90% of patients, 29 (48%) had events attributable to atherosclerotic disease; slightly more than half affected the cerebral circulation. Clearly, this group of patients was not adequately protected from the sequelae of atherosclerotic disease.
It is worth emphasizing that this study is retrospective, focusing on a specific veteran population. Thus, its findings may not apply to the general population.
Of particular disappointment was the schism between the high rate of
antihypertensive therapy and the comparatively low proportion of
individuals with controlled blood pressure, when it is likely that
control of hypertension may have the greatest potential benefit of
reducing stroke.7 This parallels the National Health and
Nutrition Examination Study (NHANES) III observations that of
hypertensive individuals in the United States, 55% are treated and
29% are actually controlled.22 Although our hypertensive
patients were more aggressively treated (86%) and controlled (51%)
than the general population of hypertensives, there remained an
unacceptable gap between medicated and effectively treated patients.
This is of concern when we consider that 58 of 61 patients (95%)
already had manifest cerebrovascular disease (Table 1).
The finding that more than two thirds of the diabetics and about one third of the entire study group had a serum glucose >7.6 mmol/L (137 mg/dL) was indicative of the unsatisfactory control of blood sugar. In the event of an acute stroke, serum glucose >7.8 mmol/L (140 mg/dL) is associated with a greater likelihood of early mortality or recurrence.23 Not only were many of our patients at high risk for stroke, recurrent stroke, and other atherosclerotic disease, they were also more likely by virtue of their diabetes24 to do poorly after having a stroke or recurrence because of the poor control of their diabetes.
Although these patients varied with respect to complexity of their
cerebrovascular disorders, in general, they had medical problems that
were fairly difficult to manage. The detection and diagnosis of new
symptoms and decision-making with respect to safety and efficacy of
therapeutic interventions often dominated much of the 
30-minute
visits. Occasionally, the urgency of specific problems eclipsed these
patients' nonurgent primary and secondary issues. Although it was
routine practice of the Stroke Clinic staff to review and query
patients about stroke risk factors, in a few instances, time did not
permit discussion of preventive measures. In these situations, plans
were made to approach the topic at the next appointment. Primary care
physicians were also relied on to reinforce lifestyle modification
advice and to implement our recommendations to adjust blood pressure
and other medications.
As a courtesy to primary physicians, we rarely prescribed or altered blood pressure, lipid-lowering, or hypoglycemic medications except when it was expedient that we do so. In some settings, however, the neurologist or other specialist may need to do this routinely. This is already widely accepted and expected in cardiology circles. Specialists who treat patients with diseases that are largely preventable should become well versed in the measures and medications required to prevent them and when appropriate should use their expertise judiciously. A Stroke Clinic like ours may be an ideal forum to aggressively treat these vascular risk factors.
Among physicians, there is a wide range of views on what are significant risk factors and how aggressively they should be managed.25 26 Improved educational approaches are needed to integrate the basis for treatment with routine practical interventions to effectively reduce these factors.27 When physicians are given evidence-based hypertension guidelines and later surveyed, they consistently treat hypertension in keeping with those guidelines.28 Still, many objections to more aggressive control of risk factors must be acknowledged and the issues rectified. For example, there is still a demand for more easily tolerated medications that may improve patient compliance and the control of hypertension.29 30
Even if pharmaceutical therapy is optimized to modify risk factors for stroke, the most effective means of reducing stroke risk are those incorporating lifestyle changes. When feasible, this should be the first approach taken with patients. Gorelick31 has discussed "windows of opportunity" for the reduction of stroke risk. In his paradigm, the optimal time to control risk factors is in preadolescence or adolescence when lifelong behaviors are being ingrained. Furthermore, findings from studies of risk factor treatment also suggest that positive or negative patient attitudes and behavior (and perhaps outcome) may cluster.32 33 Habit may be a stronger guarantor of behavior than motivation. Barring established habit, however, strong motivation may be the only entity available to induce positive change. Unfortunately, older patients are often unable to achieve control of risk factors by behavior modification and may require treatment with a strong emphasis on medications.
New strategies for the control of stroke risk factors should be considered. In a telecommunications study in which patients checked in weekly and received feedback on the control of their hypertension, those who were previously nonadherent to treatment registered a mean 6.0 mm Hg decrease, whereas control subjects had a 2.8 mm Hg increase in diastolic blood pressure.34 Physicians and patients need to be amenable to the use of new systems.
In summary, despite distinctly identified vascular risk factors and attempts to achieve their control in our study group, these factors were inadequately modified. A more aggressive dual focus on not only identification but also control of these factors, the introduction of strong incentives to improve both patient and physician behavior, and a team approach, perhaps widening the patient-doctor circle to include nurses, physicians' assistants, and other ancillary staff, may result in more careful and frequent follow-up and definitive control of stroke risk factors.
|
Acknowledgments |
|---|
We wish to thank Dr Carlos S. Kase for his critical review of this manuscript.
Received September 21, 1998; revision received October 13, 1998; accepted October 13, 1998.
|
References |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
1. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–1587.
2.
Stroke Unit Trialists' Collaboration.
Collaborative systematic review of the randomized trials of
organized inpatient (stroke unit) care after stroke. BMJ. 1997;314:1151–1159.
3.
Stroke Unit Trialists' Collaboration. How
do stroke units improve patient outcomes? A collaborative systematic
review of the randomized trials. Stroke. 1997;28:2139–2144.
4. Zivin JA. Neuroprotective therapies in stroke. Drugs. 1997;54(suppl 3):S83–S88.
5. Broderick JP. Logistics in acute stroke management. Drugs. 1997;54(suppl 3):S109–S116.
6. Collins R, Peto R, MacMahon S, Hebert P, Fiebach NH, Eberlein KA, Godwin J, Qizibash N., Taylor JO, Hennekens CH. Blood pressure, stroke, and coronary heart disease, 2: short-term reductions in blood pressure: overview of randomized drug trials in their epidemiological context. Lancet. 1990;335:827–838.[Medline] [Order article via Infotrieve]
7. MacMahon S. Blood pressure and the prevention of stroke. J Hypertens Suppl. 1996;14:S39–S46.[Medline] [Order article via Infotrieve]
8.
Wolf PA, Abbot RD, Kannel WB. Atrial fibrillation as
an independent risk factor for stroke: the Framingham study.
Stroke. 1991;22:983–988.
9.
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.
10. Iso H, Jacobs DR Jr, Wentworth D, Newton JD, Cohen JD. Serum cholesterol levels and six-year mortality from stroke in 350,977 men screened for the Multiple Risk Factor Intervention Trial. N Engl J Med. 1989;320:904–910.[Abstract]
11.
Hachinski V, Graffagnino C, Beaudry M, Bernier G, Buck
C, Donner A, Spence JD, Doig G, Wolfe BMJ. Lipids and stroke: a paradox
resolved. Arch Neurol. 1996;53:303–308.
12. Gorelick PB, Schneck M, Berglund LF, Feinberg W, Goldstone J. Status of lipids as a risk factor for stroke. Neuroepidemiology. 1997;16:107–115.[Medline] [Order article via Infotrieve]
13. Burchfiel CM, Curb JD, Rodriguez BL, Abbott RD, Chiu D, Yano K. Glucose intolerance and 22-year stroke incidence: the Honolulu Heart Program. Stroke. 1994;25:951–957.[Abstract]
14. Jones DW. Body weight and blood pressure: effects of weight reduction on hypertension. Am J Hypertens. 1996;9:S50–S54.
15. Su HY, Sheu WH, Chin HM, Jeng CY, Chen YD, Reaven GM. Effect of weight loss on blood pressure and insulin resistance in normotensive and hypertensive obese individuals. Am J Hypertens. 1995;8:1067–1071.[Medline] [Order article via Infotrieve]
16. Joseph L, Kase C, Beiser A, Wolf PA. Mild blood pressure elevation and stroke: the Framingham study. Stroke. 1998;28:277. Abstract.
17.
JNC V. The fifth report of the Joint National Committee
on Detection, Evaluation, and Treatment of High Blood Pressure.
Arch Intern Med. 1993;153:154–183.
18. US Department of Agriculture and US Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans. 4th ed. Washington, DC: US Government Printing Office; 1995. Home and Garden Bulletin 232.
19.
Expert Panel. Report of the National
Cholesterol Education Program Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in
Adults. Arch Intern Med. 1988;148:36–69.
20.
Adult Treatment Panel II. Summary of the
Second Report of the National Cholesterol Education Program
(NCEP) Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults. JAMA. 1993;269:3015–3023.
21. Hunninghake DB. Diagnosis and treatment of lipid disorders. Med Clin North Am. 1984;78:247–257.
22.
Burt VL, Cutler JA, Higgins M, Horan MJ, Labarthe
D, Whelton P, Brown C, Roccella EJ. Trends in the prevalence,
awareness, treatment and control of hypertension in the adult US
population: data from the health examination surveys, 1960 to 1991.
Hypertension. 1995;26:60–69.
23.
Sacco RL, Shi T, Zamanillo MC. Predictors of mortality
and recurrence after hospitalized cerebral infarction in an
urban community: the Northern Manhattan Stroke Study.
Neurology. 1994;44:626–634.
24.
Hier DB, Foulkes MA, Swiontoniowski M, Sacco RL,
Gorelick PB, Mohr JP, Price TR, Wolf PA. Stroke recurrence
within two years after ischemic infarction. Stroke. 1991;22:155–161.
25. Steptoe A, Wardle J. What the experts think: a European survey of expert opinion about the influence of lifestyle on health. Eur J Epidemiol. 1994;10:195–203.[Medline] [Order article via Infotrieve]
26. Fahey T, Silagy C. General practitioners' knowledge of and attitudes to the management of hypertension in elderly patients. Br J Gen Pract. 1994;44:446–449.[Medline] [Order article via Infotrieve]
27. Elford RW, Jennett P, Bell N, Szafran O, Meadows L. Putting prevention into practice. Health Rep. 1994;6:142–153.[Medline] [Order article via Infotrieve]
28. McAlister FA, Laupacis A, Teo KK, Hamilton PG, Montague TJ. A survey of clinician attitudes and management practices in hypertension. J Hum Hypertens. 1997;11:413–419.[Medline] [Order article via Infotrieve]
29. Ford GA, Asghar MN. Management of hypertension in the elderly: attitudes of general practitioners and hospital physicians. Br J Clin Pharmacol. 1995;39:465–469.[Medline] [Order article via Infotrieve]
30. Lip GY, Beevers DG. Doctors, nurses, pharmacists and patients: the Rational Evaluation and Choice in Hypertension (REACH) survey of hypertension care delivery. Blood Press Suppl. 1997;1:S6–S10.
31. Gorelick PB. Stroke prevention: windows of opportunity and failed expectations? A discussion of modifiable cardiovascular risk factors and a prevention proposal. Neuroepidemiology. 1997;16:163–173.[Medline] [Order article via Infotrieve]
32. Coronary Drug Project Research Group. Influence of adherence to treatment and response of cholesterol on mortality in the coronary drug project. N Engl J Med. 1980;303:1038–1041.[Abstract]
33. Thornton A, Lee P, Fry J. Differences between smokers, ex-smokers, passive smokers and non-smokers. J Clin Epidemiol. 1994;47:1143–1162.[Medline] [Order article via Infotrieve]
34. Friedman RH, Kazis LE, Jette A, Smith MB, Stollerman J, Torgerson J, Carey K. A telecommunications system for monitoring and counseling patients with hypertension: impact on medication adherence and blood pressure control. Am J Hypertens. 1996;9:285–292.[Medline] [Order article via Infotrieve]
This article has been cited by other articles:
 |
|
 |
|
  J Joubert, C Reid, D Barton, T Cumming, A McLean, L Joubert, J Barlow, D Ames, and S Davis Integrated care improves risk-factor modification after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model J. Neurol. Neurosurg. Psychiatry, March 1, 2009; 80(3): 279 - 284. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Chaturvedi, J. Zivin, A. Breazna, P. Amarenco, A. Callahan, L. B. Goldstein, M. Hennerici, H. Sillesen, A. Rudolph, M. A. Welch, et al. Effect of atorvastatin in elderly patients with a recent stroke or transient ischemic attack Neurology, February 24, 2009; 72(8): 688 - 694. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. A. McManus, A. Craig, C. McAlpine, P. Langhorne, and G. Ellis Does behaviour modification affect post-stroke risk factor control? Three-year follow-up of a randomized controlled trial Clinical Rehabilitation, February 1, 2009; 23(2): 99 - 105. [Abstract] [PDF]
|
|
|
|
 |
|
 E. Touze, J. Coste, M. Voicu, J. Kansao, R. Masmoudi, B. Doumenc, P. Durieux, and J.-L. Mas Importance of In-Hospital Initiation of Therapies and Therapeutic Inertia in Secondary Stroke Prevention: IMplementation of Prevention After a Cerebrovascular evenT (IMPACT) Study Stroke, June 1, 2008; 39(6): 1834 - 1843. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Chaturvedi Should Stroke Be Considered Both a Brain Attack and a Heart Attack? Stroke, June 1, 2007; 38(6): 1713 - 1714. [Full Text] [PDF]
|
|
|
|
|
|
D. A. Levine, C. I. Kiefe, G. Howard, V. J. Howard, O. D. Williams, and J. J. Allison Reduced Medication Access: A Marker for Vulnerability in US Stroke Survivors Stroke, May 1, 2007; 38(5): 1557 - 1564. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. M. Cheng, S. M. Asch, R. H. Brook, S. D. Vassar, E. L. Jacob, M. L. Lee, D. S. Chang, R. L. Sacco, A.-F. Hsiao, and B. G. Vickrey Suboptimal Control of Atherosclerotic Disease Risk Factors After Cardiac and Cerebrovascular Procedures Stroke, March 1, 2007; 38(3): 929 - 934. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Touze, J.-L. Mas, J. Rother, S. Goto, A. T. Hirsch, Y. Ikeda, C.-S. Liau, E. M. Ohman, A. J. Richard, P. W. F. Wilson, et al. Impact of Carotid Endarterectomy on Medical Secondary Prevention After a Stroke or a Transient Ischemic Attack: Results from the Reduction of Atherothrombosis for Continued Health (REACH) Registry Stroke, December 1, 2006; 37(12): 2880 - 2885. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. L. Paul and A. G. Thrift Control of Hypertension 5 Years After Stroke in the North East Melbourne Stroke Incidence Study Hypertension, August 1, 2006; 48(2): 260 - 265. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Ovbiagele, J. L. Saver, H. Bang, L. E. Chambless, A. Nassief, J. Minuk, J. F. Toole, J. R. Crouse, and for the VISP Study Investigators Statin treatment and adherence to national cholesterol guidelines after ischemic stroke Neurology, April 25, 2006; 66(8): 1164 - 1170. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. D. Flemming and R. D. Brown Jr Secondary Prevention Strategies in Ischemic Stroke: Identification and Optimal Management of Modifiable Risk Factors Mayo Clin. Proc., October 1, 2004; 79(10): 1330 - 1340. [Abstract] [PDF]
|
|
|
|
|
|
N. F. Gordon, M. Gulanick, F. Costa, G. Fletcher, B. A. Franklin, E. J. Roth, and T. Shephard Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council Stroke, May 1, 2004; 35(5): 1230 - 1240. [Full Text] [PDF]
|
|
|
|
 |
|
 N. F. Gordon, M. Gulanick, F. Costa, G. Fletcher, B. A. Franklin, E. J. Roth, and T. Shephard Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council Circulation, April 27, 2004; 109(16): 2031 - 2041. [Full Text] [PDF]
|
|
|
|
|
|
S. Volpato, C. Maraldi, A. Ble, M. Ranzini, A. Rita Atti, L. J. Dominguez, M. Barbagallo, R. Fellin, and G. Zuliani Prescription of Antithrombotic Therapy in Older Patients Hospitalized for Transient Ischemic Attack and Ischemic Stroke: The GIFA Study Stroke, April 1, 2004; 35(4): 913 - 917. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. D. DeLemos, R. P. Atkinson, S. L. Croopnick, D. A. Wentworth, and P. T. Akins How Effective Are "Community" Stroke Screening Programs at Improving Stroke Knowledge and Prevention Practices?: Results of a 3-Month Follow-Up Study Stroke, December 1, 2003; 34 (12): e247 - e249. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P.M. Rothwell, S.C. Howard, and J.D. Spence Relationship Between Blood Pressure and Stroke Risk in Patients With Symptomatic Carotid Occlusive Disease Stroke, November 1, 2003; 34(11): 2583 - 2590. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Ruland, R. Raman, S. Chaturvedi, S. Leurgans, and P. B. Gorelick Awareness, treatment, and control of vascular risk factors in African Americans with stroke Neurology, January 14, 2003; 60(1): 64 - 68. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. T Hirsch and A. M Gotto Jr Undertreatment of dyslipidemia in peripheral arterial disease and other high-risk populations: an opportunity for cardiovascular disease reduction Vascular Medicine, November 1, 2002; 7(4): 323 - 331. [Abstract] [PDF]
|
|
|
|
|
|
S. Bak, S. H. Sindrup, T. Alslev, O. Kristensen, K. Christensen, and D. Gaist Cessation of Smoking After First-Ever Stroke: A Follow-Up Study Stroke, September 1, 2002; 33(9): 2263 - 2269. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. S. Mouradian, S. R. Majumdar, A. Senthilselvan, K. Khan, and A. Shuaib How Well Are Hypertension, Hyperlipidemia, Diabetes, and Smoking Managed After a Stroke or Transient Ischemic Attack? Stroke, June 1, 2002; 33(6): 1656 - 1659. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. J. Greenlund, W. H. Giles, N. L. Keenan, J. B. Croft, G. A. Mensah, and S. L. Huston Physician Advice, Patient Actions, and Health-Related Quality of Life in Secondary Prevention of Stroke Through Diet and Exercise * The Physician's Role in Helping Patients to Increase Physical Activity and Improve Eating Habits Stroke, February 1, 2002; 33(2): 565 - 571. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Fieschi and A. Falcou Keynote address Neurology, September 1, 2001; 57(90002): S82 - 86. [Abstract] [Full Text]
|
|
|
|
|
|
T. Sappok, A. Faulstich, E. Stuckert, H. Kruck, P. Marx, and H.-C. Koennecke Compliance With Secondary Prevention of Ischemic Stroke: A Prospective Evaluation Stroke, August 1, 2001; 32(8): 1884 - 1889. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. G. Holloway, C. Benesch, and S. R. Rush Stroke prevention: Narrowing the evidence-practice gap Neurology, May 23, 2000; 54(10): 1899 - 1906. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. N. Kernan, C. M. Viscoli, L. M. Brass, R. W. Makuch, P. M. Sarrel, and R. I. Horwitz Blood Pressure Exceeding National Guidelines Among Women After Stroke Stroke, February 1, 2000; 31(2): 415 - 419. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. W. Albers, R. G. Hart, H. L. Lutsep, D. W. Newell, and R. L. Sacco Supplement to the Guidelines for the Management of Transient Ischemic Attacks : A Statement From the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association Stroke, November 1, 1999; 30(11): 2502 - 2511. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||