Guidelines for the preventive treatment of ischaemic stroke and TIA (I). Update on risk factors and life style

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Actuación sobre los factores de riesgo y estilo de vida" ] ] "textoCompleto" => "In Spain, cerebrovascular diseases are the leading cause of death in women, the third most frequent in men,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> and the most common cause of disability. The measures we describe here are designed to prevent both first-ever ischaemic strokes (IS) and future episodes in patients who have already suffered a stroke. We will also list measures intended to reduce overall vascular risk in these patients<a class="elsevierStyleCrossRef" href="#bib0010">2</a>; given the length of this chapter, we decided to publish it in 2 parts. Firstly, we will review the risk factors for IS and any modifications to those factors which may be appropriate. Secondly, we will specify different preventive treatments according to the stroke subtype. Recommendations for each section are shown in tables for better readability. Levels of evidence and recommendation grades are based on the classification system proposed by the Centre for Evidence Based Medicine at the University of Oxford<a class="elsevierStyleCrossRef" href="#bib0015">3</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Following current criteria, we included transient ischaemic attack (TIA) in the definition of IS, which also improves readability. Therefore, all recommendations included in these clinical practice guidelines are directed at preventing focal cerebral ischaemia in general, without distinguishing between cerebral infarction and TIA.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Action on risk factors (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>)Antihypertensive drugs and blood pressureEpidemiological studies and clinical trials have illustrated the relationship between blood pressure and stroke.<a class="elsevierStyleCrossRefs" href="#bib0020">4–8</a> Lifestyle changes (decreasing tobacco and alcohol consumption, losing weight, engaging in moderate physical activity, decreasing salt consumption, and increasing fruit and vegetable intake) are useful for reducing blood pressure levels.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> It has been shown that reduction in risk of stroke is proportional to a patient's decrease in blood pressure.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> Studies of different antihypertensive drugs present similar results with regard to reduction in vascular episodes. The most recent Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure indicates which levels of blood pressure are considered high and which treatments are the most appropriate in each situation.<a class="elsevierStyleCrossRef" href="#bib0035">7</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Studies of different antihypertensive agents used in secondary IS prevention have yielded inconsistent results.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> Beta blockers have not been shown to deliver significant benefits.<a class="elsevierStyleCrossRefs" href="#bib0065">13–15</a> Results from diuretics have been contradictory<a class="elsevierStyleCrossRef" href="#bib0080">16</a>; a single study of indapamide at 2.5mg/day pointed to a positive effect.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Using ACE inhibitors, such as ramipril at 10mg/day<a class="elsevierStyleCrossRef" href="#bib0090">18</a> or combination therapy with perindopril (4mg/day) and indapamide (2.5mg/day), decreases the risk of stroke recurrence, even in patients without a history of HBP.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Regarding results from ARBs, trials have shown that eprosartan performed better than nitrendipine<a class="elsevierStyleCrossRef" href="#bib0100">20</a>; telmisartan performed no better than a placebo<a class="elsevierStyleCrossRef" href="#bib0105">21</a> and similarly to ramipril<a class="elsevierStyleCrossRef" href="#bib0110">22</a>; and combination therapy with telmisartan and ramipril was associated with a higher frequency of side effects and no significant benefits.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Major vascular events decreased by an additional 15% with intensive antihypertensive treatments, regardless of the drug employed.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Some studies show differing levels of IS risk reduction for different classes of antihypertensive drugs. This could be due to the fact that some antihypertensive drugs, such as ACE inhibitors or ARBs, may have an added pleiotropic effect as well as an antihypertensive effect.<a class="elsevierStyleCrossRefs" href="#bib0060">12,24,25</a>Diabetes mellitusPatients with DM are more susceptible to developing arteriosclerosis and display a higher prevalence of HBP, obesity, and dyslipidaemia. The risk entailed by DM is considered equal to that entailed by coronary disease, which is why secondary prevention measures must be applied in these cases.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> The risk of IS is 2 to 6 times higher in diabetic patients,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> and 9.1% of recurrences are directly attributable to DM.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> Adjusting glycaemic control and normalising HbA1c are more effective for reducing the complications of microangiopathy, whereas the approach to stroke prevention should be more global and include strict blood pressure control<a class="elsevierStyleCrossRef" href="#bib0145">29</a> and administration of statins.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Results from studies of close glycaemic control are controversial, with the ACCORD study<a class="elsevierStyleCrossRef" href="#bib0155">31</a> showing a possible negative effect on mortality rates. The ADVANCE study<a class="elsevierStyleCrossRef" href="#bib0160">32</a> and Veterans Affairs Diabetes Trial<a class="elsevierStyleCrossRef" href="#bib0165">33</a> showed that glycaemic control did not reduce risk of IS.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Long-term follow-up in the DCCT and UKPDS trials suggests that maintaining HbA1c levels under or near 7% at the onset of DM is associated with a long-term reduction in macrovascular disease.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> In a subanalysis of the PROactive study,<a class="elsevierStyleCrossRef" href="#bib0175">35</a> treatment with pioglitazone in patients with prior stroke was associated with a 47% decrease in risk of recurrence.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> Based on these results, it has been recommended for preventing secondary stroke in patients with DM.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> Nevertheless, the safety of glitazone treatment has recently been called into question.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> It is therefore advisable to wait for the results of the Insulin Resistance Intervention after Stroke (IRIS) study.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>Plasma lipids and lipid-lowering drugsHigh levels of cholesterol increase risk of IS. The Asia-Pacific Cohort Studies Collaboration found a 25% higher risk of IS for each mmol/L (38.7mg/dL) increase in total cholesterol levels.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> The US Women's Pooling Project detected a similar risk increase in women aged 30 to 54.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> Several primary prevention studies have shown that statins are effective for reducing cholesterol levels and risk of stroke (by 27%–32%).<a class="elsevierStyleCrossRefs" href="#bib0210">42,43</a> Treatment with rosuvastatin decreases the risk of IS,<a class="elsevierStyleCrossRef" href="#bib0220">44</a> even in patients with high levels of high-sensitivity C-reactive protein and no hyperlipidaemia. Earlier guidelines already recommended statin use for secondary prevention of stroke or TIA in most patients based on NCEP-ATP III criteria.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> According to the SPARCL study, 80mg/day of atorvastatin significantly decreases the risk of recurrence in patients with non-cardioembolic stroke or TIA, and those with other vascular complications such as ischaemic heart disease or revascularisation procedures.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> We detected an increase in haemorrhagic stroke frequency in the atorvastatin group, especially in cases with a history of haemorrhagic stroke at time of inclusion, men, elderly subjects, and patients with stage 2 HBP, without significant interactions in baseline and recent LDL cholesterol levels.<a class="elsevierStyleCrossRef" href="#bib0235">47</a> Another exploratory study showed that decreases ≥50% with respect to baseline figures achieve the greatest reductions in risk of stroke and major coronary episodes without risk of cerebral haemorrhage.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> A meta-analysis of randomised clinical trials suggested that fibrates may play a role in patients with DM.<a class="elsevierStyleCrossRef" href="#bib0245">49</a>TobaccoTobacco consumption is associated with increased risk of all stroke subtypes, especially atherothrombotic stroke<a class="elsevierStyleCrossRefs" href="#bib0250">50–55</a> and in young patients.<a class="elsevierStyleCrossRef" href="#bib0280">56</a> Additionally, it has a synergistic effect through its link to other vascular risk factors, such as HBP, DM, use of oral contraceptives, or physical inactivity. Smoking cessation reduces the risk of stroke, coronary disease, peripheral vascular disease and death from vascular causes proportionally to the length of the period during which the subject stopped using tobacco.<a class="elsevierStyleCrossRefs" href="#bib0285">57–60</a> Passive smoking also entails a risk of cerebrovascular disease.<a class="elsevierStyleCrossRefs" href="#bib0305">61–63</a> Smokeless tobacco products are associated with increased risk of fatal stroke as well.<a class="elsevierStyleCrossRef" href="#bib0320">64</a>AlcoholRobust evidence shows that excessive consumption of alcohol is a risk factor for all types of stroke.<a class="elsevierStyleCrossRefs" href="#bib0325">65–70</a> However, whether or not light-to-moderate alcohol consumption is related to ischaemic or haemorrhagic stroke is a matter of debate.<a class="elsevierStyleCrossRefs" href="#bib0355">71,72</a> Risk of stroke with light (<12g/day) or moderate (between 12 and 24g/day) alcohol consumption is less than risk of stroke with total abstinence from alcohol. High levels of alcohol consumption (>60g/day) increases total risk of stroke and risk of both ischaemic and haemorrhagic stroke.<a class="elsevierStyleCrossRef" href="#bib0345">69</a> We found a J-shaped relationship between the risk of coronary morbidity and mortality<a class="elsevierStyleCrossRef" href="#bib0365">73</a> and IS,<a class="elsevierStyleCrossRefs" href="#bib0340">68–70</a> as well as a linear association for the risk of haemorrhagic stroke.<a class="elsevierStyleCrossRefs" href="#bib0325">65–67</a> Moderate red wine consumption is associated with lower vascular risk.<a class="elsevierStyleCrossRef" href="#bib0365">73</a> There are not enough studies to establish a relationship between alcohol consumption and recurrent stroke.Diet and physical activityIt has been shown that dietary habits are related to cerebrovascular risk.<a class="elsevierStyleCrossRefs" href="#bib0370">74–76</a> Low intakes of salt<a class="elsevierStyleCrossRef" href="#bib0385">77</a> and fat<a class="elsevierStyleCrossRef" href="#bib0390">78</a> along with regular consumption of fish,<a class="elsevierStyleCrossRef" href="#bib0395">79</a> pulses, fibre, fruits, and vegetables<a class="elsevierStyleCrossRefs" href="#bib0400">80–82</a> are associated with lower vascular mortality rates and a significant decrease in risk of cerebrovascular diseases. Sedentary lifestyle is very prevalent in the general population.<a class="elsevierStyleCrossRef" href="#bib0415">83</a> It is associated with cerebrovascular diseases<a class="elsevierStyleCrossRef" href="#bib0420">84</a> and related to other factors such as HBP, hypercholesterolaemia, obesity, and DM.<a class="elsevierStyleCrossRefs" href="#bib0425">85,86</a> Physical activity increases HDL cholesterol, reduces LDL cholesterol and triglycerides, decreases blood pressure, fosters insulin homeostasis, helps in losing and maintaining weight, promotes good mental health, and is helpful in quitting smoking.<a class="elsevierStyleCrossRefs" href="#bib0430">86–90</a> Individuals who are physically active have a lower risk of ischaemic heart disease and stroke.<a class="elsevierStyleCrossRefs" href="#bib0420">84,87,91</a> This relationship is independent of age and sex, but it should be noted that data from patients older than 80 are limited.<a class="elsevierStyleCrossRef" href="#bib0460">92</a> The benefits of exercise can be observed whether the activity is undertaken during work or leisure time.<a class="elsevierStyleCrossRef" href="#bib0420">84</a> The general recommendation is at least 30minutes of moderate-intensity exercise, most days of the week.<a class="elsevierStyleCrossRef" href="#bib0465">93</a>Asymptomatic carotid stenosisPrevalence of asymptomatic carotid artery stenosis (≥50%) increases with age. The prevalence is 0.5% in individuals younger than 50 years and higher than 10% in men older than 80 years.<a class="elsevierStyleCrossRef" href="#bib0470">94</a> After a 15-year follow-up period, 16.6% of patients may suffer an episode of stroke.<a class="elsevierStyleCrossRef" href="#bib0475">95</a> There are 2 alternative strategies: medical treatment or revascularisation using an endarterectomy or endovascular treatment with angioplasty and stenting. Initial studies of endarterectomy<a class="elsevierStyleCrossRefs" href="#bib0480">96,97</a> indicated that this treatment was beneficial, since it reduced risk of stroke after 5 years of follow-up. Nevertheless, new developments in medical treatment have raised questions about the benefit of surgical techniques, which deliver a decrease in absolute risk of stroke of only 1% per year, according to several meta-analyses.<a class="elsevierStyleCrossRefs" href="#bib0490">98–100</a> According to the CREST study,<a class="elsevierStyleCrossRef" href="#bib0505">101</a> there is a 2.5% risk of suffering periprocedural stroke during an angioplasty and a 1.4% risk during endarterectomy. Therefore, indiscriminate use of revascularisation treatment in asymptomatic patients does not seem justified provided that they receive appropriate medical treatment. Revascularisation is only recommended in selected cases according to factors such as age, comorbidity, life expectancy, and perioperative risk.<a class="elsevierStyleCrossRef" href="#bib0510">102</a> Based on the above, revascularisation can be considered for 70% to 99% carotid stenosis in men younger than 75, provided that perioperative risk is <3% and expected post-operative survival is at least 5 years.<a class="elsevierStyleCrossRefs" href="#bib0185">37,103</a> Of all patients with asymptomatic carotid stenosis, those with the highest level of risk have a history of contralateral TIAs,<a class="elsevierStyleCrossRef" href="#bib0520">104</a> silent cerebral infarcts ipsilateral to stenosis,<a class="elsevierStyleCrossRef" href="#bib0525">105</a> stenosis progression,<a class="elsevierStyleCrossRef" href="#bib0530">106</a> or microemboli detected using transcranial Doppler.<a class="elsevierStyleCrossRef" href="#bib0535">107</a> The SPACE 2 trial will compare results from current medical treatment with anti-platelet and antihypertensive drugs and statins with results from endovascular therapy or open surgical revascularisation.Heart diseaseHeart disease is the second leading cause of IS. In addition, patients with cardioembolic stroke present a higher risk of death and of new vascular events over the long term than patients with IS of arterial origin (non-cardioembolic).<a class="elsevierStyleCrossRef" href="#bib0540">108</a> Findings regarding risk of IS for different types of emboligenic heart disease are listed below. The second part of this guide will list specific recommendations for preventing IS.Atrial fibrillationAtrial fibrillation (AF) is the most frequent type of arrhythmia<a class="elsevierStyleCrossRef" href="#bib0545">109</a> with a prevalence of 6% in patients older than 65. In patients older than 85, prevalence rises to 12%.<a class="elsevierStyleCrossRef" href="#bib0550">110</a> AF is one of the main risk factors for stroke. It is estimated that 1 out of 6 strokes occur in patients with AF,<a class="elsevierStyleCrossRef" href="#bib0555">111</a> which is the cause of nearly half of all cardioembolic ISs.<a class="elsevierStyleCrossRef" href="#bib0560">112</a> AF is associated with an increase in IS risk by a factor of 3 to 4 after adjusting for other risk factors.<a class="elsevierStyleCrossRef" href="#bib0565">113</a> In cases with associated rheumatic heart disease, risk of stroke is 17 times higher than in healthy controls.<a class="elsevierStyleCrossRef" href="#bib0570">114</a> Several factors significantly increase risk of embolism: age >75 years, congestive heart failure (CHF), HBP, DM, history of thromboembolism, left ventricular dysfunction with left ventricular ejection fraction (LVEF) <35%, atrial size, presence of mitral annular calcification (MAC), presence of spontaneous echo contrast, and detection of a left atrial thrombus.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> Based on the above, researchers have designed IS risk stratification systems for patients with AF.<a class="elsevierStyleCrossRef" href="#bib0575">115</a> The CHADS2 score<a class="elsevierStyleCrossRefs" href="#bib0580">116,117</a> is the most well-known and validated risk classification method. It factors in CHF (1 point), HBP (1 point), DM (1 point), age >75 years (1 point), and history of cardiovascular disease or systemic embolism (2 points). The recently validated CHA2-DS2-VASc score<a class="elsevierStyleCrossRef" href="#bib0590">118</a> divides the study population into 2 age groups: 65–74 (1 point) and >75 (2 points). It also accounts for the following factors: vascular disease (prior AMI, peripheral artery disease, and complex aortic plaque) (1 point); and female sex (1 point). All other scores were the same as for CHADS2.Mitral stenosisBetween 10% and 20% of patients with mitral stenosis present systemic embolism. In cases of rheumatic stenosis (the most frequent cause) and a history of prior embolism, the level of risk reaches 30% to 65%. Moreover, up to 40% of patients with mitral stenosis develop AF.<a class="elsevierStyleCrossRef" href="#bib0595">119</a> They therefore have a higher risk of stroke and a poorer prognosis than those who maintain sinus rhythm.<a class="elsevierStyleCrossRef" href="#bib0600">120</a> Regarding patients with mitral stenosis and no AF or prior embolism, treatment is controversial since there are no data supporting the prescription of oral anticoagulant therapy. It is true that these patients may experience episodes of paroxysmal AF which are difficult to detect. At present, experts agree that oral anticoagulant drugs should be prescribed for patients with severe mitral stenosis and dilation of the left atrium ≥55mm or spontaneous contrast in the echocardiographic study.<a class="elsevierStyleCrossRef" href="#bib0595">119</a> One observational study comparing medical treatment, percutaneous balloon valvuloplasty, and valve replacement suggests that balloon commissurotomy is the most effective method for reducing the incidence of IS.<a class="elsevierStyleCrossRef" href="#bib0605">121</a> MAC is an infrequent non-rheumatic cause of mitral stenosis, and it is associated with distal complex aortic atheroma.<a class="elsevierStyleCrossRefs" href="#bib0610">122,123</a> The relationship between MAC and the risk of stroke is unclear; some cohort studies observe an increased risk of ischaemic heart disease and vascular death but no increase in IS,<a class="elsevierStyleCrossRef" href="#bib0620">124</a> while other studies do observe a significant increase of IS risk after adjusting for other risk factors.<a class="elsevierStyleCrossRef" href="#bib0625">125</a>Mitral valve prolapseMitral valve prolapse (MVP), the most frequent valve anomaly in adults, is present in 2.5% of population. It is particularly prevalent in individuals with connective tissue diseases. It is considered innocuous since different population-based observational studies have not detected a higher risk of stroke in subjects with MVP.<a class="elsevierStyleCrossRef" href="#bib0630">126</a>Ischaemic heart diseaseAMI is associated with a 2% absolute risk of stroke during the first 30 days after the infarct. This is due to the presence of mural thrombi in the left ventricle (LV), most of which occur during the first 2 weeks following the previous AMI (12% incidence). The majority of these cases are characterised by extensive infarcts that reduce left ventricular function or provoke dyskinesia/apical akinesia, although AMIs at any location may cause thrombi to form. The incidence of early embolism is >22%, especially in cases of moving or protruding thrombi in the LV. It is estimated that 10% of these patients will suffer from IS if they are not treated. Risk increases in cases of left ventricular dilation, ventricular dyskinesia, ejection fraction <30%, or CHF.<a class="elsevierStyleCrossRefs" href="#bib0635">127–129</a>CardiomyopathyIn dilated cardiomyopathy and other conditions with decreased LVEF, such as CHF, there is an increased risk of emboli due to stasis of blood in the LV. This risk is relatively low (1%–3% yearly) in cases of depressed LVEF and echocardiographic signs of intramural thrombi.<a class="elsevierStyleCrossRef" href="#bib0640">128</a> Stable CHF (NYHA Class II and Class III) is associated with an absolute risk of stroke of 1% per year. The relative risk increases by 18% when there is a 5% decrease in the LVEF. With more severe conditions (NYHA Class IV), risk of stroke is 4% per year.<a class="elsevierStyleCrossRef" href="#bib0640">128</a> Approximately 10% of patients with IS have a LVEF of ≤30%.<a class="elsevierStyleCrossRef" href="#bib0650">130</a>Anomalies of the interatrial septumPatent foramen ovale (PFO) is very prevalent in the general population (15%–25%), while atrial septal aneurysm (ASA) is less frequent (2.3%). The risk of stroke in patients with PFO is similar to that in the general population,<a class="elsevierStyleCrossRefs" href="#bib0655">131,132</a> but there seems to be a well-documented correlation between persistent PFO and cryptogenic stroke, especially in the younger population. This anomaly was detected in 35% to 50% of patients with cryptogenic IS vs only 4% to 10% of control subjects.<a class="elsevierStyleCrossRef" href="#bib0665">133</a> According to the PFO-ASA study, risk of stroke recurrence in PFO patients treated with acetylsalicylic acid is low after 4 years of follow-up (2.3% vs 4.2% in patients without PFO), with a higher risk when PFO is associated with ASA.<a class="elsevierStyleCrossRef" href="#bib0670">134</a> Subsequent studies did not detect any differences in risk of recurrence in patients with massive right-to-left shunt compared to patients without this anomaly.<a class="elsevierStyleCrossRef" href="#bib0675">135</a> According to a recent meta-analysis, the risk of stroke recurrence in patients with PFO does not differ from that in patients with cryptogenic stroke and no PFO.<a class="elsevierStyleCrossRef" href="#bib0680">136</a>Other risk factors for strokeHormone replacement therapy (HRT) and oral contraceptivesInitial observational studies with hormone replacement therapy<a class="elsevierStyleCrossRef" href="#bib0685">137</a> along with subsequent published articles related to the Women's Health Initiative (WHI) showed that use of HRT favoured the onset of vascular episodes.<a class="elsevierStyleCrossRefs" href="#bib0690">138,139</a> Several meta-analyses have confirmed that HRT is associated with a 30% increase in risk of stroke.<a class="elsevierStyleCrossRefs" href="#bib0700">140,141</a> This risk is not age-related, and progesterone replacement in addition to oestrogen doubles the risk of venous thromboembolism.<a class="elsevierStyleCrossRef" href="#bib0710">142</a> However, a systematic review showed that risk of stroke from use of low doses of oestrogens administered transdermally may be no higher than that associated with the oral route of administration. The review was unable to present any conclusions due to the presence of confounding factors.<a class="elsevierStyleCrossRef" href="#bib0715">143</a> Other alternative therapies also entail cerebrovascular risks. For example, tibolone is associated with risk of stroke in postmenopausal women<a class="elsevierStyleCrossRefs" href="#bib0720">144,145</a> and raloxifene may increase risk of fatal stroke in at-risk women.<a class="elsevierStyleCrossRef" href="#bib0730">146</a> HRT in postmenopausal women with prior stroke does not seem to present benefits and the treatment is associated with increased risk of stroke and stroke-related death.<a class="elsevierStyleCrossRefs" href="#bib0705">141,147–149</a>The relationship between oral contraceptives and risk of stroke is still a matter of debate. Recommendations are based on observational studies, since no randomised trials are available. Another systematic review found no association between oral contraceptives and stroke in cohort studies, while it did detect a significant increase in risk in case–control studies. This increase in risk was more evident for IS than for haemorrhagic stroke. Higher risk levels were observed in hospital-based populations than in community-based populations.<a class="elsevierStyleCrossRef" href="#bib0750">150</a> A different systematic review showed increased risk of AMI or stroke associated with the use of first and second-generation oral contraceptives. The increase in risk was more evident for stroke.<a class="elsevierStyleCrossRef" href="#bib0755">151</a> A systematic review showed that progesterone-only contraceptive use is not associated with an increased risk of stroke.<a class="elsevierStyleCrossRef" href="#bib0760">152</a> Women older than 35 years who smoke and have HBP, DM, history of migraine, or history of thrombotic complications may be at increased risk.<a class="elsevierStyleCrossRefs" href="#bib0750">150,153–157</a> Certain congenital thrombophilias, such as Factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase (MTHFR) mutation, or hyperhomocysteinaemia, are associated with an increased risk of cerebral vein thrombosis.<a class="elsevierStyleCrossRefs" href="#bib0790">158,159</a>HyperhomocysteinaemiaA meta-analysis and various systematic reviews have confirmed the association between homocysteine levels and stroke.<a class="elsevierStyleCrossRefs" href="#bib0800">160,161</a> The high risk thymidine–thymidine (TT) genotype is associated with a 21% increase in risk of ischaemic heart disease and an increase in risk of stroke that is not statistically significant.<a class="elsevierStyleCrossRef" href="#bib0810">162</a> Several studies have analysed the efficacy of folic acid or vitamin B supplements. Although vitamin supplements reduced homocysteine levels, this decrease did not have any significant effect on vascular risk.<a class="elsevierStyleCrossRefs" href="#bib0815">163–165</a> A single systematic review described an 18% decrease in risk of stroke in a group taking folic acid supplements with or without B complex vitamins compared to a control group. Researchers have observed this effect mainly in trials lasting more than 36 months in countries in which cereals are supplemented with folic acid.<a class="elsevierStyleCrossRef" href="#bib0830">166</a> According to a meta-analysis, patients with history of vascular disease show similar risks of vascular disease, coronary disease, stroke, or death whether they receive folic acid supplements or a placebo.<a class="elsevierStyleCrossRef" href="#bib0835">167</a> The VISP and VITATOPS studies have shown that folic acid, vitamin B6 and vitamin B12 supplements are safe in patients with prior stroke, but they do not reduce risk of new vascular episodes.<a class="elsevierStyleCrossRefs" href="#bib0815">163,168</a> Nevertheless, some authors point to a probable benefit in patients with markedly higher or lower homocysteine levels.<a class="elsevierStyleCrossRef" href="#bib0845">169</a> A systematic review has confirmed that there is not enough evidence to determine whether or not treatments affecting homocysteine levels can prevent stroke recurrence.<a class="elsevierStyleCrossRef" href="#bib0850">170</a>Prothrombotic statesInherited thrombophiliasObservational studies have not demonstrated a clear association between inherited thrombophilias and IS in adults.<a class="elsevierStyleCrossRefs" href="#bib0855">171–175</a> One review even concluded that routine testing for factor V Leiden, prothrombin G20210A, protein C, protein S, and antithrombin III in IS was unproductive.<a class="elsevierStyleCrossRef" href="#bib0880">176</a> Nevertheless, doctors can detect a hypercoagulable state in more than 40% of young patients with IS.<a class="elsevierStyleCrossRef" href="#bib0885">177</a> A systematic review in a paediatric population (<18 years) concluded that all the thrombophilias which it evaluated (antithrombin III deficiency, protein C deficiency, protein S deficiency, factor V Leiden, prothrombin G20210A, thermolabile MTHFR polymorphism, and antiphospholipid antibodies) were associated with increased risk of suffering new IS or cerebral venous thrombosis. Patients with multiple defects had higher levels of risk.<a class="elsevierStyleCrossRef" href="#bib0890">178</a> Two meta-analyses have researched the potential relationship between stroke and prothrombotic disorders. The first meta-analysis found significant associations between stroke and factor V Leiden, MTHFR C677T variant, and factor II G20210A mutation.<a class="elsevierStyleCrossRef" href="#bib0895">179</a> The risk of suffering stroke in the general population with these polymorphisms is low. The second meta-analysis studied the association between prothrombotic factors and arterial thrombotic episodes. Researchers could not verify a significant association between stroke and factor V Leiden; they did find slight associations between stroke and factor II G20210A mutation and MTHFR C677T mutation. These findings were more evident in young subjects (<55 years).<a class="elsevierStyleCrossRef" href="#bib0900">180</a> The relationship between cerebral venous disease and thrombophilias has been clearly demonstrated. For example, a review showed a significant relationship with cerebral venous thrombosis in patients with factor V Leiden, factor II G20210A mutation and MTHFR C677T mutation.<a class="elsevierStyleCrossRef" href="#bib0790">158</a> The risk of suffering cerebral thrombosis is high in patients who take oral contraceptives and have factor V Leiden mutation, prothrombin G20210A mutation, or hyperhomocysteinaemia.<a class="elsevierStyleCrossRef" href="#bib0795">159</a> Doctors still debate whether or not hypercoagulation studies should be carried out in patients with venous thrombosis. Additional studies are needed, and doctors should follow clinical criteria in these situations.<a class="elsevierStyleCrossRef" href="#bib0905">181</a>Acquired thrombophiliasA retrospective study in patients with antiphospholipid antibodies revealed a 4.4% probability of developing IS.<a class="elsevierStyleCrossRef" href="#bib0910">182</a> The presence of anticardiolipin antibodies was associated with an increase by a factor of 1.5 to 2.2 of risk of developing stroke in men,<a class="elsevierStyleCrossRef" href="#bib0915">183</a> and a cohort study showed a similar relationship in women.<a class="elsevierStyleCrossRef" href="#bib0920">184</a> Nevertheless, there have been no clinical trials in patients with antiphospholipid antibody syndrome and no prior thrombosis.<a class="elsevierStyleCrossRefs" href="#bib0925">185–187</a>Sleep apnoeaSleep apnoea affects up to 24% of the adult male population.<a class="elsevierStyleCrossRef" href="#bib0940">188</a> It has traditionally been associated with a risk of severe vascular episodes such as ischaemic heat disease, stroke,<a class="elsevierStyleCrossRef" href="#bib0945">189</a> CHF,<a class="elsevierStyleCrossRef" href="#bib0950">190</a> and sudden death.<a class="elsevierStyleCrossRef" href="#bib0955">191</a> In population studies, sleep apnoea showed a slight association with CHF and ischaemic heart disease after adjusting for other risk factors.<a class="elsevierStyleCrossRef" href="#bib0960">192</a> It showed a more marked association with risk of stroke.<a class="elsevierStyleCrossRefs" href="#bib0965">193–195</a>Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres170151" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec158222" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres170150" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec158221" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Action on risk factors (Table 2)" "secciones" => array:14 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Antihypertensive drugs and blood pressure" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Diabetes mellitus" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Plasma lipids and lipid-lowering drugs" ] 3 => array:2 [ "identificador" => "sec0025" "titulo" => "Tobacco" ] 4 => array:2 [ "identificador" => "sec0030" "titulo" => "Alcohol" ] 5 => array:2 [ "identificador" => "sec0035" "titulo" => "Diet and physical activity" ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Asymptomatic carotid stenosis" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Heart disease" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Atrial fibrillation" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Mitral stenosis" ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Mitral valve prolapse" ] 11 => array:2 [ "identificador" => "sec0065" "titulo" => "Ischaemic heart disease" ] 12 => array:2 [ "identificador" => "sec0070" "titulo" => "Cardiomyopathy" ] 13 => array:2 [ "identificador" => "sec0075" "titulo" => "Anomalies of the interatrial septum" ] ] ] 5 => array:3 [ "identificador" => "sec0080" "titulo" => "Other risk factors for stroke" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Hormone replacement therapy (HRT) and oral contraceptives" ] 1 => array:2 [ "identificador" => "sec0090" "titulo" => "Hyperhomocysteinaemia" ] 2 => array:3 [ "identificador" => "sec0095" "titulo" => "Prothrombotic states" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0100" "titulo" => "Inherited thrombophilias" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Acquired thrombophilias" ] ] ] 3 => array:2 [ "identificador" => "sec0110" "titulo" => "Sleep apnoea" ] ] ] 6 => array:2 [ "identificador" => "sec0115" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-05-20" "fechaAceptado" => "2011-06-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec158222" "palabras" => array:4 [ 0 => "Guidelines" 1 => "Ischaemic stroke" 2 => "Transient ischaemic attack" 3 => "Prevention" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec158221" "palabras" => array:4 [ 0 => "Guías de práctica clínica" 1 => "Prevención de ictus" 2 => "Ictus" 3 => "Ataque isquémico transitorio" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and transient ischaemic attack (TIA). MethodsWe reviewed available evidence on risk factors and means of modifying them to prevent IS and TIA. Levels of evidence and recommendation grades are based on the classification of the Centre for Evidence-Based Medicine. ResultsThis first section summarises the recommendations for action on the following factors: blood pressure, diabetes, lipids, tobacco and alcohol consumption, diet and physical activity, cardio-embolic diseases, asymptomatic carotid stenosis, hormone replacement therapy (HRT) and contraceptives, hyperhomocysteinemia, prothrombotic states and sleep apnea syndrome. ConclusionsChanges in lifestyle and pharmacological treatment for hypertension, diabetes mellitus and dyslipidemia, according to criteria of primary and secondary prevention, are recommended for preventing IS." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivoActualizar las guías terapéuticas del Comité ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN en el tratamiento preventivo de ictus isquémico (II) y ataque isquémico transitorio (AIT). MétodosRevisión de evidencias disponibles sobre los factores de riesgo y la oportunidad de su modificación para prevenir el ictus isquémico y AIT. Los niveles de evidencia y grados de recomendación se han basado en la clasificación del Centro de Medicina Basada en la Evidencia. ResultadosEn esta primera parte se resumen las recomendaciones sobre la actuación sobre los siguientes factores: presión arterial, DM, lípidos plasmáticos, consumo de tabaco y alcohol, dieta y actividad física, cardiopatías embolígenas, estenosis carotídea asintomática, terapia hormonal sustitutiva y anticonceptivos, hiperhomocisteinemía, estados protrombóticos y síndrome de apnea del sueño. ConclusionesLa modificación de los estilos de vida y el tratamiento farmacológico de la hipertensión arterial, diabetes méllitus y dislipemia según criterios de prevención primaria y secundaria se recomiendan en la prevención de ictus isquémico." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "◊" "nota" => "The affiliations of the authors and committee members are listed in the <a class="elsevierStyleCrossRef" href="#sec0135">appendix</a>." ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Fuentes B, et al. Guía para el tratamiento preventivo del ictus isquémico y AIT (I). Actuación sobre los factores de riesgo y estilo de vida. Neurología. 2012;27:560–74." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "Ad hoc committee of the SEN Study Group for Cerebrovascular Diseases constituted to draw up clinical practice guidelines for stroke. Coordinator: Exuperio Díez-Tejedor, Hospital Universitario La Paz, Madrid." "etiqueta" => "Appendix A" "identificador" => "sec0135" "apendiceSeccion" => array:2 [ 0 => array:4 [ "apendice" => "Exuperio Díez-Tejedor (Coordinator), Hospital Universitario La Paz, Madrid; Blanca Fuentes (Secretary), Hospital Universitario La Paz, Madrid; María Alonso de Leciñana, Hospital Universitario Ramón y Cajal, Madrid; José Álvarez-Sabin, Hospital Universitari Vall d’Hebron, Barcelona; Juan Arenillas, Hospital Universitario Clínico de Valladolid; Sergio Calleja, Hospital Universitario Central de Asturias, Oviedo; Ignacio Casado, Hospital San Pedro, Cáceres; Mar Castellanos, Hospital Josep Trueta, Gerona; José Castillo, Hospital Clínico Universitario, Santiago de Compostela; Antonio Dávalos, Hospital Universitari Germans Trias i Pujol, Badalona Fernando Díaz-Otero, Hospital Universitario Gregorio Marañón, Madrid; Exuperio Díez-Tejedor, Hospital Universitario La Paz, Madrid; José Antonio Egido, Hospital Clínico Universitario San Carlos, Madrid; Juan Carlos Fernández, Hospital Universitario Dr. Negrín, Las Palmas; Mar Freijo, Hospital Universitario de Basurto, Bilbao; Blanca Fuentes, Hospital Universitario La Paz, Madrid; Jaime Gállego, Hospital General de Navarra, Pamplona; Andrés García Pastor, Hospital Universitario Gregorio Marañón, Madrid; Antonio Gil-Núñez, Hospital Universitario Gregorio Marañón, Madrid; Francisco Gilo, Hospital Universitario La Princesa, Madrid; Pablo Irimia, Clínica Universitaria de Navarra, Pamplona; Aida Lago, Hospital Universitario La Fe, Valencia; José Maestre, Hospital Universitario Virgen de las Nieves, Granada; Jaime Masjuan, Hospital Universitario Ramón y Cajal, Madrid; Joan Martí-Fábregas, Hospital de la Santa Creu i Sant Pau, Barcelona; Patricia Martínez-Sánchez, Hospital Universitario La Paz, Madrid; Eduardo Martínez-Vila, Clínica Universitaria de Navarra, Pamplona; Carlos Molina, Hospital Universitario Vall d’Hebron, Barcelona; Ana Morales, Hospital Universitario Virgen de la Arrixaca, Murcia; Florentino Nombela, Hospital Universitario La Princesa, Madrid; Francisco Purroy, Hospital Universitario Arnau de Vilanova, Lérida; Marc Ribó, Hospital Universitari Vall d’Hebron, Barcelona; Manuel Rodríguez-Yañez, Hospital Clínico Universitario, Santiago de Compostela; Jaime Roquer, Hospital del Mar, Barcelona; Francisco Rubio, Hospital Universitario de Bellvitge, Barcelona; Tomás Segura, Hospital Universitario de Albacete, Albacete; Joaquín Serena, Hospital Josep Trueta, Gerona; Patricia Simal, Hospital Clínico Universitario San Carlos, Madrid; Javier Tejada, Hospital Universitario de León, León; José Vivancos, Hospital Universitario La Princesa, Madrid." "etiqueta" => "A.1" "titulo" => "Drafting committee" "identificador" => "sec0125" ] 1 => array:4 [ "apendice" => "José Álvarez-Sabín, Hospital Universitario ValldHebron, Barcelona; José Castillo, Hospital Clínico Universitario, Santiago de Compostela; Exuperio Díez-Tejedor, Hospital Universitario La Paz, Madrid; Antonio Gil-Núñez, Hospital Universitario Gregorio Marañón, Madrid; José Larracoechea, Hospital de Cruces, Bilbao; Eduardo Martínez-Vila, Clínica Universitaria de Navarra, Pamplona; Jaime Masjuan, Hospital Universitario Ramón y Cajal, Madrid; Jorge Matías-Guiu, Hospital Clínico Universitario San Carlos, Madrid; Francisco Rubio, Hospital de Bellvitge, Barcelona." "etiqueta" => "A.2" "titulo" => "Review and institutional committee" "identificador" => "sec0130" ] ] ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Level of evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type of study on which classification is based \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recommendation grades</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systematic review of randomised clinical trials (with homogeneity) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B (extrapolation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D (inconclusive studies) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Randomised clinical trial with narrow confidence interval \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B (extrapolation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D (inconclusive studies) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systematic review of cohort studies (with homogeneity) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C (extrapolation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D (inconclusive studies) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Individual cohort study (including low quality randomised clinical trials, e.g. those with a follow-up level below 80%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C (extrapolation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D (inconclusive studies) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systematic reviews of case–control studies (with homogeneity) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C (extrapolation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D (inconclusive studies) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3b \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case–control studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C (extrapolation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D (inconclusive studies) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case series or cohort studies or low quality case–control studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D (inconclusive studies) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Experts’ opinion without explicit critical appraisal or based on physiology or pathophysiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab265032.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Levels of evidence and recommendation grades. Based on the classification drawn up by the Centre for Evidence Based Medicine (CEBM).<a class="elsevierStyleCrossRef" href="#bib0005">1</a>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "BP, blood pressure." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Risk factor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recommendation grade and level of evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High blood pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Measure blood pressure regularly; apply lifestyle changes aimed at decreasing blood pressure (smoking cessation and moderate alcohol consumption, weight loss, moderate physical activity, lower salt consumption, and higher consumption of fruits and vegetables). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Antihypertensive treatment to maintain blood pressure levels <140/90. Maintaining levels <130/80 is recommended in patients with DM, kidney disease, or heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Begin antihypertensive treatment in patients with stroke/TIA after the acute phase \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Start treatment in patients with either high or normal blood pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- The treatment objective is BP <130/80mmHg (ideal level <120/80), with target BP adapted to conditions (absence of ischaemic heart disease or bilateral carotid stenosis without revascularisation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1b; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- The optimal antihypertensive treatment has not been clearly identified due to limitations of the studies that have been carried out. Available data support treatment with ACE inhibitors+diuretics, diuretics alone, or ARBs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1b; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Maintain BP <130/80 in diabetic patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Prescription of statins as a stroke prevention method, especially in patients with other vascular risk factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1b; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Control glycaemic levels and maintain HbA1c levels below 7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyslipidaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Treatment with statins is appropriate for stroke prevention in adults with ischaemic heart disease, diabetes mellitus, or high vascular risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- All patients with TIA or cerebral infarction caused by atherothrombosis or small vessel disease should be treated with atorvastatin at 80mg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1b; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Most of the patients with TIA or cerebral infarction of other aetiologies should be treated with statins due to the vascular high risk or the associated vascular diseases requiring this treatment (ischaemic heart disease, peripheral artery disease, FM, or HBP) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1b; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment onset level for LDL is ≥100mg/dl, although treatment at lower levels may be optimal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1b; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- The therapeutic objective is < 100mg/dl, or < 70mg/dl in patients with atherosclerosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1b; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tobacco \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Avoiding or giving up smoking is recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 2a; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Avoid passive exposure to tobacco \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 3b; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Use of smokeless tobacco products is not recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 2a; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Use of counselling, nicotine replacement therapy, and smoking cessation drugs may be appropriate. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 2b; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alcohol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Men should not exceed 2 alcohol units daily; women should not exceed 1 alcohol unit daily \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 2a; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asymptomatic carotid stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Carotid revascularisation may be recommended in selected patients (men younger than 75 with carotid stenosis of between 70% and 99% and expected survival of at least 5 years) with high risk of stroke, provided that perioperative risk lower than 3% is guaranteed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hormone replacement therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Not recommended for primary or secondary prevention of stroke in menopausal women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hormonal contraception \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- The risk of stroke associated with the use of low-dose oral contraceptives in women without risk factors is low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 2a; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Use of oral contraceptives is not recommended in women with congenital thrombophilia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 2a; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Use of oral contraceptives is not recommended in smokers with history of migraine, thrombotic episodes, HBP, or DM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 4; recommendation grade C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hyperhomocysteinaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Although vitamin supplements reduce homocysteine levels, this decrease does not have a significant impact on vascular risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Use of folic acid, vitamin B6, and vitamin B12 supplements in patients with a history of stroke is safe, but these supplements do not reduce risk of new vascular episodes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thrombophilias \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Available data are insufficient to support specific therapeutic recommendations in adult patients with inherited or acquired thrombophilias \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Secondary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- In patients with ischaemic stroke and inherited thrombophilia, doctors should check for deep venous thrombosis, which requires short- or long-term anticoagulant treatment depending on clinical and haematological factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 1a; recommendation grade A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Antithrombotic treatment (antiplatelet or anticoagulant agents) is recommended in the absence of venous thrombosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 2a; recommendation grade C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Aspirin and low-intensity anticoagulation may be considered as preventive treatment in patients testing positive for antiphospholipid antibodies who have suffered a first-ever ischaemic stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Level of evidence 2b; recommendation grade B \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab265033.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Modification of risk factors for stroke. Levels of evidence and recommendation grades." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:195 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Instituto Nacional de Estadística. Defunciones según causa de muerte 2006. Available from: <a class="elsevierStyleInterRef" href="http://www.ine.es/prensa/np490.pdf">http://www.ine.es/prensa/np490.pdf</a> [accessed 29.07.11]." ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Centre for Evidence Based Medicine. Available from: <a class="elsevierStyleInterRef" href="http://www.cebm.net/">http://www.cebm.net/</a> [accessed 29.07.11]." ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" 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"referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => 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"etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ …1] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 27 => array:3 [ "identificador" => 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array:3 [ "identificador" => "bib0190" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 38 => array:3 [ "identificador" => "bib0195" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 39 => array:3 [ "identificador" => "bib0200" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 40 => array:3 [ "identificador" => "bib0205" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:1 [ …1] ] ] ] ] 41 => array:3 [ "identificador" => "bib0210" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ …2] ] "host" => array:1 [ 0 => array:2 [ …2] ] ] ] ] 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Guía para el tratamiento preventivo del ictus isquémico y AIT (I). Actuación sobre los factores de riesgo y estilo de vida

B. Fuentes

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hplapazneuro@meditex.es

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, J. Gállego, A. Gil-Nuñez, A. Morales, F. Purroy, J. Roquer, T. Segura, J. Tejada, A. Lago, E. Díez-Tejedor, por el Comité ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN: , M. Alonso de Leciñana, J. Álvarez-Sabin, J. Arenillas, S. Calleja, I. Casado, M. Castellanos, J. Castillo, A. Dávalos, F. Díaz-Otero..., J.A. Egido, J.C. López-Fernández, M. Freijo, A. García Pastor, F. Gilo, P. Irimia, J. Maestre, J. Masjuan, J. Martí-Fábregas, P. Martínez-Sánchez, E. Martínez-Vila, C. Molina, F. Nombela, M. Ribó, M. Rodríguez-Yañez, F. Rubio, J. Serena, P. Simal, J. Vivancos◊Ver más

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In Spain&#44; cerebrovascular diseases are the leading cause of death in women&#44; the third most frequent in men&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the most common cause of disability&#46; The measures we describe here are designed to prevent both first-ever ischaemic strokes &#40;IS&#41; and future episodes in patients who have already suffered a stroke&#46; We will also list measures intended to reduce overall vascular risk in these patients<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#59; given the length of this chapter&#44; we decided to publish it in 2 parts&#46; Firstly&#44; we will review the risk factors for IS and any modifications to those factors which may be appropriate&#46; Secondly&#44; we will specify different preventive treatments according to the stroke subtype&#46; Recommendations for each section are shown in tables for better readability&#46; Levels of evidence and recommendation grades are based on the classification system proposed by the Centre for Evidence Based Medicine at the University of Oxford<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Following current criteria&#44; we included transient ischaemic attack &#40;TIA&#41; in the definition of IS&#44; which also improves readability&#46; Therefore&#44; all recommendations included in these clinical practice guidelines are directed at preventing focal cerebral ischaemia in general&#44; without distinguishing between cerebral infarction and TIA&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Action on risk factors &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Antihypertensive drugs and blood pressure</span><p id="par0010" class="elsevierStylePara elsevierViewall">Epidemiological studies and clinical trials have illustrated the relationship between blood pressure and stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;8</span></a> Lifestyle changes &#40;decreasing tobacco and alcohol consumption&#44; losing weight&#44; engaging in moderate physical activity&#44; decreasing salt consumption&#44; and increasing fruit and vegetable intake&#41; are useful for reducing blood pressure levels&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It has been shown that reduction in risk of stroke is proportional to a patient&#39;s decrease in blood pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> Studies of different antihypertensive drugs present similar results with regard to reduction in vascular episodes&#46; The most recent Report of the Joint National Committee on Prevention&#44; Detection&#44; Evaluation&#44; and Treatment of High Blood Pressure indicates which levels of blood pressure are considered high and which treatments are the most appropriate in each situation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Studies of different antihypertensive agents used in secondary IS prevention have yielded inconsistent results&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Beta blockers have not been shown to deliver significant benefits&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> Results from diuretics have been contradictory<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#59; a single study of indapamide at 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;day pointed to a positive effect&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Using ACE inhibitors&#44; such as ramipril at 10<span class="elsevierStyleHsp" style=""></span>mg&#47;day<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> or combination therapy with perindopril &#40;4<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; and indapamide &#40;2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; decreases the risk of stroke recurrence&#44; even in patients without a history of HBP&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Regarding results from ARBs&#44; trials have shown that eprosartan performed better than nitrendipine<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#59; telmisartan performed no better than a placebo<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and similarly to ramipril<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#59; and combination therapy with telmisartan and ramipril was associated with a higher frequency of side effects and no significant benefits&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Major vascular events decreased by an additional 15&#37; with intensive antihypertensive treatments&#44; regardless of the drug employed&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Some studies show differing levels of IS risk reduction for different classes of antihypertensive drugs&#46; This could be due to the fact that some antihypertensive drugs&#44; such as ACE inhibitors or ARBs&#44; may have an added pleiotropic effect as well as an antihypertensive effect&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;24&#44;25</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diabetes mellitus</span><p id="par0020" class="elsevierStylePara elsevierViewall">Patients with DM are more susceptible to developing arteriosclerosis and display a higher prevalence of HBP&#44; obesity&#44; and dyslipidaemia&#46; The risk entailed by DM is considered equal to that entailed by coronary disease&#44; which is why secondary prevention measures must be applied in these cases&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The risk of IS is 2 to 6 times higher in diabetic patients&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> and 9&#46;1&#37; of recurrences are directly attributable to DM&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Adjusting glycaemic control and normalising HbA1c are more effective for reducing the complications of microangiopathy&#44; whereas the approach to stroke prevention should be more global and include strict blood pressure control<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> and administration of statins&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Results from studies of close glycaemic control are controversial&#44; with the ACCORD study<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> showing a possible negative effect on mortality rates&#46; The ADVANCE study<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> and Veterans Affairs Diabetes Trial<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> showed that glycaemic control did not reduce risk of IS&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Long-term follow-up in the DCCT and UKPDS trials suggests that maintaining HbA1c levels under or near 7&#37; at the onset of DM is associated with a long-term reduction in macrovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> In a subanalysis of the PROactive study&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> treatment with pioglitazone in patients with prior stroke was associated with a 47&#37; decrease in risk of recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Based on these results&#44; it has been recommended for preventing secondary stroke in patients with DM&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Nevertheless&#44; the safety of glitazone treatment has recently been called into question&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> It is therefore advisable to wait for the results of the Insulin Resistance Intervention after Stroke &#40;IRIS&#41; study&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Plasma lipids and lipid-lowering drugs</span><p id="par0025" class="elsevierStylePara elsevierViewall">High levels of cholesterol increase risk of IS&#46; The Asia-Pacific Cohort Studies Collaboration found a 25&#37; higher risk of IS for each mmol&#47;L &#40;38&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; increase in total cholesterol levels&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The US Women&#39;s Pooling Project detected a similar risk increase in women aged 30 to 54&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> Several primary prevention studies have shown that statins are effective for reducing cholesterol levels and risk of stroke &#40;by 27&#37;&#8211;32&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a> Treatment with rosuvastatin decreases the risk of IS&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> even in patients with high levels of high-sensitivity C-reactive protein and no hyperlipidaemia&#46; Earlier guidelines already recommended statin use for secondary prevention of stroke or TIA in most patients based on NCEP-ATP III criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> According to the SPARCL study&#44; 80<span class="elsevierStyleHsp" style=""></span>mg&#47;day of atorvastatin significantly decreases the risk of recurrence in patients with non-cardioembolic stroke or TIA&#44; and those with other vascular complications such as ischaemic heart disease or revascularisation procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> We detected an increase in haemorrhagic stroke frequency in the atorvastatin group&#44; especially in cases with a history of haemorrhagic stroke at time of inclusion&#44; men&#44; elderly subjects&#44; and patients with stage 2 HBP&#44; without significant interactions in baseline and recent LDL cholesterol levels&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Another exploratory study showed that decreases &#8805;50&#37; with respect to baseline figures achieve the greatest reductions in risk of stroke and major coronary episodes without risk of cerebral haemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> A meta-analysis of randomised clinical trials suggested that fibrates may play a role in patients with DM&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Tobacco</span><p id="par0030" class="elsevierStylePara elsevierViewall">Tobacco consumption is associated with increased risk of all stroke subtypes&#44; especially atherothrombotic stroke<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50&#8211;55</span></a> and in young patients&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> Additionally&#44; it has a synergistic effect through its link to other vascular risk factors&#44; such as HBP&#44; DM&#44; use of oral contraceptives&#44; or physical inactivity&#46; Smoking cessation reduces the risk of stroke&#44; coronary disease&#44; peripheral vascular disease and death from vascular causes proportionally to the length of the period during which the subject stopped using tobacco&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">57&#8211;60</span></a> Passive smoking also entails a risk of cerebrovascular disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">61&#8211;63</span></a> Smokeless tobacco products are associated with increased risk of fatal stroke as well&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Alcohol</span><p id="par0035" class="elsevierStylePara elsevierViewall">Robust evidence shows that excessive consumption of alcohol is a risk factor for all types of stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">65&#8211;70</span></a> However&#44; whether or not light-to-moderate alcohol consumption is related to ischaemic or haemorrhagic stroke is a matter of debate&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">71&#44;72</span></a> Risk of stroke with light &#40;&#60;12<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; or moderate &#40;between 12 and 24<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; alcohol consumption is less than risk of stroke with total abstinence from alcohol&#46; High levels of alcohol consumption &#40;&#62;60<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41; increases total risk of stroke and risk of both ischaemic and haemorrhagic stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> We found a J-shaped relationship between the risk of coronary morbidity and mortality<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> and IS&#44;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">68&#8211;70</span></a> as well as a linear association for the risk of haemorrhagic stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">65&#8211;67</span></a> Moderate red wine consumption is associated with lower vascular risk&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> There are not enough studies to establish a relationship between alcohol consumption and recurrent stroke&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diet and physical activity</span><p id="par0040" class="elsevierStylePara elsevierViewall">It has been shown that dietary habits are related to cerebrovascular risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">74&#8211;76</span></a> Low intakes of salt<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> and fat<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> along with regular consumption of fish&#44;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> pulses&#44; fibre&#44; fruits&#44; and vegetables<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">80&#8211;82</span></a> are associated with lower vascular mortality rates and a significant decrease in risk of cerebrovascular diseases&#46; Sedentary lifestyle is very prevalent in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> It is associated with cerebrovascular diseases<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> and related to other factors such as HBP&#44; hypercholesterolaemia&#44; obesity&#44; and DM&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">85&#44;86</span></a> Physical activity increases HDL cholesterol&#44; reduces LDL cholesterol and triglycerides&#44; decreases blood pressure&#44; fosters insulin homeostasis&#44; helps in losing and maintaining weight&#44; promotes good mental health&#44; and is helpful in quitting smoking&#46;<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">86&#8211;90</span></a> Individuals who are physically active have a lower risk of ischaemic heart disease and stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">84&#44;87&#44;91</span></a> This relationship is independent of age and sex&#44; but it should be noted that data from patients older than 80 are limited&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> The benefits of exercise can be observed whether the activity is undertaken during work or leisure time&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> The general recommendation is at least 30<span class="elsevierStyleHsp" style=""></span>minutes of moderate-intensity exercise&#44; most days of the week&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Asymptomatic carotid stenosis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Prevalence of asymptomatic carotid artery stenosis &#40;&#8805;50&#37;&#41; increases with age&#46; The prevalence is 0&#46;5&#37; in individuals younger than 50 years and higher than 10&#37; in men older than 80 years&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> After a 15-year follow-up period&#44; 16&#46;6&#37; of patients may suffer an episode of stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a> There are 2 alternative strategies&#58; medical treatment or revascularisation using an endarterectomy or endovascular treatment with angioplasty and stenting&#46; Initial studies of endarterectomy<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">96&#44;97</span></a> indicated that this treatment was beneficial&#44; since it reduced risk of stroke after 5 years of follow-up&#46; Nevertheless&#44; new developments in medical treatment have raised questions about the benefit of surgical techniques&#44; which deliver a decrease in absolute risk of stroke of only 1&#37; per year&#44; according to several meta-analyses&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">98&#8211;100</span></a> According to the CREST study&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a> there is a 2&#46;5&#37; risk of suffering periprocedural stroke during an angioplasty and a 1&#46;4&#37; risk during endarterectomy&#46; Therefore&#44; indiscriminate use of revascularisation treatment in asymptomatic patients does not seem justified provided that they receive appropriate medical treatment&#46; Revascularisation is only recommended in selected cases according to factors such as age&#44; comorbidity&#44; life expectancy&#44; and perioperative risk&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">102</span></a> Based on the above&#44; revascularisation can be considered for 70&#37; to 99&#37; carotid stenosis in men younger than 75&#44; provided that perioperative risk is &#60;3&#37; and expected post-operative survival is at least 5 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#44;103</span></a> Of all patients with asymptomatic carotid stenosis&#44; those with the highest level of risk have a history of contralateral TIAs&#44;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a> silent cerebral infarcts ipsilateral to stenosis&#44;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">105</span></a> stenosis progression&#44;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">106</span></a> or microemboli detected using transcranial Doppler&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">107</span></a> The SPACE 2 trial will compare results from current medical treatment with anti-platelet and antihypertensive drugs and statins with results from endovascular therapy or open surgical revascularisation&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Heart disease</span><p id="par0050" class="elsevierStylePara elsevierViewall">Heart disease is the second leading cause of IS&#46; In addition&#44; patients with cardioembolic stroke present a higher risk of death and of new vascular events over the long term than patients with IS of arterial origin &#40;non-cardioembolic&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">108</span></a> Findings regarding risk of IS for different types of emboligenic heart disease are listed below&#46; The second part of this guide will list specific recommendations for preventing IS&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Atrial fibrillation</span><p id="par0055" class="elsevierStylePara elsevierViewall">Atrial fibrillation &#40;AF&#41; is the most frequent type of arrhythmia<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">109</span></a> with a prevalence of 6&#37; in patients older than 65&#46; In patients older than 85&#44; prevalence rises to 12&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">110</span></a> AF is one of the main risk factors for stroke&#46; It is estimated that 1 out of 6 strokes occur in patients with AF&#44;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">111</span></a> which is the cause of nearly half of all cardioembolic ISs&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">112</span></a> AF is associated with an increase in IS risk by a factor of 3 to 4 after adjusting for other risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">113</span></a> In cases with associated rheumatic heart disease&#44; risk of stroke is 17 times higher than in healthy controls&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">114</span></a> Several factors significantly increase risk of embolism&#58; age &#62;75 years&#44; congestive heart failure &#40;CHF&#41;&#44; HBP&#44; DM&#44; history of thromboembolism&#44; left ventricular dysfunction with left ventricular ejection fraction &#40;LVEF&#41; &#60;35&#37;&#44; atrial size&#44; presence of mitral annular calcification &#40;MAC&#41;&#44; presence of spontaneous echo contrast&#44; and detection of a left atrial thrombus&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Based on the above&#44; researchers have designed IS risk stratification systems for patients with AF&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">115</span></a> The CHADS2 score<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">116&#44;117</span></a> is the most well-known and validated risk classification method&#46; It factors in CHF &#40;1 point&#41;&#44; HBP &#40;1 point&#41;&#44; DM &#40;1 point&#41;&#44; age &#62;75 years &#40;1 point&#41;&#44; and history of cardiovascular disease or systemic embolism &#40;2 points&#41;&#46; The recently validated CHA2-DS2-VASc score<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">118</span></a> divides the study population into 2 age groups&#58; 65&#8211;74 &#40;1 point&#41; and &#62;75 &#40;2 points&#41;&#46; It also accounts for the following factors&#58; vascular disease &#40;prior AMI&#44; peripheral artery disease&#44; and complex aortic plaque&#41; &#40;1 point&#41;&#59; and female sex &#40;1 point&#41;&#46; All other scores were the same as for CHADS2&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mitral stenosis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Between 10&#37; and 20&#37; of patients with mitral stenosis present systemic embolism&#46; In cases of rheumatic stenosis &#40;the most frequent cause&#41; and a history of prior embolism&#44; the level of risk reaches 30&#37; to 65&#37;&#46; Moreover&#44; up to 40&#37; of patients with mitral stenosis develop AF&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">119</span></a> They therefore have a higher risk of stroke and a poorer prognosis than those who maintain sinus rhythm&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">120</span></a> Regarding patients with mitral stenosis and no AF or prior embolism&#44; treatment is controversial since there are no data supporting the prescription of oral anticoagulant therapy&#46; It is true that these patients may experience episodes of paroxysmal AF which are difficult to detect&#46; At present&#44; experts agree that oral anticoagulant drugs should be prescribed for patients with severe mitral stenosis and dilation of the left atrium &#8805;55<span class="elsevierStyleHsp" style=""></span>mm or spontaneous contrast in the echocardiographic study&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">119</span></a> One observational study comparing medical treatment&#44; percutaneous balloon valvuloplasty&#44; and valve replacement suggests that balloon commissurotomy is the most effective method for reducing the incidence of IS&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">121</span></a> MAC is an infrequent non-rheumatic cause of mitral stenosis&#44; and it is associated with distal complex aortic atheroma&#46;<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">122&#44;123</span></a> The relationship between MAC and the risk of stroke is unclear&#59; some cohort studies observe an increased risk of ischaemic heart disease and vascular death but no increase in IS&#44;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">124</span></a> while other studies do observe a significant increase of IS risk after adjusting for other risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">125</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mitral valve prolapse</span><p id="par0065" class="elsevierStylePara elsevierViewall">Mitral valve prolapse &#40;MVP&#41;&#44; the most frequent valve anomaly in adults&#44; is present in 2&#46;5&#37; of population&#46; It is particularly prevalent in individuals with connective tissue diseases&#46; It is considered innocuous since different population-based observational studies have not detected a higher risk of stroke in subjects with MVP&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">126</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ischaemic heart disease</span><p id="par0070" class="elsevierStylePara elsevierViewall">AMI is associated with a 2&#37; absolute risk of stroke during the first 30 days after the infarct&#46; This is due to the presence of mural thrombi in the left ventricle &#40;LV&#41;&#44; most of which occur during the first 2 weeks following the previous AMI &#40;12&#37; incidence&#41;&#46; The majority of these cases are characterised by extensive infarcts that reduce left ventricular function or provoke dyskinesia&#47;apical akinesia&#44; although AMIs at any location may cause thrombi to form&#46; The incidence of early embolism is &#62;22&#37;&#44; especially in cases of moving or protruding thrombi in the LV&#46; It is estimated that 10&#37; of these patients will suffer from IS if they are not treated&#46; Risk increases in cases of left ventricular dilation&#44; ventricular dyskinesia&#44; ejection fraction &#60;30&#37;&#44; or CHF&#46;<a class="elsevierStyleCrossRefs" href="#bib0635"><span class="elsevierStyleSup">127&#8211;129</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Cardiomyopathy</span><p id="par0075" class="elsevierStylePara elsevierViewall">In dilated cardiomyopathy and other conditions with decreased LVEF&#44; such as CHF&#44; there is an increased risk of emboli due to stasis of blood in the LV&#46; This risk is relatively low &#40;1&#37;&#8211;3&#37; yearly&#41; in cases of depressed LVEF and echocardiographic signs of intramural thrombi&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">128</span></a> Stable CHF &#40;NYHA Class II and Class III&#41; is associated with an absolute risk of stroke of 1&#37; per year&#46; The relative risk increases by 18&#37; when there is a 5&#37; decrease in the LVEF&#46; With more severe conditions &#40;NYHA Class IV&#41;&#44; risk of stroke is 4&#37; per year&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">128</span></a> Approximately 10&#37; of patients with IS have a LVEF of &#8804;30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">130</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Anomalies of the interatrial septum</span><p id="par0080" class="elsevierStylePara elsevierViewall">Patent foramen ovale &#40;PFO&#41; is very prevalent in the general population &#40;15&#37;&#8211;25&#37;&#41;&#44; while atrial septal aneurysm &#40;ASA&#41; is less frequent &#40;2&#46;3&#37;&#41;&#46; The risk of stroke in patients with PFO is similar to that in the general population&#44;<a class="elsevierStyleCrossRefs" href="#bib0655"><span class="elsevierStyleSup">131&#44;132</span></a> but there seems to be a well-documented correlation between persistent PFO and cryptogenic stroke&#44; especially in the younger population&#46; This anomaly was detected in 35&#37; to 50&#37; of patients with cryptogenic IS vs only 4&#37; to 10&#37; of control subjects&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">133</span></a> According to the PFO-ASA study&#44; risk of stroke recurrence in PFO patients treated with acetylsalicylic acid is low after 4 years of follow-up &#40;2&#46;3&#37; vs 4&#46;2&#37; in patients without PFO&#41;&#44; with a higher risk when PFO is associated with ASA&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">134</span></a> Subsequent studies did not detect any differences in risk of recurrence in patients with massive right-to-left shunt compared to patients without this anomaly&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">135</span></a> According to a recent meta-analysis&#44; the risk of stroke recurrence in patients with PFO does not differ from that in patients with cryptogenic stroke and no PFO&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">136</span></a></p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Other risk factors for stroke</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hormone replacement therapy &#40;HRT&#41; and oral contraceptives</span><p id="par0085" class="elsevierStylePara elsevierViewall">Initial observational studies with hormone replacement therapy<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">137</span></a> along with subsequent published articles related to the Women&#39;s Health Initiative &#40;WHI&#41; showed that use of HRT favoured the onset of vascular episodes&#46;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">138&#44;139</span></a> Several meta-analyses have confirmed that HRT is associated with a 30&#37; increase in risk of stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0700"><span class="elsevierStyleSup">140&#44;141</span></a> This risk is not age-related&#44; and progesterone replacement in addition to oestrogen doubles the risk of venous thromboembolism&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">142</span></a> However&#44; a systematic review showed that risk of stroke from use of low doses of oestrogens administered transdermally may be no higher than that associated with the oral route of administration&#46; The review was unable to present any conclusions due to the presence of confounding factors&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">143</span></a> Other alternative therapies also entail cerebrovascular risks&#46; For example&#44; tibolone is associated with risk of stroke in postmenopausal women<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">144&#44;145</span></a> and raloxifene may increase risk of fatal stroke in at-risk women&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">146</span></a> HRT in postmenopausal women with prior stroke does not seem to present benefits and the treatment is associated with increased risk of stroke and stroke-related death&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">141&#44;147&#8211;149</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The relationship between oral contraceptives and risk of stroke is still a matter of debate&#46; Recommendations are based on observational studies&#44; since no randomised trials are available&#46; Another systematic review found no association between oral contraceptives and stroke in cohort studies&#44; while it did detect a significant increase in risk in case&#8211;control studies&#46; This increase in risk was more evident for IS than for haemorrhagic stroke&#46; Higher risk levels were observed in hospital-based populations than in community-based populations&#46;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">150</span></a> A different systematic review showed increased risk of AMI or stroke associated with the use of first and second-generation oral contraceptives&#46; The increase in risk was more evident for stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">151</span></a> A systematic review showed that progesterone-only contraceptive use is not associated with an increased risk of stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">152</span></a> Women older than 35 years who smoke and have HBP&#44; DM&#44; history of migraine&#44; or history of thrombotic complications may be at increased risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0750"><span class="elsevierStyleSup">150&#44;153&#8211;157</span></a> Certain congenital thrombophilias&#44; such as Factor V Leiden&#44; prothrombin G20210A&#44; methylenetetrahydrofolate reductase &#40;MTHFR&#41; mutation&#44; or hyperhomocysteinaemia&#44; are associated with an increased risk of cerebral vein thrombosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">158&#44;159</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hyperhomocysteinaemia</span><p id="par0095" class="elsevierStylePara elsevierViewall">A meta-analysis and various systematic reviews have confirmed the association between homocysteine levels and stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0800"><span class="elsevierStyleSup">160&#44;161</span></a> The high risk thymidine&#8211;thymidine &#40;TT&#41; genotype is associated with a 21&#37; increase in risk of ischaemic heart disease and an increase in risk of stroke that is not statistically significant&#46;<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">162</span></a> Several studies have analysed the efficacy of folic acid or vitamin B supplements&#46; Although vitamin supplements reduced homocysteine levels&#44; this decrease did not have any significant effect on vascular risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">163&#8211;165</span></a> A single systematic review described an 18&#37; decrease in risk of stroke in a group taking folic acid supplements with or without B complex vitamins compared to a control group&#46; Researchers have observed this effect mainly in trials lasting more than 36 months in countries in which cereals are supplemented with folic acid&#46;<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">166</span></a> According to a meta-analysis&#44; patients with history of vascular disease show similar risks of vascular disease&#44; coronary disease&#44; stroke&#44; or death whether they receive folic acid supplements or a placebo&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">167</span></a> The VISP and VITATOPS studies have shown that folic acid&#44; vitamin B6 and vitamin B12 supplements are safe in patients with prior stroke&#44; but they do not reduce risk of new vascular episodes&#46;<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">163&#44;168</span></a> Nevertheless&#44; some authors point to a probable benefit in patients with markedly higher or lower homocysteine levels&#46;<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">169</span></a> A systematic review has confirmed that there is not enough evidence to determine whether or not treatments affecting homocysteine levels can prevent stroke recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">170</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prothrombotic states</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Inherited thrombophilias</span><p id="par0100" class="elsevierStylePara elsevierViewall">Observational studies have not demonstrated a clear association between inherited thrombophilias and IS in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0855"><span class="elsevierStyleSup">171&#8211;175</span></a> One review even concluded that routine testing for factor V Leiden&#44; prothrombin G20210A&#44; protein C&#44; protein S&#44; and antithrombin III in IS was unproductive&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">176</span></a> Nevertheless&#44; doctors can detect a hypercoagulable state in more than 40&#37; of young patients with IS&#46;<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">177</span></a> A systematic review in a paediatric population &#40;&#60;18 years&#41; concluded that all the thrombophilias which it evaluated &#40;antithrombin III deficiency&#44; protein C deficiency&#44; protein S deficiency&#44; factor V Leiden&#44; prothrombin G20210A&#44; thermolabile MTHFR polymorphism&#44; and antiphospholipid antibodies&#41; were associated with increased risk of suffering new IS or cerebral venous thrombosis&#46; Patients with multiple defects had higher levels of risk&#46;<a class="elsevierStyleCrossRef" href="#bib0890"><span class="elsevierStyleSup">178</span></a> Two meta-analyses have researched the potential relationship between stroke and prothrombotic disorders&#46; The first meta-analysis found significant associations between stroke and factor V Leiden&#44; MTHFR C677T variant&#44; and factor II G20210A mutation&#46;<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">179</span></a> The risk of suffering stroke in the general population with these polymorphisms is low&#46; The second meta-analysis studied the association between prothrombotic factors and arterial thrombotic episodes&#46; Researchers could not verify a significant association between stroke and factor V Leiden&#59; they did find slight associations between stroke and factor II G20210A mutation and MTHFR C677T mutation&#46; These findings were more evident in young subjects &#40;&#60;55 years&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">180</span></a> The relationship between cerebral venous disease and thrombophilias has been clearly demonstrated&#46; For example&#44; a review showed a significant relationship with cerebral venous thrombosis in patients with factor V Leiden&#44; factor II G20210A mutation and MTHFR C677T mutation&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">158</span></a> The risk of suffering cerebral thrombosis is high in patients who take oral contraceptives and have factor V Leiden mutation&#44; prothrombin G20210A mutation&#44; or hyperhomocysteinaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">159</span></a> Doctors still debate whether or not hypercoagulation studies should be carried out in patients with venous thrombosis&#46; Additional studies are needed&#44; and doctors should follow clinical criteria in these situations&#46;<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">181</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Acquired thrombophilias</span><p id="par0105" class="elsevierStylePara elsevierViewall">A retrospective study in patients with antiphospholipid antibodies revealed a 4&#46;4&#37; probability of developing IS&#46;<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">182</span></a> The presence of anticardiolipin antibodies was associated with an increase by a factor of 1&#46;5 to 2&#46;2 of risk of developing stroke in men&#44;<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">183</span></a> and a cohort study showed a similar relationship in women&#46;<a class="elsevierStyleCrossRef" href="#bib0920"><span class="elsevierStyleSup">184</span></a> Nevertheless&#44; there have been no clinical trials in patients with antiphospholipid antibody syndrome and no prior thrombosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0925"><span class="elsevierStyleSup">185&#8211;187</span></a></p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sleep apnoea</span><p id="par0110" class="elsevierStylePara elsevierViewall">Sleep apnoea affects up to 24&#37; of the adult male population&#46;<a class="elsevierStyleCrossRef" href="#bib0940"><span class="elsevierStyleSup">188</span></a> It has traditionally been associated with a risk of severe vascular episodes such as ischaemic heat disease&#44; stroke&#44;<a class="elsevierStyleCrossRef" href="#bib0945"><span class="elsevierStyleSup">189</span></a> CHF&#44;<a class="elsevierStyleCrossRef" href="#bib0950"><span class="elsevierStyleSup">190</span></a> and sudden death&#46;<a class="elsevierStyleCrossRef" href="#bib0955"><span class="elsevierStyleSup">191</span></a> In population studies&#44; sleep apnoea showed a slight association with CHF and ischaemic heart disease after adjusting for other risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0960"><span class="elsevierStyleSup">192</span></a> It showed a more marked association with risk of stroke&#46;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">193&#8211;195</span></a></p></span></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "xres170151"
          "titulo" => array:5 [
            0 => "Abstract"
            1 => "Objective"
            2 => "Methods"
            3 => "Results"
            4 => "Conclusions"
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          "titulo" => "Keywords"
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          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Objetivo"
            2 => "M&#233;todos"
            3 => "Resultados"
            4 => "Conclusiones"
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        3 => array:2 [
          "identificador" => "xpalclavsec158221"
          "titulo" => "Palabras clave"
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        4 => array:3 [
          "identificador" => "sec0005"
          "titulo" => "Action on risk factors &#40;Table 2&#41;"
          "secciones" => array:14 [
            0 => array:2 [
              "identificador" => "sec0010"
              "titulo" => "Antihypertensive drugs and blood pressure"
            ]
            1 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Diabetes mellitus"
            ]
            2 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Plasma lipids and lipid-lowering drugs"
            ]
            3 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Tobacco"
            ]
            4 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Alcohol"
            ]
            5 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Diet and physical activity"
            ]
            6 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Asymptomatic carotid stenosis"
            ]
            7 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Heart disease"
            ]
            8 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Atrial fibrillation"
            ]
            9 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Mitral stenosis"
            ]
            10 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Mitral valve prolapse"
            ]
            11 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Ischaemic heart disease"
            ]
            12 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Cardiomyopathy"
            ]
            13 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Anomalies of the interatrial septum"
            ]
          ]
        ]
        5 => array:3 [
          "identificador" => "sec0080"
          "titulo" => "Other risk factors for stroke"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Hormone replacement therapy &#40;HRT&#41; and oral contraceptives"
            ]
            1 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Hyperhomocysteinaemia"
            ]
            2 => array:3 [
              "identificador" => "sec0095"
              "titulo" => "Prothrombotic states"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0100"
                  "titulo" => "Inherited thrombophilias"
                ]
                1 => array:2 [
                  "identificador" => "sec0105"
                  "titulo" => "Acquired thrombophilias"
                ]
              ]
            ]
            3 => array:2 [
              "identificador" => "sec0110"
              "titulo" => "Sleep apnoea"
            ]
          ]
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        6 => array:2 [
          "identificador" => "sec0115"
          "titulo" => "Conflicts of interest"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-05-20"
    "fechaAceptado" => "2011-06-29"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec158222"
          "palabras" => array:4 [
            0 => "Guidelines"
            1 => "Ischaemic stroke"
            2 => "Transient ischaemic attack"
            3 => "Prevention"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec158221"
          "palabras" => array:4 [
            0 => "Gu&#237;as de pr&#225;ctica cl&#237;nica"
            1 => "Prevenci&#243;n de ictus"
            2 => "Ictus"
            3 => "Ataque isqu&#233;mico transitorio"
          ]
        ]
      ]
    ]
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke &#40;IS&#41; and transient ischaemic attack &#40;TIA&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We reviewed available evidence on risk factors and means of modifying them to prevent IS and TIA&#46; Levels of evidence and recommendation grades are based on the classification of the Centre for Evidence-Based Medicine&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This first section summarises the recommendations for action on the following factors&#58; blood pressure&#44; diabetes&#44; lipids&#44; tobacco and alcohol consumption&#44; diet and physical activity&#44; cardio-embolic diseases&#44; asymptomatic carotid stenosis&#44; hormone replacement therapy &#40;HRT&#41; and contraceptives&#44; hyperhomocysteinemia&#44; prothrombotic states and sleep apnea syndrome&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Changes in lifestyle and pharmacological treatment for hypertension&#44; diabetes mellitus and dyslipidemia&#44; according to criteria of primary and secondary prevention&#44; are recommended for preventing IS&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Actualizar las gu&#237;as terap&#233;uticas del Comit&#233; ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN en el tratamiento preventivo de ictus isqu&#233;mico &#40;II&#41; y ataque isqu&#233;mico transitorio &#40;AIT&#41;&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n de evidencias disponibles sobre los factores de riesgo y la oportunidad de su modificaci&#243;n para prevenir el ictus isqu&#233;mico y AIT&#46; Los niveles de evidencia y grados de recomendaci&#243;n se han basado en la clasificaci&#243;n del Centro de Medicina Basada en la Evidencia&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En esta primera parte se resumen las recomendaciones sobre la actuaci&#243;n sobre los siguientes factores&#58; presi&#243;n arterial&#44; DM&#44; l&#237;pidos plasm&#225;ticos&#44; consumo de tabaco y alcohol&#44; dieta y actividad f&#237;sica&#44; cardiopat&#237;as embol&#237;genas&#44; estenosis carot&#237;dea asintom&#225;tica&#44; terapia hormonal sustitutiva y anticonceptivos&#44; hiperhomocisteinem&#237;a&#44; estados protromb&#243;ticos y s&#237;ndrome de apnea del sue&#241;o&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La modificaci&#243;n de los estilos de vida y el tratamiento farmacol&#243;gico de la hipertensi&#243;n arterial&#44; diabetes m&#233;llitus y dislipemia seg&#250;n criterios de prevenci&#243;n primaria y secundaria se recomiendan en la prevenci&#243;n de ictus isqu&#233;mico&#46;</p>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9674;"
        "nota" => "<p class="elsevierStyleNotepara">The affiliations of the authors and committee members are listed in the <a class="elsevierStyleCrossRef" href="#sec0135">appendix</a>&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Fuentes B&#44; et al&#46; Gu&#237;a para el tratamiento preventivo del ictus isqu&#233;mico y AIT &#40;I&#41;&#46; Actuaci&#243;n sobre los factores de riesgo y estilo de vida&#46; Neurolog&#237;a&#46; 2012&#59;27&#58;560&#8211;74&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Ad hoc committee of the SEN Study Group for Cerebrovascular Diseases constituted to draw up clinical practice guidelines for stroke&#46;</span></p> <p id="par0125" class="elsevierStylePara elsevierViewall">Coordinator&#58; Exuperio D&#237;ez-Tejedor&#44; Hospital Universitario La Paz&#44; Madrid&#46;</p>"
            "etiqueta" => "Appendix A"
            "identificador" => "sec0135"
            "apendiceSeccion" => array:2 [
              0 => array:4 [
                "apendice" => "<p id="par0130" class="elsevierStylePara elsevierViewall">Exuperio D&#237;ez-Tejedor &#40;Coordinator&#41;&#44; Hospital Universitario La Paz&#44; Madrid&#59; Blanca Fuentes &#40;Secretary&#41;&#44; Hospital Universitario La Paz&#44; Madrid&#59; Mar&#237;a Alonso de Leci&#241;ana&#44; Hospital Universitario Ram&#243;n y Cajal&#44; Madrid&#59; Jos&#233; &#193;lvarez-Sabin&#44; Hospital Universitari Vall d&#8217;Hebron&#44; Barcelona&#59; Juan Arenillas&#44; Hospital Universitario Cl&#237;nico de Valladolid&#59; Sergio Calleja&#44; Hospital Universitario Central de Asturias&#44; Oviedo&#59; Ignacio Casado&#44; Hospital San Pedro&#44; C&#225;ceres&#59; Mar Castellanos&#44; Hospital Josep Trueta&#44; Gerona&#59; Jos&#233; Castillo&#44; Hospital Cl&#237;nico Universitario&#44; Santiago de Compostela&#59; Antonio D&#225;valos&#44; Hospital Universitari Germans Trias i Pujol&#44; Badalona Fernando D&#237;az-Otero&#44; Hospital Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#59; Exuperio D&#237;ez-Tejedor&#44; Hospital Universitario La Paz&#44; Madrid&#59; Jos&#233; Antonio Egido&#44; Hospital Cl&#237;nico Universitario San Carlos&#44; Madrid&#59; Juan Carlos Fern&#225;ndez&#44; Hospital Universitario Dr&#46; Negr&#237;n&#44; Las Palmas&#59; Mar Freijo&#44; Hospital Universitario de Basurto&#44; Bilbao&#59; Blanca Fuentes&#44; Hospital Universitario La Paz&#44; Madrid&#59; Jaime G&#225;llego&#44; Hospital General de Navarra&#44; Pamplona&#59; Andr&#233;s Garc&#237;a Pastor&#44; Hospital Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#59; Antonio Gil-N&#250;&#241;ez&#44; Hospital Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#59; Francisco Gilo&#44; Hospital Universitario La Princesa&#44; Madrid&#59; Pablo Irimia&#44; Cl&#237;nica Universitaria de Navarra&#44; Pamplona&#59; Aida Lago&#44; Hospital Universitario La Fe&#44; Valencia&#59; Jos&#233; Maestre&#44; Hospital Universitario Virgen de las Nieves&#44; Granada&#59; Jaime Masjuan&#44; Hospital Universitario Ram&#243;n y Cajal&#44; Madrid&#59; Joan Mart&#237;-F&#225;bregas&#44; Hospital de la Santa Creu i Sant Pau&#44; Barcelona&#59; Patricia Mart&#237;nez-S&#225;nchez&#44; Hospital Universitario La Paz&#44; Madrid&#59; Eduardo Mart&#237;nez-Vila&#44; Cl&#237;nica Universitaria de Navarra&#44; Pamplona&#59; Carlos Molina&#44; Hospital Universitario Vall d&#8217;Hebron&#44; Barcelona&#59; Ana Morales&#44; Hospital Universitario Virgen de la Arrixaca&#44; Murcia&#59; Florentino Nombela&#44; Hospital Universitario La Princesa&#44; Madrid&#59; Francisco Purroy&#44; Hospital Universitario Arnau de Vilanova&#44; L&#233;rida&#59; Marc Rib&#243;&#44; Hospital Universitari Vall d&#8217;Hebron&#44; Barcelona&#59; Manuel Rodr&#237;guez-Ya&#241;ez&#44; Hospital Cl&#237;nico Universitario&#44; Santiago de Compostela&#59; Jaime Roquer&#44; Hospital del Mar&#44; Barcelona&#59; Francisco Rubio&#44; Hospital Universitario de Bellvitge&#44; Barcelona&#59; Tom&#225;s Segura&#44; Hospital Universitario de Albacete&#44; Albacete&#59; Joaqu&#237;n Serena&#44; Hospital Josep Trueta&#44; Gerona&#59; Patricia Simal&#44; Hospital Cl&#237;nico Universitario San Carlos&#44; Madrid&#59; Javier Tejada&#44; Hospital Universitario de Le&#243;n&#44; Le&#243;n&#59; Jos&#233; Vivancos&#44; Hospital Universitario La Princesa&#44; Madrid&#46;</p>"
                "etiqueta" => "A&#46;1"
                "titulo" => "Drafting committee"
                "identificador" => "sec0125"
              ]
              1 => array:4 [
                "apendice" => "<p id="par0135" class="elsevierStylePara elsevierViewall">Jos&#233; &#193;lvarez-Sab&#237;n&#44; Hospital Universitario ValldHebron&#44; Barcelona&#59; Jos&#233; Castillo&#44; Hospital Cl&#237;nico Universitario&#44; Santiago de Compostela&#59; Exuperio D&#237;ez-Tejedor&#44; Hospital Universitario La Paz&#44; Madrid&#59; Antonio Gil-N&#250;&#241;ez&#44; Hospital Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#59; Jos&#233; Larracoechea&#44; Hospital de Cruces&#44; Bilbao&#59; Eduardo Mart&#237;nez-Vila&#44; Cl&#237;nica Universitaria de Navarra&#44; Pamplona&#59; Jaime Masjuan&#44; Hospital Universitario Ram&#243;n y Cajal&#44; Madrid&#59; Jorge Mat&#237;as-Guiu&#44; Hospital Cl&#237;nico Universitario San Carlos&#44; Madrid&#59; Francisco Rubio&#44; Hospital de Bellvitge&#44; Barcelona&#46;</p>"
                "etiqueta" => "A&#46;2"
                "titulo" => "Review and institutional committee"
                "identificador" => "sec0130"
              ]
            ]
          ]
        ]
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Level of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type of study on which classification is based&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Recommendation grades</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systematic review of randomised clinical trials &#40;with homogeneity&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B &#40;extrapolation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D &#40;inconclusive studies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1b&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Randomised clinical trial with narrow confidence interval&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B &#40;extrapolation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D &#40;inconclusive studies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systematic review of cohort studies &#40;with homogeneity&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C &#40;extrapolation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D &#40;inconclusive studies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2b&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Individual cohort study &#40;including low quality randomised clinical trials&#44; e&#46;g&#46; those with a follow-up level below 80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C &#40;extrapolation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D &#40;inconclusive studies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systematic reviews of case&#8211;control studies &#40;with homogeneity&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C &#40;extrapolation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D &#40;inconclusive studies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3b&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case&#8211;control studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C &#40;extrapolation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D &#40;inconclusive studies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case series or cohort studies or low quality case&#8211;control studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D &#40;inconclusive studies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Experts&#8217; opinion without explicit critical appraisal or based on physiology or pathophysiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab265032.png"
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Levels of evidence and recommendation grades&#46; Based on the classification drawn up by the Centre for Evidence Based Medicine &#40;CEBM&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BP&#44; blood pressure&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Risk factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Recommendation grade and level of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Primary prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Measure blood pressure regularly&#59; apply lifestyle changes aimed at decreasing blood pressure &#40;smoking cessation and moderate alcohol consumption&#44; weight loss&#44; moderate physical activity&#44; lower salt consumption&#44; and higher consumption of fruits and vegetables&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Antihypertensive treatment to maintain blood pressure levels &#60;140&#47;90&#46; Maintaining levels &#60;130&#47;80 is recommended in patients with DM&#44; kidney disease&#44; or heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Secondary prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Begin antihypertensive treatment in patients with stroke&#47;TIA after the acute phase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Start treatment in patients with either high or normal blood pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- The treatment objective is BP &#60;130&#47;80<span class="elsevierStyleHsp" style=""></span>mmHg &#40;ideal level &#60;120&#47;80&#41;&#44; with target BP adapted to conditions &#40;absence of ischaemic heart disease or bilateral carotid stenosis without revascularisation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1b&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- The optimal antihypertensive treatment has not been clearly identified due to limitations of the studies that have been carried out&#46; Available data support treatment with ACE inhibitors<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>diuretics&#44; diuretics alone&#44; or ARBs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1b&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Primary prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Maintain BP &#60;130&#47;80 in diabetic patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Prescription of statins as a stroke prevention method&#44; especially in patients with other vascular risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1b&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Secondary prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Control glycaemic levels and maintain HbA1c levels below 7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dyslipidaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Primary prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Treatment with statins is appropriate for stroke prevention in adults with ischaemic heart disease&#44; diabetes mellitus&#44; or high vascular risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Secondary prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- All patients with TIA or cerebral infarction caused by atherothrombosis or small vessel disease should be treated with atorvastatin at 80<span class="elsevierStyleHsp" style=""></span>mg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1b&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Most of the patients with TIA or cerebral infarction of other aetiologies should be treated with statins due to the vascular high risk or the associated vascular diseases requiring this treatment &#40;ischaemic heart disease&#44; peripheral artery disease&#44; FM&#44; or HBP&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1b&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treatment onset level for LDL is &#8805;100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; although treatment at lower levels may be optimal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1b&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- The therapeutic objective is &#60;&#160;100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; or &#60;&#160;70<span class="elsevierStyleHsp" style=""></span>mg&#47;dl in patients with atherosclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1b&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tobacco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Avoiding or giving up smoking is recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 2a&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Avoid passive exposure to tobacco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 3b&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Use of smokeless tobacco products is not recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 2a&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Use of counselling&#44; nicotine replacement therapy&#44; and smoking cessation drugs may be appropriate&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 2b&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Men should not exceed 2 alcohol units daily&#59; women should not exceed 1 alcohol unit daily&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 2a&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asymptomatic carotid stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Carotid revascularisation may be recommended in selected patients &#40;men younger than 75 with carotid stenosis of between 70&#37; and 99&#37; and expected survival of at least 5 years&#41; with high risk of stroke&#44; provided that perioperative risk lower than 3&#37; is guaranteed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hormone replacement therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Not recommended for primary or secondary prevention of stroke in menopausal women&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hormonal contraception&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- The risk of stroke associated with the use of low-dose oral contraceptives in women without risk factors is low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 2a&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Use of oral contraceptives is not recommended in women with congenital thrombophilia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 2a&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Use of oral contraceptives is not recommended in smokers with history of migraine&#44; thrombotic episodes&#44; HBP&#44; or DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 4&#59; recommendation grade C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hyperhomocysteinaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Primary prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Although vitamin supplements reduce homocysteine levels&#44; this decrease does not have a significant impact on vascular risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Secondary prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Use of folic acid&#44; vitamin B6&#44; and vitamin B12 supplements in patients with a history of stroke is safe&#44; but these supplements do not reduce risk of new vascular episodes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thrombophilias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Primary prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Available data are insufficient to support specific therapeutic recommendations in adult patients with inherited or acquired thrombophilias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Secondary prevention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- In patients with ischaemic stroke and inherited thrombophilia&#44; doctors should check for deep venous thrombosis&#44; which requires short- or long-term anticoagulant treatment depending on clinical and haematological factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 1a&#59; recommendation grade A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Antithrombotic treatment &#40;antiplatelet or anticoagulant agents&#41; is recommended in the absence of venous thrombosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 2a&#59; recommendation grade C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Aspirin and low-intensity anticoagulation may be considered as preventive treatment in patients testing positive for antiphospholipid antibodies who have suffered a first-ever ischaemic stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Level of evidence 2b&#59; recommendation grade B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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      "titulo" => "References"
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        0 => array:2 [
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                0 => array:1 [
                  "referenciaCompleta" => "Instituto Nacional de Estad&#237;stica&#46; Defunciones seg&#250;n causa de muerte 2006&#46; Available from&#58; <a class="elsevierStyleInterRef" href="http://www.ine.es/prensa/np490.pdf">http&#58;&#47;&#47;www&#46;ine&#46;es&#47;prensa&#47;np490&#46;pdf</a> &#91;accessed 29&#46;07&#46;11&#93;&#46;"
                ]
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              "identificador" => "bib0010"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
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Article information

ISSN: 21735808
Original language: English

DOI:10.1016/j.nrleng.2011.06.004

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Year/Month	Html	Pdf	Total

2024 October	9	4	13
2024 September	24	8	32
2024 August	24	1	25
2024 July	18	10	28
2024 June	15	8	23
2024 May	20	5	25
2024 April	24	4	28
2024 March	30	8	38
2024 February	15	5	20
2024 January	25	5	30
2023 December	13	13	26
2023 November	21	14	35
2023 October	19	6	25
2023 September	11	11	22
2023 August	14	8	22
2023 July	12	4	16
2023 June	8	3	11
2023 May	23	12	35
2023 April	15	9	24
2023 March	13	10	23
2023 February	13	11	24
2023 January	21	9	30
2022 December	55	6	61
2022 November	28	15	43
2022 October	27	8	35
2022 September	21	15	36
2022 August	26	14	40
2022 July	19	27	46
2022 June	26	11	37
2022 May	29	14	43
2022 April	53	11	64
2022 March	39	26	65
2022 February	75	16	91
2022 January	67	16	83
2021 December	35	19	54
2021 November	32	17	49
2021 October	46	16	62
2021 September	36	16	52
2021 August	48	12	60
2021 July	14	11	25
2021 June	19	14	33
2021 May	34	12	46
2021 April	35	14	49
2021 March	23	5	28
2021 February	19	12	31
2021 January	28	12	40
2020 December	33	13	46
2020 November	37	9	46
2020 October	31	7	38
2020 September	51	9	60
2020 August	39	8	47
2020 July	22	13	35
2020 June	39	9	48
2020 May	22	8	30
2020 April	22	3	25
2020 March	41	6	47
2020 February	29	5	34
2020 January	56	7	63
2019 December	38	12	50
2019 November	20	8	28
2019 October	22	8	30
2019 September	17	6	23
2019 August	25	10	35
2019 July	24	14	38
2019 June	38	27	65
2019 May	97	67	164
2019 April	59	49	108
2019 March	24	12	36
2019 February	25	2	27
2019 January	21	9	30
2018 December	24	7	31
2018 November	39	15	54
2018 October	26	31	57
2018 September	25	7	32
2018 August	20	10	30
2018 July	4	3	7
2018 June	22	6	28
2018 May	27	6	33
2018 April	26	9	35
2018 March	6	4	10
2018 February	8	3	11
2018 January	1	6	7
2017 December	7	2	9
2017 November	5	6	11
2017 October	22	5	27
2017 September	22	3	25
2017 August	19	5	24
2017 July	16	10	26
2017 June	15	8	23
2017 May	25	5	30
2017 April	21	8	29
2017 March	16	28	44
2017 February	7	2	9
2017 January	20	6	26
2016 December	22	6	28
2016 November	23	5	28
2016 October	20	15	35
2016 September	45	10	55
2016 August	30	5	35
2016 July	17	3	20
2016 June	20	7	27
2016 May	27	17	44
2016 April	14	23	37
2016 March	29	29	58
2016 February	17	24	41
2016 January	16	28	44
2015 December	13	18	31
2015 November	25	29	54
2015 October	28	26	54
2015 September	39	17	56
2015 August	33	20	53
2015 July	17	12	29
2015 June	17	8	25
2015 May	21	23	44
2015 April	39	29	68
2015 March	41	14	55
2015 February	47	28	75
2015 January	61	11	72
2014 December	108	17	125
2014 November	59	14	73
2014 October	82	16	98
2014 September	60	16	76
2014 August	56	11	67
2014 July	51	16	67
2014 June	58	17	75
2014 May	39	18	57
2014 April	28	6	34
2014 March	54	15	69
2014 February	37	14	51
2014 January	25	18	43
2013 December	34	15	49
2013 November	42	20	62
2013 October	58	12	70
2013 September	51	17	68
2013 August	50	23	73
2013 July	17	10	27

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