http://cardiologia.publicacionmedica.com/contenido/images/stemi_aha_2013.pdf

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Background Statins reduce the incidence of strokes among patients at increased risk for cardiovascular disease; whether they reduce the risk of stroke after a recent stroke or transient ischemic attack (TIA) remains to be established. Methods We randomly assigned 4731 patients who had had a stroke or TIA within one to six months before study entry, had low-density lipoprotein (LDL) cholesterol levels of 100 to 190 mg per deciliter (2.6 to 4.9 mmol per liter), and had no known coronary heart disease to double-blind treatment with 80 mg of atorvastatin per day or placebo. The primary end point was a first nonfatal or fatal stroke. Results The mean LDL cholesterol level during the trial was 73 mg per deciliter (1.9 mmol per liter) among patients receiving atorvastatin and 129 mg per deciliter (3.3 mmol per liter) among patients receiving placebo. During a median follow-up of 4.9 years, 265 patients (11.2 percent) receiving atorvastatin and 311 patients (13.1 percent) receiving placebo had a fatal or nonfatal stroke (5-year absolute reduction in risk, 2.2 percent; adjusted hazard ratio, 0.84; 95 percent confidence interval, 0.71 to 0.99; P=0.03; unadjusted P=0.05). The atorvastatin group had 218 ischemic strokes and 55 hemorrhagic strokes, whereas the placebo group had 274 ischemic strokes and 33 hemorrhagic strokes. The five-year absolute reduction in the risk of major cardiovascular events was 3.5 percent (hazard ratio, 0.80; 95 percent confidence interval, 0.69 to 0.92; P=0.002). The overall mortality rate was similar, with 216 deaths in the atorvastatin group and 211 deaths in the placebo group (P=0.98), as were the rates of serious adverse events. Elevated liver enzyme values were more common in patients taking atorvastatin. Conclusions In patients with recent stroke or TIA and without known coronary heart disease, 80 mg of atorvastatin per day reduced the overall incidence of strokes and of cardiovascular events, despite a small increase in the incidence of hemorrhagic stroke. (ClinicalTrials.gov number, NCT00147602 [ClinicalTrials.gov].).

High-dose atorvastatin after stroke or transient ischemic attack.

### Preamble

A primary challenge in the development of clinical practice guidelines is keeping pace with the stream of new data on which recommendations are based. In an effort to respond promptly to new evidence, the American College of Cardiology Foundation/American Heart Association (ACCF/AHA)

https://onlinelibrary.wiley.com/doi/pdf/10.1002/ccd.22351

2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update)†

BackgroundPatients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease. MethodsIn this multicenter, double-blind trial, we randomly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo. Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index. The primary outcome was fatal or nonfatal stroke or myocardial infarction. ResultsBy 4.8 years, a primary outcome had occurred in 175 of 1939 patients (9.0%) in the pioglitazone group and in 228 of 1937 (11.8%) in the placebo group...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1506930

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack

Background Combination antiplatelet therapy with clopidogrel and aspirin may reduce the rate of recurrent stroke during the first 3 months after a minor ischemic stroke or transient ischemic attack (TIA). A trial of combination antiplatelet therapy in a Chinese population has shown a reduction in the risk of recurrent stroke. We tested this combination in an international population. Methods In a randomized trial, we assigned patients with minor ischemic stroke or high-risk TIA to receive either clopidogrel at a loading dose of 600 mg on day 1, followed by 75 mg per day, plus aspirin (at a dose of 50 to 325 mg per day) or the same range of doses of aspirin alone. The dose of aspirin in each group was selected by the site investigator. The primary efficacy outcome in a time-to-event analysis was the risk of a composite of major ischemic events, which was defined as ischemic stroke, myocardial infarction, or death from an ischemic vascular event, at 90 days. Results A total of 4881 patients were en...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1800410

Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA.

Developing and implementing successful interventions often depend upon effectively addressing ethnicity and social class factors, as these influence sexual behavior and its risks. Sexual attitudes differ across cultures. In most cultures, there are strong standards regarding sexual behavior which differ for men and women. Cultural differences also affect the extent to which early sexual behavior is considered acceptable.

Guidelines for Prevention, I

1.What's at Stake: Consequences of Risky Sexual Behavior. 2.Factors That Influence Sexual Behavior: Causes, Mediators, and Moderators of High-Risk Sexual Behavior. 3.Models of Prevention. 4.Guidelines for Prevention, I: Ethnicity and Social Class Considerations. 5.Guidelines for Intervention, II: Women. 6.Guidelines for Intervention, III: Gay Men and Bisexuals. Epilogue. Index.

High-risk sexual behavior : interventions with vulnerable populations

High-risk sexual behavior

The tendency to engage in high-risk sexual behavior may be influenced by a number of factors. In this chapter, we will examine the effects of psychological variables, such as low self-esteem, locus of control, dissociation, and denial, on sexual practices. We will also look at the evidence for effects of alcohol and other drugs on sexual behavior. The ways in which poverty and the associated lack of opportunity impact risky behavior will be discussed, as will the effects of lack of knowledge about sex, about reproductive biology, and about their associated risks.

Factors that Influence Sexual Behavior

In this chapter, four specific, powerful models of prevention currently in use are presented, together with the effective intervention strategies that have developed out of these models. First, underlying theoretical concepts are described. Prochaska and DiClemente (1984) have delineated a five-stage model as a transtheoretical approach to understanding how human beings change behavior. The five stages (precontemplation, contemplation, preparation, action, and maintenance) are described here, along with the implications of this model for changing high-risk sexual behavior. Other cognitive behavioral constructs are then described which have been shown to be effective in designing effective intervention strategies, including the Theory of Reasoned Action (Azjen & Fishbein, 1980) and the Information-Motivation-Behavioral Skills (IMB) Model developed by Fisher and Fisher (1992) specifically for HIV prevention work. Various applications of the IMB Model are described, including the use of Natural Opinion Leaders (NOLs; Kelly et al., 1991) who generate support for the intervention among their peers. Next, “Reducing the Risk,” a school-based intervention to decrease high-risk sexual behavior (Kirby, Barth, Leland, & Fetro, 1991), is described. Models for preventing teen pregnancy are then discussed, which include attention to the effects of personality factors, cognitive components, and social and environmental elements.

Elizabeth Rankin

Papers

Guidelines for Prevention, I

High-risk sexual behavior : interventions with vulnerable populations

High-risk sexual behavior

Factors that Influence Sexual Behavior

Models of Prevention