The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

These findings support the hypothesis that sleep duration is associated with obesity in a large longitudinally monitored United States sample. These observations support earlier experimental sleep studies and provide a basis for future studies on weight control interventions that increase the quantity and quality of sleep.

Background-Stroke incidence is greater in blacks than in whites; data on Hispanics are limited. Comparing subtype-specific ischemic stroke incidence rates may help to explain race-ethnic differences in stroke risk. The aim of this population-based study was to determine ischemic stroke subtype incidence rates for whites, blacks, and Hispanics living in one community. Methods and Results-A comprehensive stroke surveillance system incorporating multiple overlapping strategies was used to identify all cases of first ischemic stroke occurring between July 1, 1993, and June 30, 1997, in northern Manhattan. Ischemic stroke subtypes were determined according to a modified NINDS scheme, and age-adjusted, race-specific incidence rates calculated. The annual age-adjusted incidence of first ischemic stroke per 100 000 was 88 (95% CI, 75 to 101) in whites, 149 (95% CI, 132 to 165) in Hispanics, and 191 (95% CI, 160 to 221) in blacks. Among blacks compared with whites, the relative rate of intracranial atherosclerotic stroke was 5.85 (95% CI, 1.82 to 18.73); extracranial atherosclerotic stroke, 3.18 (95% CI, 1.42 to 7.13); lacunar stroke, 3.09 (95% CI, 1.86 to 5.11); and cardioembolic stroke, 1.58 (95% CI, 0.99 to 2.52). Among Hispanics compared with whites, the relative rate of intracranial atherosclerotic stroke was 5.00 (95% CI, 1.69 to 14.76); extracranial atherosclerotic stroke, 1.71 (95% CI, 0.80 to 3.63); lacunar stroke, 2.32 (95% CI, 1.48 to 3.63); and cardioembolic stroke, 1.42 (95% CI, 0.97 to 2.09). Conclusions-The high ischemic stroke incidence among blacks and Hispanics compared with whites is due to higher rates of all ischemic stroke subtypes.

Abstract-Depriving healthy subjects of sleep has been shown to acutely increase blood pressure and sympathetic nervous system activity. Prolonged short sleep durations could lead to hypertension through extended exposure to raised 24-hour blood pressure and heart rate, elevated sympathetic nervous system activity, and increased salt retention. Such forces could lead to structural adaptations and the entrainment of the cardiovascular system to operate at an elevated pressure equilibrium. Sleep disorders are associated with cardiovascular disease, but we are not aware of any published prospective population studies that have shown a link between short sleep duration and the incidence of hypertension in subjects without apparent sleep disorders. We assessed whether short sleep duration would increase the risk for hypertension incidence by conducting longitudinal analyses of the first National Health and Nutrition Examination Survey (nϭ4810) using Cox proportional hazards models and controlling for covariates. Hypertension incidence (nϭ647) was determined by physician diagnosis, hospital record, or cause of death over the 8-to 10-year follow-up period between 1982 and 1992. Sleep durations of Յ5 hours per night were associated with a significantly increased risk of hypertension (hazard ratio, 2.10; 95% CI, 1.58 to 2.79) in subjects between the ages of 32 and 59 years, and controlling for the potential confounding variables only partially attenuated this relationship. The increased risk continued to be significant after controlling for obesity and diabetes, which was consistent with the hypothesis that these variables would act as partial mediators. Short sleep duration could, therefore, be a significant risk factor for hypertension.

Stroke mortality is reported to be greater in blacks than in whites, but stroke incidence data for blacks and Hispanics are sparse. The aim of this study was to determine and compare stroke incidence rates among whites, blacks, and Hispanics living in the same urban community. A population-based incidence study was conducted to identify all cases of first stroke occurring in northern Manhattan, New York City, between July 1, 1993, and June 30, 1996. The population of this area was approximately 210,000 at that time, based on 1990 US Census data. Surveillance for hospitalized and nonhospitalized stroke consisted of daily screening of all admissions, discharges, and computed tomography logs at Columbia-Presbyterian Medical Center, the only hospital in the region, and review of discharge lists from outside hospitals, telephone surveys of random households, and contacts with community physicians, Visiting Nurses' Services, and community agencies. Stroke incidence increased with age and was greater in men than in women. The average annual age-adjusted stroke incidence rate at age > or =20 years, per 100,000 population, was 223 for blacks, 196 for Hispanics, and 93 for whites. Blacks had a 2.4-fold and Hispanics a twofold increase in stroke incidence compared with whites. Cerebral infarct accounted for 77 percent of all strokes, intracerebral hemorrhage for 17 percent, and subarachnoid hemorrhage for 6 percent. These data from the Northern Manhattan Stroke Study suggest that part of the reported excess stroke mortality among blacks in the United States may be a reflection of racial/ethnic differences in stroke incidence.