Circulation. 2002;106:388-391
doi: 10.1161/01.CIR.0000020190.45892.75
doi: 10.1161/01.CIR.0000020190.45892.75
(Circulation. 2002;106:388.)
© 2002 American Heart Association, Inc.
AHA Scientific Statement |
AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update
Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases
Key Words: AHA Scientific Statements • prevention • risk factors • cardiovascular disease • stroke
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Introduction |
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The initial Guide to the Primary Prevention of Cardiovascular Diseases was published in 1997 as an aid to healthcare professionals and their patients without established coronary artery disease or other atherosclerotic diseases.1 It was intended to complement the American Heart Association (AHA)/American College of Cardiology (ACC) Guidelines for Preventing Heart Attack and Death in Patients with Atherosclerotic Cardiovascular Disease (updated2) and to provide the healthcare professional with a comprehensive approach to patients across a wide spectrum of risk. The imperative to prevent the first episode of coronary disease or stroke or the development of aortic aneurysm and peripheral arterial disease remains as strong as ever because of the still-high rate of first events that are fatal or disabling or require expensive intensive medical care. The evidence that most cardiovascular disease is preventable continues to grow. Results of long-term prospective studies consistently identify persons with low levels of risk factors as having lifelong low levels of heart disease and stroke.3,4 Moreover, these low levels of risk factors are related to healthy lifestyles. Data from the Nurses Health Study,5 for example, suggest that in women, maintaining a desirable body weight, eating a healthy diet, exercising regularly, not smoking, and consuming a moderate amount of alcohol could account for an 84% reduction in risk, yet only 3% of the women studied were in that category. Clearly, the majority of the causes of cardiovascular disease are known and modifiable.
This 2002 update of the Guide acknowledges a number of advances in the field of primary prevention since 1997. Research continues to refine the recommendations on detection and management of established risk factors, including evidence against the safety and efficacy of interventions once thought promising (eg, antioxidant vitamins).6 This, in turn, has stimulated a large number of additional guidelines for specific demographic groups (eg, women), on individual risk factors (eg, diabetes, smoking), and for the primary prevention of stroke. In all of these guidelines, there is an increasing emphasis on further stratifying patients by level of risk and matching the intensity of interventions to the hazard for cardiovascular disease events.7
Therefore, this 2002 update of the Primary Prevention Guide serves to integrate other guidelines and consensus statements developed since the initial Guide’s approval. This Guide might be viewed as the entry point to the more specific and detailed recommendations and the rationale behind them. The recommendations, as presented in the accompanying tables, are therefore consistent with the following recommendations: Agency for Healthcare Policy and Research Guidelines on Treating Tobacco Use and Dependence8; the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI)9; the AHA Dietary Guidelines, Revision 200010; the AHA Statement on Alcohol and Heart Disease11; the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults12; American Heart Association Scientific Statements and Advisories on Physical Activity13,14 and the American College of Sports Medicine Guidelines15; the Clinical Guidelines for the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults from the National Heart, Lung, and Blood Institute Expert Panel16 and an accompanying statement from the AHA Nutrition Committee17; the American Diabetes Association Standards of Medical Care for Patients with Diabetes18,19 and the AHA Statement on Diabetes and Cardiovascular Disease20; the AHA Guidelines on the Primary Prevention of Stroke21; AHA Guidelines for Prevention of Cardiovascular Disease in Women22; ACC/AHA/European Society of Cardiology (ESC) Guidelines for the Management of Patients With Atrial Fibrillation23; the AHA Scientific Statement on Hormone Replacement Therapy and Cardiovascular Disease24; and the US Preventive Services Task Force evidence for use of aspirin in primary prevention.25 The aspirin guidelines recommended here agree with the Task Force Report in the use of aspirin in persons at high coronary and stroke risk but use a 
10% risk per 10 years rather than >6% risk over 10 years. This improves the likelihood of a positive balance of coronary risk reduction over bleeding and hemorrhagic stroke caused by aspirin.26,27
Although this Guide largely applies to adults, it does identify high-risk patients for whom screening and intervention in first-degree relatives (including children) would be an important aspect of primary prevention. However, this Guide will not provide specific recommendations for the reduction of cardiovascular risk in children and adolescents. This important issue will be the subject of a separate guide. However, a family-centered approach to primary prevention should be emphasized, inasmuch as it recognizes both the genetic and behavioral causes of the well-established familial aggregation of heart disease and stroke.
This Guide is intended to assist primary care providers in their assessment, management, and follow-up of patients who may be at risk for but who have not yet manifested cardiovascular disease. The continuing message is that adoption of healthy life habits remains the cornerstone of primary prevention, including the avoidance of tobacco (including secondhand smoke), healthy dietary patterns, weight control, and regular, appropriate exercise. An important role of healthcare providers is to support and reinforce these public health recommendations for all patients.
Table 1 is presented to guide the identification and assessment of modifiable risk. The assessment of absolute cardiac risk is increasingly advocated by international organizations and by individual risk factor guidelines in the United States.12,25,28 The Framingham database has been widely used, though we acknowledge that the multiple risk score may not apply equally to all sex, race, and ethnic groups.29,30 The use of more sophisticated technologies than a risk factor inventory and global risk score has been addressed,31 and we conclude that most screening tests for occult atherosclerosis remain in the research arena, with the exception of the ankle-brachial blood pressure index. Similarly, those recommended interventions involving "nutriceutical" and pharmaceutical interventions in Table 2 have support from randomized clinical trials establishing their efficacy and safety. More controversial interventions, such as very low-fat diets,32 dietary supplements,6,33 and potentially cardioprotective drugs other than aspirin require additional investigation in well-designed clinical trials in persons without established cardiovascular disease.
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The gap between which evidence-based interventions are recommended and what is actualized is large.34,35 Guidelines, even when based on the best available evidence from randomized, controlled trials, cannot be successfully implemented without acceptance by the entire healthcare team, including physicians, nurses, nutritionists, and other healthcare professionals. A physician-patient partnership must be forged, on the physician’s part by assessing and communicating risk and by codeveloping with the patient a plan of preventive action. New tools for providers are available to foster this partnership, such as the AHA’s Get With the Guidelines.36 Information for the public on cardiovascular and stroke risk factors is available on the AHA web site.37
The challenge for healthcare professionals is to engage greater numbers of patients, at an earlier stage of their disease, in comprehensive cardiovascular risk reduction with the use of interventions that are designed to circumvent or alleviate barriers to participation and adherence, so that many more individuals may realize the benefits that primary prevention can provide. The healthcare professional should create an environment supportive of risk factor change, including long-term reinforcement of adherence to lifestyle and drug interventions. Practice-based systems for risk factor monitoring, reminders, and support services need to be established, reimbursed, and otherwise supported by managed care organizations and third-party payers. Primary prevention, by its very nature, requires a lifetime of interactions that virtually define successful provider-patient relationships.
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Footnotes |
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The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on February 21, 2002. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0226. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4426, fax 410-528-4264, or e-mail kbradle@lww.com. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.
*From the Population Science Committee of the American Heart Association. 
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R. S. Vasan Biomarkers of Cardiovascular Disease: Molecular Basis and Practical Considerations Circulation, May 16, 2006; 113(19): 2335 - 2362. [Full Text] [PDF]
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S. M. Grundy Metabolic Syndrome: Connecting and Reconciling Cardiovascular and Diabetes Worlds J. Am. Coll. Cardiol., March 21, 2006; 47(6): 1093 - 1100. [Abstract] [Full Text] [PDF]
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R. L. Sacco, R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, P. Gorelick, J. Halperin, R. Harbaugh, et al. Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline. Circulation, March 14, 2006; 113(10): e409 - e449. [Abstract] [Full Text] [PDF]
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M. Pignone, S. Earnshaw, J. A. Tice, and M. J. Pletcher Aspirin, statins, or both drugs for the primary prevention of coronary heart disease events in men: a cost-utility analysis. Ann Intern Med, March 7, 2006; 144(5): 326 - 336. [Abstract] [Full Text] [PDF]
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H. F. McGruder, J. B. Croft, and Z.-J. Zheng Characteristics of an "Ill-Defined" Diagnosis for Stroke: Opportunities for Improvement Stroke, March 1, 2006; 37(3): 781 - 789. [Abstract] [Full Text] [PDF]
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P. Kohli and P. Greenland Role of the Metabolic Syndrome in Risk Assessment for Coronary Heart Disease JAMA, February 15, 2006; 295(7): 819 - 821. [Full Text] [PDF]
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G. L. Gierach, B. D. Johnson, C. N. Bairey Merz, S. F. Kelsey, V. Bittner, M. B. Olson, L. J. Shaw, S. Mankad, C. J. Pepine, S. E. Reis, et al. Hypertension, Menopause, and Coronary Artery Disease Risk in the Women's Ischemia Syndrome Evaluation (WISE) Study J. Am. Coll. Cardiol., February 7, 2006; 47(3_Suppl_S): S50 - S58. [Abstract] [Full Text] [PDF]
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R. L. Sacco, R. Adams, G. Albers, M. J. Alberts, O. Benavente, K. Furie, L. B. Goldstein, P. Gorelick, J. Halperin, R. Harbaugh, et al. Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline. Stroke, February 1, 2006; 37(2): 577 - 617. [Abstract] [Full Text] [PDF]
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J. S. Berger, M. C. Roncaglioni, F. Avanzini, I. Pangrazzi, G. Tognoni, and D. L. Brown Aspirin for the Primary Prevention of Cardiovascular Events in Women and Men: A Sex-Specific Meta-analysis of Randomized Controlled Trials JAMA, January 18, 2006; 295(3): 306 - 313. [Abstract] [Full Text] [PDF]
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L. L. Yan, M. L. Daviglus, K. Liu, J. Stamler, R. Wang, A. Pirzada, D. B. Garside, A. R. Dyer, L. Van Horn, Y. Liao, et al. Midlife Body Mass Index and Hospitalization and Mortality in Older Age JAMA, January 11, 2006; 295(2): 190 - 198. [Abstract] [Full Text] [PDF]
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M. E. Clouse, J. Chen, H. M. Krumholz, M. E. Clouse, J. Chen, and H. M. Krumholz Noninvasive Screening for Coronary Artery Disease With Computed Tomography Is Useful Circulation, January 3, 2006; 113(1): 125 - 146. [Full Text] [PDF]
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S. M. Grundy, J. I. Cleeman, S. R. Daniels, K. A. Donato, R. H. Eckel, B. A. Franklin, D. J. Gordon, R. M. Krauss, P. J. Savage, S. C. Smith Jr, et al. Diagnosis and Management of the Metabolic Syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement Circulation, October 25, 2005; 112(17): 2735 - 2752. [Full Text] [PDF]
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D. E. Laaksonen, L. Niskanen, K. Nyyssonen, K. Punnonen, T.-P. Tuomainen, and J. T. Salonen C-reactive protein in the prediction of cardiovascular and overall mortality in middle-aged men: a population-based cohort study Eur. Heart J., September 1, 2005; 26(17): 1783 - 1789. [Abstract] [Full Text] [PDF]
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J. J. Saseen ASHP Therapeutic Position Statement on the Daily Use of Aspirin for Preventing Cardiovascular Events Am. J. Health Syst. Pharm., July 1, 2005; 62(13): 1398 - 1405. [Full Text] [PDF]
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H. Koga, S. Sugiyama, K. Kugiyama, K. Watanabe, H. Fukushima, T. Tanaka, T. Sakamoto, M. Yoshimura, H. Jinnouchi, and H. Ogawa Elevated Levels of VE-Cadherin-Positive Endothelial Microparticles in Patients With Type 2 Diabetes Mellitus and Coronary Artery Disease J. Am. Coll. Cardiol., May 17, 2005; 45(10): 1622 - 1630. [Abstract] [Full Text] [PDF]
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C. Heiss, S. Keymel, U. Niesler, J. Ziemann, M. Kelm, and C. Kalka Impaired Progenitor Cell Activity in Age-Related Endothelial Dysfunction J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1441 - 1448. [Abstract] [Full Text] [PDF]
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Task Force Members, L. H. Schwamm, A. Pancioli, J. E. Acker III, L. B. Goldstein, R. D. Zorowitz, T. J. Shephard, P. Moyer, M. Gorman, S. C. Johnston, et al. Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association's Task Force on the Development of Stroke Systems Stroke, March 1, 2005; 36(3): 690 - 703. [Full Text] [PDF]
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L. H. Schwamm, A. Pancioli, J. E. Acker III, L. B. Goldstein, R. D. Zorowitz, T. J. Shephard, P. Moyer, M. Gorman, S. C. Johnston, P. W. Duncan, et al. Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association's Task Force on the Development of Stroke Systems Circulation, March 1, 2005; 111(8): 1078 - 1091. [Full Text] [PDF]
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L. Mosca, A. H. Linfante, E. J. Benjamin, K. Berra, S. N. Hayes, B. W. Walsh, R. P. Fabunmi, J. Kwan, T. Mills, and S. L. Simpson National Study of Physician Awareness and Adherence to Cardiovascular Disease Prevention Guidelines Circulation, February 1, 2005; 111(4): 499 - 510. [Abstract] [Full Text] [PDF]
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R. Bugiardini and C. N. Bairey Merz Angina With "Normal" Coronary Arteries: A Changing Philosophy JAMA, January 26, 2005; 293(4): 477 - 484. [Abstract] [Full Text] [PDF]
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R. J. Johnson, D. I. Feig, J. Herrera-Acosta, and D.-H. Kang Resurrection of Uric Acid as a Causal Risk Factor in Essential Hypertension Hypertension, January 1, 2005; 45(1): 18 - 20. [Full Text] [PDF]
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P. van der Harst, M. Volbeda, A. A. Voors, H. Buikema, S. Wassmann, M. Bohm, G. Nickenig, and W. H. van Gilst Vascular Response to Angiotensin II Predicts Long-Term Prognosis in Patients Undergoing Coronary Artery Bypass Grafting Hypertension, December 1, 2004; 44(6): 930 - 934. [Abstract] [Full Text] [PDF]
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K.-T. Khaw, S. Bingham, A. Welch, R. Luben, E. O'Brien, N. Wareham, and N. Day Blood pressure and urinary sodium in men and women: the Norfolk Cohort of the European Prospective Investigation into Cancer (EPIC-Norfolk) Am. J. Clinical Nutrition, November 1, 2004; 80(5): 1397 - 1403. [Abstract] [Full Text] [PDF]
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C. H. Hennekens, G. L. Knatterud, and M. A. Pfeffer Use of Aspirin to Reduce Risks of Cardiovascular Disease in Patients With Diabetes: Clinical and research challenges Diabetes Care, November 1, 2004; 27(11): 2752 - 2754. [Full Text] [PDF]
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S. Ornstein, R. G. Jenkins, P. J. Nietert, C. Feifer, L. F. Roylance, L. Nemeth, S. Corley, L. Dickerson, W. D. Bradford, and C. Litvin A Multimethod Quality Improvement Intervention To Improve Preventive Cardiovascular Care: A Cluster Randomized Trial Ann Intern Med, October 5, 2004; 141(7): 523 - 532. [Abstract] [Full Text] [PDF]
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G. J. Balady, M. G. Larson, R. S. Vasan, E. P. Leip, C. J. O'Donnell, and D. Levy Usefulness of Exercise Testing in the Prediction of Coronary Disease Risk Among Asymptomatic Persons as a Function of the Framingham Risk Score Circulation, October 5, 2004; 110(14): 1920 - 1925. [Abstract] [Full Text] [PDF]
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K.-T. Khaw, N. Wareham, S. Bingham, R. Luben, A. Welch, and N. Day Association of Hemoglobin A1c with Cardiovascular Disease and Mortality in Adults: The European Prospective Investigation into Cancer in Norfolk Ann Intern Med, September 21, 2004; 141(6): 413 - 420. [Abstract] [Full Text] [PDF]
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I. Meissner, B. K. Khandheria, S. G. Sheps, G. L. Schwartz, D. O. Wiebers, J. P. Whisnant, J. L. Covalt, T. M. Petterson, T. J.H. Christianson, and Y. Agmon Atherosclerosis of the aorta: Risk factor, risk marker, or innocent bystander?: A prospective population-based transesophageal echocardiography study J. Am. Coll. Cardiol., September 1, 2004; 44(5): 1018 - 1024. [Abstract] [Full Text] [PDF]
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H. Eyre, R. Kahn, R. M. Robertson, and and the ACS/ADA/AHA Collaborative Writing Committe Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association Stroke, August 1, 2004; 35(8): 1999 - 2010. [Abstract] [Full Text] [PDF]
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H. Eyre, R. Kahn, and R. M. Robertson Preventing Cancer, Cardiovascular Disease, and Diabetes: A common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association Diabetes Care, July 1, 2004; 27(7): 1812 - 1824. [Abstract] [Full Text] [PDF]
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H. Eyre, R. Kahn, R. M. Robertson, the ACS/ADA/AHA Collaborative Writing Committee, ACS/ADA/AHA Collaborative Writing Committee Member, N. G. Clark, C. Doyle, Y. Hong, T. Gansler, T. Glynn, et al. Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association Circulation, June 29, 2004; 109(25): 3244 - 3255. [Abstract] [Full Text] [PDF]
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E. R. Cox, M. Frisse, A. Behm, and K. A. Fairman Over-the-Counter Pain Reliever and Aspirin Use Within a Sample of Long-term Cyclooxygenase 2 Users Arch Intern Med, June 14, 2004; 164(11): 1243 - 1246. [Full Text] [PDF]
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M. J. LaMonte, M. Z. Nichaman, S. N. Blair, J. K. Ninomiya, M. H. Criqui, A. Gamst, G. L'Italien, J. L. Whyte, and R. S. Chen Physical Activity and the Metabolic Syndrome Association With Myocardial Infarction and Stroke * Response Circulation, June 8, 2004; 109(22): e314 - e314. [Full Text] [PDF]
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J. Liu, Y. Hong, R. B. D'Agostino Sr, Z. Wu, W. Wang, J. Sun, P. W. F. Wilson, W. B. Kannel, and D. Zhao Predictive Value for the Chinese Population of the Framingham CHD Risk Assessment Tool Compared With the Chinese Multi-provincial Cohort Study JAMA, June 2, 2004; 291(21): 2591 - 2599. [Abstract] [Full Text] [PDF]
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R. D. Brook, B. Franklin, W. Cascio, Y. Hong, G. Howard, M. Lipsett, R. Luepker, M. Mittleman, J. Samet, S. C. Smith Jr, et al. Air Pollution and Cardiovascular Disease: A Statement for Healthcare Professionals From the Expert Panel on Population and Prevention Science of the American Heart Association Circulation, June 1, 2004; 109(21): 2655 - 2671. [Abstract] [Full Text] [PDF]
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N. F. Gordon, M. Gulanick, F. Costa, G. Fletcher, B. A. Franklin, E. J. Roth, and T. Shephard Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council Stroke, May 1, 2004; 35(5): 1230 - 1240. [Full Text] [PDF]
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N. F. Gordon, M. Gulanick, F. Costa, G. Fletcher, B. A. Franklin, E. J. Roth, and T. Shephard Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council Circulation, April 27, 2004; 109(16): 2031 - 2041. [Full Text] [PDF]
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O. Honda, S. Sugiyama, K. Kugiyama, H. Fukushima, S. Nakamura, S. Koide, S. Kojima, N. Hirai, H. Kawano, H. Soejima, et al. Echolucent carotid plaques predict future coronary events in patients with coronary artery disease J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1177 - 1184. [Abstract] [Full Text] [PDF]
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Expert Panel/Writing Group, L. Mosca, L. J. Appel, E. J. Benjamin, K. Berra, N. Chandra-Strobos, R. P. Fabunmi, D. Grady, C. K. Haan, S. N. Hayes, et al. Evidence-based guidelines for cardiovascular disease prevention in women J. Am. Coll. Cardiol., March 3, 2004; 43(5): 900 - 921. [Abstract] [Full Text] [PDF]
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L. Mosca and for the Expert Panel/WritingGroup Summary of the American Heart Association's Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women Arterioscler. Thromb. Vasc. Biol., March 1, 2004; 24(3): 394 - 396. [Full Text]
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L. Mosca, L. J. Appel, E. J. Benjamin, K. Berra, N. Chandra-Strobos, R. P. Fabunmi, D. Grady, C. K. Haan, S. N. Hayes, D. R. Judelson, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women Arterioscler. Thromb. Vasc. Biol., March 1, 2004; 24(3): e29 - 50. [Full Text]
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