Acknowledgments We thank medical librarians Ann Farrell at Mayo Clinic Rochester and Tara Brigham at Mayo Clinic Florida for assistance with a sys- tematic review of the medical literature. Migraine cont'd Closure of patent foramen ovale is not indicated for preventing stroke in patients with migraine (Class III; Level of Evidence B). New recommendation Drug abuse Referral to an appropriate therapeutic program is reasonable for patients who abuse drugs that have been associated with stroke, including cocaine, khat, and amphetamines (Class IIa; Level of Evidence C). Wording slightly revised to specifically list drugs associated with stroke Sleep-disordered breathing Because of its association with stroke risk, screening for sleep apnea through a detailed history, including structured questionnaires such as the Epworth Sleepiness Scale and Berlin Questionnaire, physical examination, and, if indicated, polysomnography may be considered (Class IIb; Level of Evidence C). Wording slightly revised to include polysomnography and use of specific questionnaires. Recommendation class and LOE have been downgraded. Elevated lipoprotein(a) The clinical benefit of using lipoprotein(a) in stroke risk prediction is not well established (Class IIb; Level of Evidence B). New recommendation Inflammation and infection Treatment of patients with high-sensitivity C-reactive protein >2.0 mg/dL with a statin to decrease stroke risk might be considered (Class IIb; Level of Evidence B). The revised recommendation now defines elevated high-sensitivity C-reactive protein as >2.0 mg/ dL in the context of considering statin initiation Antiplatelet agents and aspirin The use of aspirin for cardiovascular (including but not specific to stroke) prophylaxis is reasonable for people whose risk is sufficiently high (10-y risk >10%) for the benefits to outweigh the risks associated with treatment. A cardiovascular risk calculator to assist in estimating 10-y risk can be found online at http://my.americanheart.org/cvriskcalculator (Class IIa; Level of Evidence A). Reworded to include cardiovascular risk calculator and link; changed from Class I to IIa Aspirin might be considered for the prevention of a first stroke in people with chronic kidney disease (ie, estimated glomerular filtration rate <45 mL min 1 ) (Class IIb; Level of Evidence C). This recommendation does not apply to severe kidney disease (stage 4 or 5; estimated glomerular filtration rate <30 mL min 1 ). New recommendation Cilostazol may be reasonable for the prevention of a first stroke in people with peripheral arterial disease (Class IIb; Level of Evidence B). New recommendation As a result of a lack of relevant clinical trials, antiplatelet regimens other than aspirin and cilostazol are not recommended for the prevention of a first stroke (Class III; Level of Evidence C). New recommendation ACC indicates American College of Cardiology; AHA, American Heart Association; CDC, Centers for Disease Control and Prevention; CV, cardiovascular; INR, international normalized ratio; LOE, level of evidence; and NCEP, National Cholesterol Education Program. *This table does not include recommendations that have been removed. Table 5. Continued Section 2014 Recommendation Description of Change from 2011 Meschia et al Guidelines for the Primary Prevention of Stroke 3805 Writing Group Disclosures Writing Group Member Employment Research Grant Other Research Support Speakers Bureau/ Honoraria Expert Witness Ownership Interest Consultant/Advisory Board Other James F. Meschia Mayo Clinic NINDS None None None None None None Cheryl Bushnell Wake Forest University Baptist Medical Center World Federation of Neurology None None None None None None Bernadette Boden-Albala New York University, Global Institute of Public Health NIH None None None None None None Lynne T. Braun Rush University Medical Center NIH None None None None Nurse Practitioner Advisory Board*; UpToDate* None Dawn M. Bravata Department of Veteran Affairs Department of Veteran Affairs ; NIH/NHLBI None None None None None None Seemant Chaturvedi University of Miami Miller School of Medicine None None None None None Abbott Vascular*; Boehringer-Ingelheim*; Thornhill Research* W.L. Gore* None Mark A. Creager Brigham and Women s Hospital Medtronic ; NIH None None None None AstraZeneca ; Baxter Healthcare*; Merck (via TIMI Group)*; Novartis*; Takeda* None Robert H. Eckel University of Colorado at Denver None None None None None Amarin*; Amylin*; Genetech*; Janssen, Johnson & Johnson*; Lilly*; Novo Nordisk*; Regulus*; Sanofi-Aventis* None Mitchell S.V. Elkind Columbia University BMS/Sanofi ; diaDexus, Inc NIH None None Merck Organon (Nuvaring and stroke) ; Novartis (aliskiren and stroke)* None BMS-Pfizer Pharmaceutical Partnership*; Janssen*; Daiichi Sankyo*; Biogen IDEC* None Myriam Fornage University of Texas Health Science Center at Houston None None None None None None None Larry B. Goldstein Duke University None None Pfizer* None None Daiichi Sankyo* None Steven M. Greenberg Massachusetts General Hospital NIH/NINDS None None None None None None Susanna E. Horvath Columbia University None None None None None None None Costantino Iadecola Weill Cornell Medical College None None None None None None None Edward C. Jauch Medical University of South Carolina NIH/NINDS None None None None None None Wesley S. Moore University of California at Los Angeles None None None None None None None John A. Wilson Wake Forest School of Medicine None None None None None None None This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be significant if (a) the person receives $10000 or more during any 12-month period, or 5% or more of the person s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10000 or more of the fair market value of the entity. A relationship is considered to be modest if it is less than significant under the preceding definition. *Modest. Significant. Disclosures References 1. 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Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E, Hatsukami TS, Higashida RT, Johnston SC, Kidwell CS, Lutsep HL, Reviewer Disclosures Reviewer Employment Research Grant Other Research Support Speakers Bureau/ Honoraria Expert Witness Ownership Interest Consultant/Advisory Board Other Kevin M. Cockroft Penn State Hershey Medical Center None None None None None Covidien Neurovascular* None Karen L. Furie Rhode Island Hospital None None None None None None None David M Greer Yale University None None None None None None None Millie Hepburn-Smith NYU Langone Medical Center None None None None None American Association of NeuroScience Nurses (member of the Board of Directors)*; National Aphasia Association (Board of Directors)* None Steven J. Kittner University of Maryland 1U01NS069208 The Stroke Genetics Network (SiGN) Study is an NINDS-funded international consortium to study the genetics of ischemic stroke and ischemic stroke Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) is an NINDS-funded study of the risk factors for intracerebral hemorrhage occurrence and outcome* None None None None None None Tatjana Rundek University of Miami None None None None None None None This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be significant if (a) the person receives $10000 or more during any 12-month period, or 5% or more of the person s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10000 or more of the fair market value of the entity. 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