Educating Community Pharmacists About Stroke Risks and Primary Stroke Prevention

Release Date: February 1, 2011

Expiration Date: February 28, 2013


Alan W. Y. Chock, PharmD
Assistant Professor of Pharmacy Practice

Karen K. O’Brien, BS Pharm, PharmD
Assistant Professor of Pharmacy Sciences

Julie A. Stading, PharmD, CDE
Associate Professor of Pharmacy Practice
Creighton University School of Pharmacy and Health Professions
Omaha, Nebraska

Janet L. Shea, BSN, MPA
Hampden-Wilbraham Regional School District Nursing Staff
Wilbraham, Massachusetts


Drs. Chock, O’Brien, and Stading and Ms. Shea have no actual or potential conflicts of interest in relation to this activity.

Postgraduate Healthcare Education, LLC does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced, objective, and scientifically rigorous. Occasionally, authors may express opinions that represent their own viewpoint. Conclusions drawn by participants should be derived from objective analysis of scientific data.


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Credits: 2.0 hours (0.20 ceu)
Type of Activity: Knowledge


This accredited activity is targeted to pharmacists. Estimated time to complete this activity is 120 minutes.

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Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.


To educate community pharmacists about stroke risk factors and primary stroke prevention.


After completing this activity, participants should be able to:

  1. Discuss the etiology and pathophysiology of stroke.
  2. Specify the common modifiable risk factors of stroke and how pharmacists can positively impact patients’ health status.
  3. Describe the status of public knowledge about stroke, including risk factors, prevention, emergency treatment, and recognition of stroke symptoms.
  4. Explain the role of the pharmacist in teaching the public about stroke education and prevention.

Stroke represents a major health concern for the American public, ranking as the third leading cause of death in the United States, and a leading cause of disability.1 Approximately 795,000 Americans suffer a stroke annually, with about 610,000 of these individuals experiencing their first event.2 Every 40 seconds, someone in the U.S. suffers a stroke.2 More than 134,000 individuals die annually from stroke, with a death attributable to stroke occurring every 4 minutes on average.1,2 The morbidity burden for victims, families, and society is ponderous. Twenty percent of stroke survivors require some form of institutional care 3 months after their vascular incident, while 15% to 30% of survivors suffer permanent disabilities.1 The estimated combined direct and indirect cost of stroke in 2010 is estimated to be $73.7 billion dollars.2

Modifying certain behaviors has been shown to decrease stroke incidence.1 Recognizing the signs and symptoms of strokes will help patients identify the need for medical treatment. Prompt, appropriate care may decrease the level of disability and risk of death from stroke. Therefore, having the knowledge to take quick action can be critical. Pharmacists are an integral part of the health care team, managing patients who have suffered a stroke. But what if they could help their patients avoid stroke? In the case of a first stroke, accounting for more than 77% of all strokes,1 the potential savings in terms of human suffering and cost expenditures are enormous. Because they are accessible to the public and considered trusted sources of health information, pharmacists have an opportunity to play a comprehensive role in preventing a first stroke (primary prevention) by educating the public about risk factors, healthy lifestyle choices, and the need to seek medical attention for stroke symptoms in a timely manner.


Stroke is caused by a lack of blood flow to brain tissue, resulting in neuronal deprivation of nutrients such as glucose and oxygen. As neurons are remarkably sensitive to perfusion, damage quickly ensues. Strokes may be classified as ischemic or hemorrhagic.

Ischemic stroke occurs when cerebral arterial blood flow is disrupted or completely occluded and is typically caused by intracranial thrombosis (blood clot formation) or extracranial embolism.3 With respect to stroke, a blood clot that forms intracranially is called a thrombus, whereas a blood clot, or any other mass, that forms elsewhere in the body and moves into a cerebral vessel is called a thrombotic embolus. Intracranial thrombosis occurs more commonly in large vessels such as the carotid arteries and less frequently in smaller cerebral arteries. A thrombotic embolus usually develops in the heart or extracranial arteries. The most common etiology of thrombus formation is atherosclerosis.3 Without nutrient-rich blood perfusion, cells and neurons will be exposed to a process known as ischemic cascade. In this sequence, dead (infarcted) brain cells are surrounded by hypoperfused (ischemic) tissues. The hypoperfused areas, or penumbra region, consist of compromised, though still living, brain cells that are potentially salvageable by neuroprotective medical interventions during a narrow time frame.4 Without successful medical treatment, the ischemic tissue will also die. Because anatomic structures and functions are neurologically linked to specific regions of the brain, hypoperfused brain tissue will affect the correlated body function. The stroke victim will display deficits based on the particular location of neurologic damage. The goal of initial stroke treatment is to interrupt the ischemic cascade and minimize brain cell death in order to retain maximal normal body function.

Hemorrhagic stroke is caused more commonly by intracerebral hemorrhage, where bleeding occurs directly into brain tissue. This type of stroke is frequently associated with uncontrolled hypertension and, to a smaller extent, antithrombotic or thrombolytic therapies. Less often, blood may enter the subdural or subarachnoid areas of the brain secondary to trauma or ruptured aneurysm.4 Predicting which deficits will result from a hemorrhagic stroke is challenging because confounding traumatic factors, such as increased intracranial pressure and brain edema, may add to the initial tissue damage from the bleed.3 Hemorrhagic strokes are associated with greater morbidity and higher mortality rates than ischemic strokes. Hemorrhagic stroke damage is believed to result from negative mechanical and neurotoxic effects of blood and its degradation products on neuronal tissues.4

It is difficult to classify stroke by clinical examination alone. A prompt CT scan or MRI is advisable for accurate diagnosis and treatment because therapies intended for ischemic stroke could have devastating consequences for a hemorrhagic stroke victim. Until recently, it was believed that no more than 20% of strokes were caused by hemorrhage, but in 2008 a one-year review found 41.9% of strokes to be hemorrhagic.5 Further studies are needed to better ascertain the true incidence.


Many factors, categorized as either modifiable or nonmodifiable, may confer an increased risk of stroke.1 Nonmodifiable risk factors include age; gender (males greater than females except for ages 35-44 and >85 years); family history; history of low birth weight; and race (risk for black, Hispanic/Latino, and Native American heritage greater than for white).1 Hypertension, diabetes, hyperlipidemia, smoking, obesity, and atrial fibrillation are well-documented modifiable risk factors. All people can decrease their chance for stroke through healthier lifestyle choices and by following recommended medical regimens. People who live healthy lifestyles have an 80% lower risk for first-time stroke compared to those with unhealthy behaviors.1 Even those at increased risk for stroke due to nonmodifiable factors can benefit from improvement in their health habits. Thus, it is important for everyone to recognize common modifiable stroke risk factors and know how to make healthy changes to decrease their risk for stroke. We will consider several of these factors and discuss educational interventions pharmacists can implement.


High blood pressure is considered a major independent risk factor for stroke, with stroke risk increasing as blood pressure rises.1,6 The Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure considers blood pressure less than 120/80 mmHg normotensive. Systolic blood pressure from 120 to 140 mmHg and/or diastolic blood pressure 80 to 90 mmHg is categorized as prehypertension. Patients in this category are generally managed with lifestyle modifications (TABLE 1) rather than antihypertensive medications. Compelling indications for initiating antihypertensive drug therapy in prehypertension include congestive heart failure, myocardial infarction, diabetes, chronic renal failure, and prior stroke.6


The JNC 7 recommends lowering blood pressure in hypertensive patients to <140/90 mmHg to prevent cardiovascular disease (CVD), including stroke.6 Due to a much higher probability of developing CVD, some subgroups of patients require tighter blood pressure control. For example, persons with diabetes and/ or renal disease should maintain blood pressure below 130/80 mmHg.6,7 Ongoing studies seek to identify optimal blood pressure ranges.

Antihypertensive medication therapy has demonstrated a 32% reduction of stroke occurrence.1 In spite of this compelling evidence, hypertension remains poorly controlled. Approximately two-thirds of hypertension is undetected or inadequately treated.8 Various categories of antihypertensive medications have demonstrated efficacy in decreasing stroke incidence in hypertensive patients (TABLE 2). However, it remains unclear whether any particular class of antihypertensive agent provides superior stroke prevention. Most patients can achieve blood pressure control through combinations of two or more antihypertensives, and lowering blood pressure is generally considered more important than which agent one selects to reach target levels.1

Pharmacists can help patients reduce their stroke risk by educating them about the strong link between high blood pressure and stroke, routinely checking patients’ blood pressure, and counseling patients about the need to consistently take their antihypertensives.


Diabetes, particularly type 2, is often accompanied by atherogenic risk factors, including hypertension and hyperlipidemia, which lead to an increased risk for developing atherosclerosis.1 Thus, diabetes is regarded as an independent risk factor for ischemic stroke.7

The hemoglobin A1C test (HbA1C) measures the amount of glycosylated hemoglobin in the blood. Glycosylated hemoglobin is formed by the attachment of glucose to hemoglobin in the red blood cells. HbA1C identifies the average blood glucose level over a period of approximately 3 months and is used clinically to diagnose diabetes, monitor blood glucose control, and serve as a predictor for diabetes complications.

Studies in both type 1 and type 2 diabetes have clearly demonstrated that intensively lowering blood glucose (HbA1C <6.5%) is associated with decreased rates of microvascular (retinopathy and nephropathy) and neuropathic complications.7 However, the relationship between tight glycemic control and lowering stroke risk is less certain. A recent prospective cohort study, the Northern Manhattan Study (NOMAS), provided some evidence for the benefits of tighter glucose control for primary stroke prevention.9 Additional studies will be necessary to further elucidate this relationship. Current American Diabetes Association (ADA) guidelines recommend HbA1C <7% and fasting blood glucose <130 mg/dL for diabetes control and stroke prevention.7 More stringent goals will generally be established for lowering blood pressure and hyperlipidemia in patients with diabetes in an effort to prevent CVD, including stroke.

Pharmacists can help their diabetes patients by ensuring that they have a blood glucose monitor and that they know how to correctly perform self-monitoring of blood glucose (SMBG). Patients should know their blood glucose and HbA1C targets and understand how these numbers impact their disease. Further, they should recognize that atherogenic risk factors are elevated in diabetes and confer a higher risk for stroke. Thus, careful adherence to medication therapy to control these risks is important. Pharmacists can also recommend and assist patients in adopting healthy lifestyle modifications (TABLE 1).

Low-density lipoprotein (LDL) cholesterol is the main component in the formation of atherosclerotic plaque. HMG-CoA reductase inhibitors (statins) are the primary treatment choice to lower LDL, and they have shown the greatest reduction in ischemic stroke rate of all LDL-lowering medications currently marketed in the U.S.10,11 The JUPITER (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin) trial, published in 2008, demonstrated a 48% reduction in the rate of fatal and nonfatal stroke and no greater incidence of hemorrhagic stroke in the rosuvastatin treatment group compared to those in the placebo group.12 People in the study had no history of cardiovascular disease, a baseline LDL cholesterol <130 mg/dL, and a C-reactive protein ≥2 mg/L. Besides reducing LDL, statins possess other vasculoprotective characteristics that may decrease stroke risk, including inhibition of inflammatory response, stabilization of atherosclerotic plaques, and increase of cerebral blood flow.8 Fibrates, such as gemfibrozil, and niacin in addition to a low-fat, lowcholesterol diet may contribute to reduction in the risk of stroke. Despite the beneficial effects seen with medical treatment, less than half of patients actually take lipid-lowering medication beyond 12 months.13 Pharmacists are in a key position to track adherence to drug therapy. Providing education on the risk reduction of stroke may lead to a significant increase in compliance with therapy.

The recommendations of the National Cholesterol Education Program/Adult Treatment Panel (NCEP/ ATP) by the National Heart, Lung, and Blood Institute (NHLBI) provide the most common guidelines for managing hyperlipidemia. Medications aimed at decreasing stroke risk in hyperlipidemia are listed in TABLE 3.


Cigarette smoking confers a 50% increased risk compared to nonsmoking for ischemic and hemorrhagic stroke and is associated with 12% to 14% of all stroke deaths.1,8 Surprisingly, passive smoke inhalation, or exposure to secondhand smoke, nearly doubles the stroke risk of that associated with active smoking.1 Reports from the Surgeon General note that the morbidity risk increases the longer a person smokes. Smoking appears to be a greater stroke risk factor for those under 65 years of age and for men.14 Women taking oral contraceptives (OC) have up to 2.1 times the risk of stroke compared to women who neither smoke nor use OC (the control group). However, women who both smoke and use OC have up to 7.2 times the stroke risk of the control group.1

Fortunately, cessation of tobacco smoking leads to a prompt risk reduction, approaching the stroke risk of those who never smoked.1 “Cold turkey” discontinuation of smoking is possible but difficult, and the results are frequently transitory. Behavioral and pharmacologic treatments have proven efficacious in cessation.14 A single treatment modality may be successful but poses a significant likelihood of relapse. Combining counseling with a pharmacologic agent offers a more effective and enduring solution.15 Treatment guidelines from the U.S. Department of Health and Human Services (HHS) recommend counseling as an important part of a smoking cessation program. Additionally, the social support provided by telephone hotlines and group counseling benefits those attempting to stop smoking.15

Nicotine replacement therapy (NRT) is the recommended first-line pharmaceutical agent for smoking cessation.15 NRT products (e.g., gum, inhalers, lozenges, transdermal patches) include a variety of formulations with controlled amounts of nicotine. Tapering the amount of nicotine over time allows the body to adjust to decreased nicotine levels, reducing cravings while minimizing withdrawal symptoms. Other medications such as bupropion (Zyban) and varenicline (Chantix) are effective first-line drugs that either reduce or ease nicotine withdrawal symptoms. Bupropion may be given concomitantly with NRT. Varenicline blocks the nicotine effect in relapsed smokers. In case of failure or intolerance to first-line medications, second-line medications such as nortriptyline and clonidine may be considered. However, these medications are not FDA approved for smoking cessation.

Clearly, pharmacists can help lower first-time stroke risk by providing literature about smoking cessation and community support resources, discussing risks with OC users, and helping patients choose appropriate NRT therapy.


Approximately 97 million people in the U.S. are either overweight or obese, and thus at an increased risk for many diseases including stroke.16 Helping people control their weight is a major public health challenge.

The goal of therapy is weight reduction and maintenance of a healthy weight. The NHLBI guidelines recommend a two-step treatment approach: 1) assess the level of obesity and risk of complications, and 2) initiate a routine of diet modification, physical activity, behavioral therapy, and, if necessary, a drug regimen.16

The body mass index (BMI) is a tool used to assess the status of overweight/obesity using a person’s weight and height. It provides a measure, in kilograms per meter squared, of total body fat content and is a more accurate indicator of obesity than body weight alone. A BMI of 18.5–24.9 kg/m2 is considered normal. Twenty-five to 29.9 kg/m2 is considered overweight, and anything higher is considered obese.

Measurement of waist circumference constitutes another assessment tool. Excessive abdominal fat is a risk factor for disease (i.e., type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease). Waist circumference >40 in (102 cm) in men and >35 in (88 cm) in women confers disease risk, irrespective of weight classification. Therefore, both BMI and waist circumference should be measured at baseline and to monitor for therapeutic efficacy.

All overweight and obese patients benefit from weight loss.16 However, overweight/obese individuals with concomitant coronary heart disease (CHD), atherosclerotic disease, diabetes, or sleep apnea have an increased risk of stroke. Maintaining a healthy weight is critical for such patients, and for those with three or more of the following cardiovascular risk factors: tobacco smoking, hypertension, high LDL, elevated serum triglycerides, low high-density lipoprotein (HDL), impaired fasting glucose, family history of CHD, and age (males 45 years or older, females 55 years or older).

Physical inactivity, often associated with obesity, is an independent risk factor for type 2 diabetes, CVD including stroke, and early death.

Losing Weight: The initial goal of weight loss therapy is a 10% decrease in body weight, which should occur over a period of about 6 months.16 Even moderate weight loss, if maintained, positively impacts the patient’s risk for stroke and other disease. However, too rapid weight loss may result in the development of gallstones and electrolyte imbalance and is poorly maintained.

The NHLBI recommends reducing caloric intake by 500-1,000 kcal/day, resulting in 1 to 2 lb lost per week. As weight decreases, the body requires less energy (calories) for both resting metabolism and movement, and for most people it becomes increasingly difficult to adhere to a diet after 6 months. Unfortunately, just when patients are losing motivation to diet, they must consume even fewer calories to continue losing weight. Further discussion of dietary and activity choices can benefit patients at this juncture.

Maintaining Weight Loss: When lifestyle modification alone is not effective for weight loss, medication may be useful. However, the NHBLI stresses that medication is an adjunct therapy and is considered secondary to a reduced calorie diet, increased physical exercise, and behavioral modification.16 Medications for weight loss are categorized as short-term and long-term (TABLE 4). For weight loss maintenance, short-term therapy is not usually recommended. Thus, efforts to maintain a healthy weight and avoid obesity-related complications may be indefinite.


All short-term medications are sympathomimetic central nervous system stimulants.16 Weight loss occurs through appetite suppression and increased caloric expenditure resulting from alteration of the body’s metabolic rate. Orlistat (alli, Xenical) is the only FDA approved long-term treatment available in the U.S. It prevents gastrointestinal absorption of dietary fat by inhibiting pancreatic lipase. While on orlistat, patients should be monitored for potential liver dysfunction. Another long-term medication, sibutramine (Meridia), was pulled off the market in October 2010, under recommendation of the FDA, due to increased risk of heart attack and stroke.17

Atrial Fibrillation
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the U.S., affecting approximately 2.3 million people in 2001, or 1% of the U.S. population. By 2050, it is estimated that this number will reach 5.6 million.18 The incidence of stroke is five times higher in patients with AF, and the risk increases with age. About 1.5% of AF patients 50 to 59 years of age have a stroke, compared to 23.5% of 80- to 89-year-olds.19

AF is characterized by extremely rapid beating of the atria, limiting effective atrial contraction to propel blood into the ventricles. This leads to blood pooling and stasis, with resultant thrombus formation. If the thrombus becomes dislodged, the patient may suffer a thromboembolic event, including stroke.

Antithrombotic treatment has demonstrated benefit in decreasing stroke risk. CHADS2 is a stratification system that predicts stroke risk in patients with AF, and it is used to determine appropriate anticoagulation therapy for a patient. CHADS2 is an acronym for stroke risk factors: Congestive heart failure, Hypertension, Age >75 years, Diabetes, and prior Stroke or transient ischemic attack (TIA). One point is added for the presence of each risk factor, except that a stroke or TIA is worth 2 points. The higher the total CHADS2 score, the greater the stroke risk.1 Scores range from 0 to 6 points: 0 points = low risk; 1 point = moderate risk; ≥2 points = high risk.

As stroke incidence increases with the age of the AF patient, so too does the bleeding risk associated with anticoagulation therapy. As a rule, if stroke risk exceeds bleeding risk, treat the patient with an anticoagulant. While warfarin is the mainstay of therapy for most patients with AF, those with low risk may be adequately treated with aspirin or, as an alternative, clopidogrel.1 Combining aspirin and clopidogrel is more effective than aspirin alone at reducing stroke risk, but increases the possibility of a major bleed compared to aspirin monotherapy. Those at moderate risk for stroke may receive warfarin or combination aspirin and clopidogrel if not eligible for warfarin. Those at high risk may be treated with warfarin alone, warfarin and aspirin, or the alternative of aspirin and clopidogrel. Note that the combination use of these medications increases the risk of a bleed, necessitating careful patient counseling.

The international normalized ratio (INR) is an internationally standardized method devised by the World Health Organization to report the status of blood coagulation. AF patients treated with warfarin generally undergo monthly INR monitoring. For most patients, the goal INR is 2 to 3. Lower numbers increase the risk of clotting, while higher numbers increase bleeding risk.

On October 19, 2010, dabigatran (Pradaxa), an oral direct thrombin inhibitor, received FDA approval for stroke prevention in patients with nonvalvular AF.20 Dabigatran provides the same degree of thrombus inhibition as warfarin, yet monthly INR monitoring is not required.4 A recent study compared the incidence of stroke in patients receiving warfarin (INR goal 2-3) or dabigatran (110 mg bid or 150 mg bid).21 The incidence of stroke and major bleeds was similar in the dabigatran 110 mg and warfarin groups. The dabigatran 150 mg group demonstrated increased stroke prevention compared to the warfarin group, but had a higher incidence of major bleeds. Although a causal link has not been established, the incidence of myocardial infarction was higher in both dabigatran groups compared to warfarin. Further analysis of this issue is warranted. Dyspepsia was noted to be higher in the dabigatran groups compared to the warfarin group, but overall most patients tolerated therapy well.

Regarding dabigatran overdose, no reversing antidote is presently available, as opposed to warfarin overdose, which can be reversed with vitamin K. Therefore, fresh frozen plasma or blood transfusion would be necessary should the patient experience a bleeding problem.

Despite its potential problems, dabigatran does provide an alternative to those who may not tolerate warfarin therapy.


General actions pharmacists can take to help patients safely address their risk factors for stroke include:

  • Discuss with the patient how and why to take medication(s).
  • Counsel patients about the need to consistently take their medications, and encourage them to discuss troublesome side effects with you or their physician before discontinuing medications.
  • Advise patients that there are many options from which to choose if price, side effects, or dosing regimen limits adherence to therapy.
  • Warn patients not to titrate medication doses them selves unless they have been instructed to do so by their physician.
  • Ask patients if they have any medications from other pharmacies in order to monitor their complete list and make accurate recommendations.
  • Monitor patients for OTC and herbal medication use, and assist in choosing appropriate products.
  • Monitor for regimen adherence, and provide further counseling if necessary.
  • Warn patients not to take aspirin for a suspected stroke in case the stroke is hemorrhagic, but to call 911 immediately.
  • Recommend, and assist patients in adopting, healthy lifestyle modifications.

Pharmacists should refer to the SIDEBAR (Stroke Resources for Pharmacists) for additional information about stroke and its common modifiable risk factors.

Stroke REsources for Pharmacists


Stroke is poorly understood by the general public, and community pharmacists can help change this. Though patients possess a variety of educational levels and English-language skills, the pharmacist should not assume any particular person has a good understanding of medical information. In the Healthy People 2020 objectives, the HHS proposed increasing the proportion of adults over the age of 20 years who are aware of and can respond to the early warning signs and symptoms of a stroke.22

A variety of easily accessible Web sites offer stroke information for professionals and the public. The National Stroke Association (NSA) provides clear information on its Web site (, including an easily remembered stroke assessment (FIGURE 1).23


To improve the chance of recovery in the event of stroke, it is critical for the public to recognize stroke symptoms, call 911 immediately, and to use emergency medical services (EMS) for transport to the hospital. The pharmacist’s public education campaign should also include these common stroke symptoms (from the NSA):

  • SUDDEN numbness or weakness of face, arm, or leg—especially on one side of the body.
  • SUDDEN confusion; trouble speaking or understanding.
  • SUDDEN trouble seeing in one or both eyes.
  • SUDDEN trouble walking, dizziness, loss of balance or coordination.
  • SUDDEN severe headache with no known cause.

Keep in mind that the public will retain limited knowledge about any medical topic, so provide concise, understandable information. The pharmacist is a knowledgeable community resource for education on risk factors, stroke prevention, stroke recognition, and the necessity of immediate emergency medical treatment.


In outpatient practice settings, such as community or primary care, pharmacists have already positively contributed to the medical community’s mission to care for patients with modifiable stroke risk factors.24-27 Yet with 610,000 Americans suffering a first-time stroke annually,2 a great need exists for outpatient pharmacists to educate the public about stroke risk factors, primary stroke prevention, and the necessity for prompt emergency stroke care. What if pharmacists seized the opportunity to educate their patients about stroke prevention? What if these pharmacist-driven interventions really encouraged patients to take an active role in improving their health? What if Americans were living longer, healthier lives with decreased stroke-related morbidity and mortality?

In fact, pharmacist involvement can improve disease and disability prevention, leading to fewer physician visits, decreased need for medical treatment, lower health care costs, and, most important, improved quality of life for patients. Using the many available resources, community pharmacists should acquire the knowledge and skills to pursue this goal. Certainly it won’t be easy, as outpatient pharmacists often simultaneously juggle high prescription volumes, insurance reconciliation, patient counseling, inventory management, and myriad other duties with limited time, staff support, and other resources.28 Yet creativity and the will to improve their patients’ health may combine to overcome the challenges. Medication therapy management sessions, patientcentered medical homes, community group settings, outreach programs, and dedicated space in pharmacies may provide opportunities for clinicians to educate the public. Pharmacists are available to anyone who passes by the pharmacy of any retail store, grocery store, or outpatient clinic. Pharmacists are the clinicians most accessible to the public,29,30 and they can promote this access to increase the public’s knowledge of stroke prevention and care.


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