Secondary stroke prevention

To reduce the risk of stroke recurrence, international clinical guidelines recommend various secondary prevention strategies.

 

Guidelines for secondary stroke prevention aim to standardize patient care

European Stroke Organisation (ESO), World Stroke Organization (WSO) and American Heart Association (AHA)/American Stroke Association (ASA) guidelines provide comprehensive recommendations to reduce the risk of recurrent ischemic stroke in people who have suffered a stroke or TIA.

ESO

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AHA/ASA

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WSO guidelines

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Antiplatelet therapy is indicated after non-cardioembolic ischemic stroke or high-risk TIA for secondary stroke prevention

Dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy (SAPT) is often used to reduce the risk of secondary stroke, although DAPT recommendations are dependent upon the timing and severity of the index ischemic event.

Treatment guidelines generally recommend people who have suffered an acute minor non-cardioembolic ischemic stroke or TIA in the previous 24 hours initially receive DAPT with acetylsalicylic acid (ASA) and ticagrelor/clopidogrel for up to 90 days, followed by SAPT to reduce the risk of recurrent ischemic event.

 

Use of DAPT is limited as the cumulative risk of bleeding begins to outweigh the risk of secondary ischemic stroke

Long-term use of DAPT has been shown to have no benefit over SAPT for recurrent stroke prevention, and to have a significantly increased risk of major bleeding. The exact duration of DAPT at which the risk of bleeding begins to outweigh the benefit of stroke prevention is unknown, but evidence suggests this may be after 90 days.

 

Beyond the initial weeks, DAPT shows no added benefit over SAPT for preventing recurrent strokes, but continues to increase the risk of bleeding.

DAPT and SAPT

Lipid-lowering and antihypertensive therapies combined with lifestyle changes are also essential for secondary stroke prevention

Statins

Statins are the first-line treatment for lowering low-density lipoprotein cholesterol (LDL-C) in patients who have had a stroke or TIA

In patients with ischemic stroke or TIA and atherosclerotic disease, statins and ezetimibe are recommended to lower LDL-C to a goal of <70 mg/dL to reduce the risk of recurrent stroke and other cardiovascular events.

Antihypertensive

Antihypertensive therapy is recommended for all patients with hypertension and a history of stroke or TIA

People who have suffered a stroke or TIA and have a BP of ≥130/80 mm Hg are recommended antihypertensive treatments to reduce the risk of recurrence.

Lifestyle changes

Lifestyle changes regarding nutrition, physical activity, and smoking and substance abuse cessation are also recommended

A Mediterranean diet, reduced sodium intake, regular physical activity, reduction or cessation of alcohol consumption, and cessation of smoking and substance abuse are recommended to reduce the risk of a second stroke.

"The only thing we all share that's identical is this fear of having a second stroke."
Unveil Sas’ story
secondary stroke deserves another look
Image created from Kolmos, et al. 2021, Kleindorfer, et al. 2021, Mead, et al. 2023, Dawson, et al. 2022, Dawson, et al. 2021, and Feigin, et al. 2023
For patients who have suffered from a stroke

There is a need for action to improve secondary stroke prevention.

Stroke and TIA clinical overview

The incidence of stroke is high and so is the human cost.

Stroke survivor stories

Making the invisible visible.

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