From the Guidelines
Secondary stroke prevention should prioritize a comprehensive approach that includes management of vascular risk factors, lifestyle modifications, and antithrombotic therapy, as recommended by the 2021 American Heart Association/American Stroke Association guideline 1. The management of vascular risk factors is crucial in secondary stroke prevention, including diabetes, smoking cessation, lipids, and especially hypertension, with intensive medical management and goals of therapy tailored to the individual patient 1. Key lifestyle modifications for preventing a second stroke include:
- A healthy diet, with low-salt and Mediterranean diets recommended for stroke risk reduction 1
- Regular physical activity, with patients encouraged to perform physical activity in a supervised and safe manner 1
- Smoking cessation and limiting alcohol consumption to moderate levels
- Weight management targeting a BMI of 18.5-25 Antithrombotic therapy, including antiplatelet or anticoagulant agents, is recommended for nearly all patients without contraindications, with the combination of antiplatelets and anticoagulation typically not indicated for secondary stroke prevention 1. Additionally, patient education on stroke risk factor reduction, signs and symptoms of stroke, and the importance of a healthy lifestyle is essential for secondary stroke prevention, with evidence-based educational strategies that are individualized and tailored to patients’ health needs and medical conditions 1. Overall, a comprehensive approach to secondary stroke prevention that incorporates management of vascular risk factors, lifestyle modifications, antithrombotic therapy, and patient education can help reduce the risk of recurrent strokes and improve patient outcomes.
From the Research
Strategies for Preventing Secondary CVA or Stroke
The following strategies are recommended for preventing secondary cerebrovascular accident (CVA) or stroke:
- Antiplatelet therapy: Single-antiplatelet therapy (SAPT) with aspirin, aspirin/extended-release dipyridamole, or clopidogrel reduces the risk of recurrent ischemic stroke in patients with non-cardioembolic ischemic stroke or transient ischemic attack (TIA) 2, 3, 4, 5
- Dual-antiplatelet therapy (DAPT): DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than SAPT in patients with minor acute noncardioembolic ischemic stroke or high-risk TIA 2, 6, 5
- Antihypertensive therapy: Antihypertensive treatment is recommended for secondary stroke prevention for both hypertensive and normotensive patients 3, 6
- Cholesterol-lowering therapy: HMG-CoA reductase inhibitor (statin) therapy to obtain an intensive lipid-lowering effect is also highly recommended 3, 6
- Glycemic control: Glycemic control to prevent microvascular complications from diabetes mellitus or pioglitazone in selected patients with insulin resistance but not diabetes mellitus 3, 6
- Selection of appropriate antiplatelet therapy: Selection of appropriate antiplatelet therapy should also be based on compliance, drug tolerance, or resistance 2, 4
Antiplatelet Drugs for Secondary Prevention
The following antiplatelet drugs are recommended for secondary prevention of patients with ischemic stroke or TIA:
- Aspirin ≤ 150 mg/day: significantly reduces the risk of all strokes 5
- Clopidogrel: significantly reduces the risk of all strokes and cardiovascular events 5
- Dipyridamole + aspirin: significantly reduces the risk of all strokes 5
- Ticagrelor: significantly reduces the risk of all strokes 5
- Cilostazol: significantly reduces the risk of all strokes, but data are limited to the Asian population 5
- Ticlopidine: significantly reduces the risk of all strokes 5
Considerations for Antiplatelet Therapy
The following considerations should be taken into account when selecting antiplatelet therapy:
- Aspirin resistance and genotyping of clopidogrel metabolism: individualizing approach in antiplatelet therapy is important 4
- Bleeding complications: antithrombotic therapy increases the incidence of bleeding and worsens the severity of the bleeding events 3, 6
- Patient's condition and stroke mechanism: choosing antithrombotic agents and their intensity (dosage) appropriate to the stroke mechanism and the patient's condition are essential for secondary stroke prevention 3, 6