What are the strategies for preventing a secondary cerebrovascular accident (CVA) or stroke?

From the Guidelines

Secondary stroke prevention should prioritize a comprehensive approach including pharmacological therapy, lifestyle modifications, and physical activity to reduce the risk of recurrent strokes, as evidenced by the 2021 guideline from the American Heart Association/American Stroke Association 1. The cornerstone of secondary prevention includes antiplatelet therapy, typically starting with aspirin 81-325 mg daily, clopidogrel 75 mg daily, or a combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily. For patients with atrial fibrillation, anticoagulation with direct oral anticoagulants (DOACs) such as apixaban 5 mg twice daily, rivaroxaban 20 mg daily, or dabigatran 150 mg twice daily is recommended over warfarin unless there are specific contraindications. Aggressive management of hypertension is crucial, aiming for a target blood pressure below 130/80 mmHg using medications like ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics. Lipid management with high-intensity statins such as atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily is recommended regardless of baseline LDL levels. Some key points to consider in secondary stroke prevention include:

• Adhering to pharmacological secondary prevention strategies is an important self-care behavior in stroke secondary prevention, with multimodal interventions improving compliance with antithrombotic medications and statins 1.
• Physical activity is particularly important for the prevention of secondary complications related to recurrent stroke and other CVDs, with emerging evidence of the beneficial impact of regular physical activity and exercise in stroke survivors on CVD risk factors 1.
• Lifestyle modifications are equally important, including smoking cessation, limiting alcohol consumption to moderate levels, maintaining a Mediterranean or DASH diet, regular physical activity (at least 150 minutes of moderate-intensity exercise weekly), and weight management targeting a BMI of 18.5-24.9. These interventions work synergistically to address the underlying pathophysiological mechanisms of stroke, including atherosclerosis, thrombosis, and hypertension-related vascular damage, thereby significantly reducing the risk of recurrent cerebrovascular events. Regular physical activity can be effective in reducing the risk of a second stroke by 80% when integrated into a comprehensive plan of care that includes diet modification and use of cholesterol-lowering medications, antihypertensive medications, and aspirin 1. Healthcare professionals should consider ways to educate stroke survivors and caregivers on the importance of cardiovascular risk reduction and help set goals for their continued participation in physical activity and exercise. Overall, a comprehensive approach to secondary stroke prevention, including pharmacological therapy, lifestyle modifications, and physical activity, is crucial to reducing the risk of recurrent strokes and improving outcomes for patients who have already experienced a stroke or TIA.

From the Research

Strategies for Preventing Secondary CVA or Stroke

The following strategies can be employed to prevent secondary cerebrovascular accident (CVA) or stroke:

• Antithrombotic therapy: Antithrombotic agents, including antiplatelets and anticoagulants, play a crucial role in secondary stroke prevention 2, 3, 4, 5, 6.
• Antiplatelet therapy: Antiplatelet agents, such as aspirin, clopidogrel, and extended-release dipyridamole, are recommended for patients with non-cardioembolic ischemic stroke or transient ischemic attack (TIA) 2, 3, 4, 5, 6.
• Anticoagulant therapy: Anticoagulants, such as warfarin and direct oral anticoagulants (DOACs), are recommended for patients with cardioembolic strokes, particularly those with non-valvular atrial fibrillation 2, 3, 4.
• Dual antiplatelet therapy (DAPT): DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than single antiplatelet therapy (SAPT) in patients with minor acute non-cardioembolic stroke or high-risk TIA 2.
• Risk factor control: Controlling modifiable risk factors, such as hypertension, dyslipidaemia, and diabetes mellitus, is essential for secondary stroke prevention 3, 4.
• Lifestyle modification: Lifestyle modifications, such as a healthy diet, regular exercise, and smoking cessation, can also help reduce the risk of recurrent stroke 3, 4.
• Cholesterol-lowering therapy: Cholesterol-lowering therapy, principally with statins, can help reduce the risk of recurrent stroke 4.
• Glycemic control: Glycemic control is important for preventing microvascular complications from diabetes mellitus 4.

Considerations for Choosing Antithrombotic Agents

When choosing antithrombotic agents, the following factors should be considered:

• Underlying stroke mechanism: The choice of antithrombotic agent depends on the underlying stroke mechanism 2, 3, 4.
• Bleeding risk profile: The risk of bleeding should be carefully weighed against the benefits of antithrombotic therapy 2, 3, 4.
• Cytochrome P450 2C19 polymorphisms: Cytochrome P450 2C19 polymorphisms can affect the metabolism of certain antithrombotic agents 2.
• Compliance and drug tolerance: Patient compliance and drug tolerance should be considered when choosing an antithrombotic agent 2, 3, 4.