From the Guidelines
The annual risk of a subsequent stroke is approximately 4% for an individual who experiences an initial stroke or TIA, with a case mortality rate of 41% after a recurrent stroke versus 22% after an initial stroke. This risk can be mitigated with appropriate secondary stroke prevention measures, including blood pressure control, antiplatelet therapy, statins, and lifestyle modifications 1. The most recent guidelines from the American Heart Association/American Stroke Association emphasize the importance of controlling modifiable risk factors, such as blood pressure, diet, physical inactivity, smoking, and abdominal obesity, which account for 82% and 90% of the population-attributable risk for ischemic and hemorrhagic stroke, respectively 1.
Key factors that increase the risk of recurrent stroke include:
- Atherosclerotic disease
- Atrial fibrillation
- Uncontrolled hypertension
- Diabetes
- Prior strokes
To reduce recurrence risk, a comprehensive approach is essential, including:
- Antiplatelet therapy, such as aspirin 81-325mg daily, clopidogrel 75mg daily, or aspirin-dipyridamole combination
- Anticoagulation with direct oral anticoagulants or warfarin for those with atrial fibrillation
- Blood pressure control, with a target below 130/80 mmHg using appropriate antihypertensives
- Statins, regardless of baseline cholesterol levels, typically atorvastatin 40-80mg or rosuvastatin 20-40mg daily
- Lifestyle modifications, including smoking cessation, limiting alcohol intake, maintaining a Mediterranean or DASH diet, regular physical activity, and achieving a healthy weight 1.
Regular monitoring of vascular risk factors and medication adherence significantly improves outcomes by addressing the underlying pathophysiological mechanisms that lead to recurrent strokes, such as atherosclerosis, thromboembolism, and small vessel disease. A modeling study showed that targeting multiple risk factors has additive benefits for secondary prevention, with an 80% cumulative risk reduction in recurrent vascular events achievable with a combination of aspirin, statin, and antihypertensive medications, combined with diet modification and exercise 1.
From the Research
Stroke Recurrence Rate
- Recurrent strokes make up almost 25% of the nearly 800,000 strokes that occur annually in the United States 2.
- The risk of recurring stroke has been demonstrated in multiple studies, yet only approximately 5% of stroke patients receive appropriate therapy in a timely manner 3.
- Risk factors for ischemic stroke include hypertension, diabetes mellitus, hyperlipidemia, sleep apnea, and obesity 2.
Prevention Strategies
- Antiplatelet therapy is recommended to reduce the risk of recurrent ischemic stroke 2, 4.
- Aspirin is recommended as initial treatment to prevent recurrent ischemic stroke 2, 4.
- Clopidogrel is recommended as an alternative monotherapy and in patients allergic to aspirin 2.
- The combination of clopidogrel and aspirin is not recommended for long-term use (more than two to three years) because of increased bleeding risk 2.
Treatment Options
- Aspirin/dipyridamole is at least as effective as aspirin alone, but it is not as well tolerated 2.
- Warfarin should not be used for prevention of recurrent ischemic stroke 2.
- Oral anticoagulation therapy reduces risk of vascular events in patients with atrial fibrillation, but long-term monitoring is necessary and many patients cannot achieve optimum anticoagulation 5.
- Clopidogrel plus aspirin is not superior to oral anticoagulation therapy for prevention of vascular events in patients with atrial fibrillation at high risk of stroke 5.