What is the recommended maintenance therapy for an adult or geriatric patient with a history of stroke?

Maintenance Therapy for Patients with History of Stroke

All stroke patients require lifelong antiplatelet therapy, aggressive blood pressure control targeting <140/90 mmHg (or <120/80 mmHg for lacunar stroke), high-intensity statin therapy, and structured lifestyle modifications including moderate-intensity exercise for at least 30 minutes daily. 1, 2, 3

Antiplatelet Therapy

For most stroke patients, initiate long-term antiplatelet monotherapy with clopidogrel 75 mg daily as the preferred agent. 1, 3 Acceptable alternatives include aspirin 81 mg daily or aspirin plus extended-release dipyridamole if clopidogrel is not tolerated. 3

• Never use dual antiplatelet therapy (aspirin plus clopidogrel) for long-term maintenance beyond 21-30 days post-stroke—this increases bleeding risk without additional cerebrovascular benefit. 3
• For patients with intracranial atherosclerosis (50-99% stenosis), aspirin 325 mg daily is recommended over warfarin to reduce recurrent stroke and vascular death. 1
• Warfarin is reserved for specific indications: atrial fibrillation, mechanical heart valves, or cardioembolic sources—not for routine atherosclerotic stroke prevention. 4

Blood Pressure Management

Target blood pressure <140/90 mmHg for most stroke patients, or <120/80 mmHg for lacunar stroke patients. 1, 3 This is the single most important modifiable risk factor for recurrent stroke. 3

• Initiate antihypertensive therapy in all stroke patients regardless of baseline blood pressure, unless contraindicated by symptomatic hypotension. 3
• For lacunar stroke specifically, aggressive BP control to <120/80 mmHg through both medication and lifestyle modifications is critical. 3

Lipid Management

Prescribe high-intensity statin therapy targeting LDL-C <70 mg/dL or ≥50% reduction from baseline for all ischemic stroke patients. 1, 2, 3

• Statin therapy is beneficial even in patients with normal baseline cholesterol levels. 3
• Consider adding ezetimibe or PCSK9 inhibitors in selected patients who do not achieve target LDL-C with statin monotherapy. 5

Lifestyle Modifications

Enroll patients in cardiac rehabilitation or structured exercise programs—these reduce recurrent stroke/TIA events (RR 0.23, NNT=3) and mortality (RR 0.11, NNT=8). 3

• Prescribe moderate-intensity aerobic exercise for at least 30 minutes daily. 1, 3
• Implement a Mediterranean diet pattern: low in saturated fat and sodium, high in fruits and vegetables. 3
• Restrict salt intake aggressively—this was a key component of interventions showing 81% reduction in composite cardiovascular endpoints (adjusted HR 0.194). 3
• Counsel on smoking cessation if applicable. 6, 5

Screening for Complications

Screen regularly for depression (affects up to 25% at 2 years), cognitive impairment, fall risk, fatigue, pain, spasticity, and thromboembolism. 1, 2, 3

• Use validated screening tools for depression and cognitive impairment at each visit. 2
• Assess functional status and activities of daily living to identify rehabilitation needs. 1, 2
• Screen for swallowing difficulties, infections, and venous thromboembolism—failing to address these complications worsens outcomes. 2

Diabetes Management

For patients with diabetes, target hemoglobin A1c ≤7% to prevent microvascular complications. 2

• Consider pioglitazone in selected patients with insulin resistance but not diabetes mellitus. 5

Atrial Fibrillation Management

For stroke patients with atrial fibrillation, anticoagulation with warfarin (target INR 2.0-3.0) or a direct oral anticoagulant is recommended over antiplatelet therapy alone. 4, 5

• Direct oral anticoagulants are preferred over warfarin for nonvalvular atrial fibrillation due to improved safety profile. 5

Carotid Stenosis Management

For patients with symptomatic carotid stenosis 70-99%, carotid endarterectomy is recommended in addition to medical therapy. 1

• Medical management alone is appropriate for stenosis <70% or asymptomatic stenosis. 1

Medication Adherence Strategies

Use multimodal behavioral interventions including motivational interviewing and self-management skills training—up to 40% of stroke patients are nonadherent to medications. 3, 7

• Multimodal interventions improve compliance with antithrombotics (OR 1.45) and statins (OR 2.53). 3
• Active behavioral engagement is essential—passive education alone is ineffective. 3
• Address financial hardship, ensure patients understand why medications are prescribed and how to refill them. 7

Follow-Up and Coordination

Schedule initial primary care review within 2-4 weeks following hospital discharge, then establish regular follow-up intervals. 2

• Obtain and review hospital records documenting stroke event details, anatomic location, presumed pathogenesis, and emergency therapy received. 2
• Document a brief narrative of the patient's stroke to anchor stroke-specific care for future visits. 2
• Establish coordinated care between neurologist, internist, and primary care physician. 3
• Screen for ongoing physical issues, medication adherence, and need for rehabilitation services at each visit. 2

Rehabilitation Services

Initiate rehabilitation therapy as early as possible once medically stable, and ensure ongoing access to physical therapy, occupational therapy, and speech therapy as needed. 2

• Approximately 15-30% of stroke patients are permanently disabled and require ongoing rehabilitation. 1
• Use standardized screening evaluations to identify patients with residual impairments requiring rehabilitation. 1

Caregiver Support

Involve caregivers in the care plan with patient consent—caregivers play a central role in post-stroke management. 2, 8

• Foster patient-centered care by creating an environment where patients can express values, aspirations, questions, and fears. 2
• Address caregiver needs and burden, which is broadly neglected in research. 8

Common Pitfalls to Avoid

• Do not extend dual antiplatelet therapy beyond 21-30 days without specific indication (e.g., acute coronary syndrome). 3
• Do not use anticoagulation for atherosclerotic stroke—anticoagulation is not superior to antiplatelet therapy and increases bleeding risk. 3
• Do not treat individual risk factors in isolation—multimodal interventions addressing multiple risk factors simultaneously reduce recurrent stroke risk by up to 80%. 3
• Do not rely on passive education—active behavioral engagement with exercise, salt restriction, and nutrition counseling reduces composite cardiovascular endpoints by 81% (adjusted HR 0.194). 3
• Do not delay transfer to appropriate care settings—earlier admission to stroke units (within 2 days) is associated with fewer complications. 2

Synergistic Effect of Combined Interventions

A 24-week multimodal program combining exercise, salt restriction, and nutrition advice reduced composite cardiovascular endpoints (stroke death, cardiac death, hospitalization for recurrence, MI, angina, or peripheral artery disease) by 81% at 2.9-year follow-up (adjusted HR 0.194,95% CI 0.121-0.737). 3

• The synergistic effect of combining pharmacological therapy (antiplatelet, statin, antihypertensive) with structured lifestyle interventions (exercise, diet, smoking cessation) and behavioral support (motivational interviewing, medication adherence programs) provides the greatest reduction in recurrent stroke risk and mortality. 3, 8