Maintenance Therapy for Secondary Stroke Prevention
For patients with a history of stroke, long-term antiplatelet therapy is the cornerstone of maintenance treatment, with aspirin 75-325 mg daily, clopidogrel 75 mg daily, or aspirin/extended-release dipyridamole 25/200 mg twice daily as first-line options, combined with high-intensity statin therapy and blood pressure control. 1
Antiplatelet Therapy Selection
Single antiplatelet therapy is recommended for long-term maintenance unless there is an indication for anticoagulation such as atrial fibrillation 1:
- Aspirin 75-325 mg daily (most commonly 81 mg in practice) 1
- Clopidogrel 75 mg daily - preferred over aspirin based on recent guidelines 1, 2
- Aspirin 25 mg/extended-release dipyridamole 200 mg twice daily - more effective than aspirin alone but less well tolerated due to headache 1
Among these options, clopidogrel or aspirin/dipyridamole are suggested over aspirin monotherapy for superior efficacy in preventing recurrent stroke 1.
Important Caveat on Dual Antiplatelet Therapy
Long-term dual antiplatelet therapy (aspirin plus clopidogrel) is NOT recommended for routine secondary stroke prevention due to increased bleeding risk and mortality without additional benefit beyond 21-90 days 1, 3. The exception is if there is another indication such as recent coronary stenting 1.
Anticoagulation for Cardioembolic Stroke
If the stroke was cardioembolic due to atrial fibrillation, oral anticoagulation is mandatory 1:
- Direct oral anticoagulants (DOACs) - apixaban, dabigatran, edoxaban, or rivaroxaban are preferred over warfarin 1, 4
- Warfarin (INR 2.0-3.0) is reserved for patients with mechanical heart valves or moderate-to-severe mitral stenosis 1
- Anticoagulation should generally be initiated within 1-2 weeks after stroke onset, balancing hemorrhagic transformation risk 1
High-Intensity Statin Therapy
All stroke patients require high-intensity statin therapy regardless of baseline LDL cholesterol 1, 5:
- Target LDL-C <70 mg/dL (or ≥50% reduction from baseline) 1, 5
- Use atorvastatin or rosuvastatin at high doses 1, 5
- Recheck lipid panel 4-12 weeks after initiation to confirm target achievement 5
Blood Pressure Management
Target blood pressure <140/90 mmHg using antihypertensive therapy 1, 5:
- ACE inhibitors or angiotensin receptor blockers are preferred, alone or combined with thiazide diuretics 5
- For patients with intracranial atherosclerotic stenosis (50-99%), target systolic BP <140 mmHg 1
- Monitor blood pressure at each clinical visit 5
Lifestyle Modifications
Comprehensive lifestyle interventions are essential components of maintenance therapy 1, 5:
- Smoking cessation - mandatory for all patients 1, 5
- Physical activity - at least moderate intensity exercise, minimum 10 minutes 3-4 times weekly 1, 5
- Mediterranean-type diet with sodium restriction 1, 5
- Weight management - target BMI <25 kg/m² 5
Special Considerations for Intracranial Atherosclerotic Disease
For patients with moderate-to-high-grade intracranial stenosis (50-99%) 1:
- Aspirin 325 mg daily is recommended over oral anticoagulation 1
- Angioplasty and stenting is NOT recommended; medical therapy is superior 1
- Dual antiplatelet therapy has not been proven superior to single therapy in this population 1
Monitoring and Follow-Up
Regular monitoring is critical to ensure therapeutic targets are maintained 5:
- Lipid panel every 4-12 weeks initially, then annually once stable 5
- Blood pressure at every visit 5
- Medication adherence assessment 1
- Screening for recurrent symptoms 1
Common Pitfalls to Avoid
Do not continue dual antiplatelet therapy beyond 21-90 days unless there is a specific coronary indication, as bleeding risk outweighs benefit 1, 3. Do not use anticoagulation for non-cardioembolic stroke, as it increases bleeding without reducing recurrent stroke compared to antiplatelet therapy 1. Do not delay statin initiation or use moderate-intensity statins when high-intensity therapy is indicated 1, 5.