Ischemic stroke secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]Maryam Hadipour, M.D.[3]


Secondary prevention of ischemic stroke is mainly directed to lifestyle modifications, treatment of modifiable risk factors, and treatment of specific cause of ischemic stroke.

Secondary Prevention

Specific recommendations for prevention strategies often depend on the ischemic stroke/transient ischemic attack subtype. Patients presenting with signs and symptoms of acute stroke will undergo an evaluation tailored to ensure that, when appropriate, they receive reperfusion therapy. Secondary stroke prevention includes antiplatelet therapy, statins and antihypertensives. Aspirin, clopidogrel, or a combination of aspirin with dipyridamole are first-line options for secondary stroke prevention in the absence of atrial fibrillation. Dual antiplatelet therapy has a benefit in the first three weeks after stroke, but patients should change to a single antiplatelet drug after this time. Anticoagulants are indicated if the patient has atrial fibrillation. Avoid combinations of anticoagulants and antiplatelet drugs. Patients should be started on statins after an ischaemic stroke. High doses are recommended even if cholesterol concentrations are normal. Antihypertensive drugs are recommended for all patients with systolic blood pressures greater than 140 mmHg. ACE inhibitors, calcium channel blockers and diuretics are first-line options.[1][2][3][4]

Life style modification for secondary prevention

Life style modification measures which may help reduce the risk of recurrent stroke and prevent complications may include:

  • Increased physical activity
  • Eating healthy balanced diet
  • Smoking cessation
  • Decreased alcohol intake

Treatment of modifiable risk factors

  • Treatment and maintainence of hypertension, diabetes mellitus and hyperlipidemias[5]
  • Treatment of underlying coronary artery disease
  • Treatment of atrial fibrillation and maintaining anticoagulant prophylaxis in high risk patients
  • Proper management and follow up of genetic hypercoaguable conditions
  • Use of long term antiplatelet therapy such as aspirin, clopidogrel or combination therapy may be used to prevent recurrent ischemic stroke.[5]

Secondary prevention of complications of ischemic stroke

The preventive measures which may help prevent complications of ischemic stroke include:[6][7]

  • Use of intermittent pneumatic compressions and low molecular weight heparin in patients with high risk of thromboembolism
  • There is no prophylaxis for prevention of seizures in patients with ischemic stroke. However, one episode of seizure may mandate the use of antiepileptic medication to prevent recurrence.[6]
  • Proper positioning of patient, and the use of thick feed with the help of nasogastric tube for feeding to prevent aspiration pneumonia in patients with cranial nerve palsies affecting pharyngeal motility and gag reflex[8]
  • Pressure ulcers may be prevented by use of air mattress and regular change in position of patient[7]

Secondary prevention for specific causes of ischemic stroke[9]

Cause of ischemic stroke Revascularization Multifactorial risk reduction
Carotid endartectomy Carotid stenting Other Surgical options Antiplatelet therapy Statins Antihypertensives Anticoagulants
Large artery disease Carotid Artery Stenosis
Carotid occlusion
Vertebral artery stenosis Angioplasty
Large vessel atherosclerosis Percutaneous transluminal angioplasty ✔✔ ✔✔ ✔✔ ✔✔
Arterial dissection Endovascular surgical repair
Cardiac embolism Atrial fibrillation
Valvular heart disease
Mitral valve disease
Recent MI/ left ventricular thrombus
Heart failure
Dilated cardiomyopathy
Hematological disorders Protein C/S deficiency
Sickle cell disease Repeated blood transfusions and


Antithrombin III deficiency
Antiphospholipid antibody syndrome

For AHA/ASA guidelines on secondary prevention of ischemic stroke, please click here


  1. Diener HC, Hankey GJ (April 2020). "Primary and Secondary Prevention of Ischemic Stroke and Cerebral Hemorrhage: JACC Focus Seminar". J Am Coll Cardiol. 75 (15): 1804–1818. doi:10.1016/j.jacc.2019.12.072. PMID 32299593 Check |pmid= value (help).
  2. Berge E (August 2011). "Should high blood pressure be lowered in the acute stroke?". J Hypertens. 29 (8): 1478–9. doi:10.1097/HJH.0b013e32834a019b. PMID 21750435.
  3. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, B<rown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL (December 2019). "Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 50 (12): e344–e418. doi:10.1161/STR.0000000000000211. PMID 31662037. Vancouver style error: non-Latin character (help)
  4. Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS (July 2021). "2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association". Stroke. 52 (7): e364–e467. doi:10.1161/STR.0000000000000375. PMID 34024117 Check |pmid= value (help).
  5. 5.0 5.1 Adams HP (2009). "Secondary prevention of atherothrombotic events after ischemic stroke". Mayo Clin Proc. 84 (1): 43–51. doi:10.1016/S0025-6196(11)60807-0. PMC 2664570. PMID 19121254.
  6. 6.0 6.1 Kappelle LJ, Van Der Worp HB (2004). "Treatment or prevention of complications of acute ischemic stroke". Curr Neurol Neurosci Rep. 4 (1): 36–41. PMID 14683626.
  7. 7.0 7.1 Anders J, Heinemann A, Leffmann C, Leutenegger M, Pröfener F, von Renteln-Kruse W (2010). "Decubitus ulcers: pathophysiology and primary prevention". Dtsch Arztebl Int. 107 (21): 371–81, quiz 382. doi:10.3238/arztebl.2010.0371. PMC 2883282. PMID 20539816.
  8. Armstrong JR, Mosher BD (2011). "Aspiration pneumonia after stroke: intervention and prevention". Neurohospitalist. 1 (2): 85–93. doi:10.1177/1941875210395775. PMC 3726080. PMID 23983842.
  9. Donnan GA, Fisher M, Macleod M, Davis SM (2008). "Stroke". Lancet. 371 (9624): 1612–23. doi:10.1016/S0140-6736(08)60694-7. PMID 18468545.

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