Secondary stroke prevention

Abstract

Secondary stroke prevention can reduce the risk of recurrent stroke by approximately 90%. To achieve such a reduction, early implementation of preventative measures and administration of therapy appropriate to the underlying cause of the presenting transient ischemic attack or stroke are crucial. Smoking cessation and a Cretan Mediterranean diet are each more effective than any single medication in reducing the risk of recurrent stroke. Control of resistant hypertension can markedly reduce the risk of intracerebral hemorrhage and lacunar infarction but might require therapy that is specific to the underlying cause. New antiplatelet agents have been developed or are in development that might avoid the issues of resistance and drug interactions that prevail with established agents of this type. Furthermore, new anticoagulants in development offer promise of replacing warfarin, and devices to occlude the atrial appendage are on the horizon for patients with atrial fibrillation. Carotid endarterectomy is appropriate for severe symptomatic carotid stenosis, while stenting might be appropriate for symptomatic stenosis where the surgical risk is high. Most patients with asymptomatic stenosis, however, should be treated with medical therapy, unless indicators of high stroke risk are present. In this narrative Review, I discuss recent advances in secondary stroke prevention.