Therapeutic interventions for prevention of recurrent ischemic stroke

Patients who suffer ischemic stroke or transient ischemic attack (TIA) are at increased risk for subsequent cerebrovascular events. Secondary prevention is essential to reduce risks of recurrence and should include lifestyle modification to improve cardiovascular health, along with strict control of blood pressure, glucose, and lipids. Recurrent stroke in ischemic stroke patients is likely to be the same subtype as the initial stroke, and treatment should be unique to the stroke subtype and patient risk factors. This article presents an overview of the recommendations for the secondary prevention of ischemic stroke or TIA and a review of the evidence supporting the role of antiplatelet therapy in managing the risk of recurrent noncardioembolic stroke. Although anticoagulants are recommended preventive treatment for cardioembolic stroke, they can increase the patient's risk of bleeding complications and are not recommended for all subtypes of ischemic stroke. The American Heart Association/American Stroke Association guidelines recommend 3 antiplatelet regimens for the secondary prevention of noncardioembolic ischemic stroke: aspirin (ASA), clopidogrel, and combined ASA + extended-release (ER) dipyridamole (DP). ASA + ER-DP is recommended over ASA alone. Several studies have established the effectiveness of these 3 antiplatelet regimens as first-line options in the secondary prevention of noncardioembolic ischemic stroke. Clopidogrel monotherapy is a reasonable alternative for patients who cannot tolerate ASA. ASA + ER-DP has been shown to be more effective than ASA alone and does not increase the risk of bleeding. Effective secondary prevention must also address modifiable risk factors, such as obesity, smoking, and excessive alcohol consumption.