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Secondary prevention after ischaemic stroke
Prevention after stroke is chosen by mechanism: an antiplatelet for arterial disease, an anticoagulant for embolism from the heart, surgery for symptomatic carotid stenosis — and for everyone, aggressive control of blood pressure and lipids.
Why it matters in the exam
Questions present a patient after stroke with one decisive finding (atrial fibrillation, carotid stenosis, patent foramen ovale, intracranial stenosis) and ask for the right treatment. The numeric targets are tested too: blood pressure below 130/80, LDL below 70 mg/dL, and when a foramen ovale is closed. A common distractor is adding an antiplatelet to an anticoagulant without a reason. Even when the mechanism is unknown, risk-factor control prevents most recurrent events.
Key points
- Prevention follows mechanism: antiplatelet for arteries, anticoagulant for the heart, surgery for the carotid.
- In atrial fibrillation a DOAC is preferred, without routine aspirin.
- Symptomatic carotid stenosis of 70 to 99 percent — surgery; under 50 percent — drugs only.
- Severe intracranial stenosis — aspirin and clopidogrel for 90 days, not a stent.
- Targets: blood pressure below 130/80 and LDL below 70 mg/dL.
Summary table
| Mechanism | Treatment | Target or detail |
|---|---|---|
| Atherosclerosis or small-vessel disease | One antiplatelet: aspirin 50 to 325 mg, clopidogrel 75 mg, or aspirin with dipyridamole | Dual therapy only for a limited time after a minor event or in intracranial stenosis |
| Atrial fibrillation | Oral anticoagulant, a DOAC preferred over warfarin | Early start is reasonable according to infarct size; do not add routine aspirin |
| Symptomatic carotid stenosis | 70 to 99 percent — endarterectomy (or stenting in selected cases); 50 to 69 percent — according to patient factors | Under 50 percent — medical therapy only |
| Intracranial stenosis of 70 to 99 percent | Aspirin plus clopidogrel for 90 days and aggressive risk-factor treatment | Stenting is not first-line |
| Patent foramen ovale | Closure at age 18 to 60 with an embolic-appearing stroke and no other cause | In older patients — medical therapy |
| Risk factors for all | Blood pressure below 130/80, LDL below 70 mg/dL (statin and ezetimibe if needed), HbA1c 7 or less in diabetes | Smoking cessation, exercise and a Mediterranean diet |
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Sources
- AHA/ASA Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack, 2021 — Risk factor control and antithrombotic therapy
- ELAN Trial: Early versus Later Anticoagulation for Stroke with Atrial Fibrillation (NEJM), 2023 — Timing of DOAC start
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.