Secondary prevention of stroke:
What, when and how long?
Stroke Foundation: PRABAHO

Lifestyle
modification
Mediterranean type diet
Daily sodium intake of less than 1.5g is ideal
Atleast 10min of moderate intensity aerobic
activity 4 times per week or atleast 20min
of vigorous aerobic activity twice a week
Smoking cessation
Moderation of alcohol consumption

Hypertension
Target BP 130/80mmHg or less
Start treatment if BP more than
130/80mmHg in patients without
h/o hypertension

Diabetes mellitus
Target HbA1c 7% or less
GLP1 receptor agonist and SGLT2 inhibitor
reduces risk of stroke when added to
metformin and lifestyle modification

Dyslipidemia
 Target LDL 70mg/dl or less
 High intensity statin therapy is beneficial
 Add ezetimibe if target not reached
 Add PCSK9 inhibitor if LDL more than 70mg/dl despite
statin+ezetimibe and patient has another major ASCVD or
multiple high risk conditions

 Icosapentethyl 2g BD for patients with triglyceride 135-
499mg/dl and LDL 41-100mg/dl on moderate-high
intenisty statin therapy with HbA1c less than 10%, no
h/o pancreatitis, AF, or severe heart failure
 Identify and manage severe hypertriglyceridemia (TG
level 500mg/dl or more) with very low fat diet, omega3
fatty acids, fibrates, and avoidance of refined
carbohydrate and alcohol

Antiplatelets
 Aspirin 50-325mg/day or clopidogrel 75mg/day for non-
cardioembolic stroke
 Aspirin+Clopidogrel for minor (NIHSS 3 or less) non-
cardioembolic stroke, high risk TIA (ABCD2 score 4 or more) or
intracranial atheroslerosis. Should be initiated within 7 days
(ideally within 24 hours) and continued for 21 days in case of
minor stroke or high risk TIA. In case of ICAD, it should be
initiated within 30 days and continued upto 90 days.

 Aspirin+Ticagrelor for non-cardioembolic stroke with NIHSS 5 or
less, TIA with ABCD2 score 6 or more, or symptomatic
intra/extracranial stenosis more than 30%. Should be initiated
within 24 hours and continued for 30 days.
 Cilostazol 200mg/day may be added to aspirin or clopidogrel for
stroke/TIA due to 50-99% stenosis of major intracranial artery
 Single antiplatelet should be continued after completion of dual
antiplatelet therapy

Anticoagulants
Indicated in stroke patients having
Atrial fibrillation or flutter
Mechanical heart valve or assist device
LA/LV thrombus (for 3 months)
Anterior AMI with EF less than 50% (for 3 months)
Congenital cyanotic heart disease
Extracranial carotid/vertebral dissection
Antiphospholipid syndrome

Special situations

Apixaban and warfarin can be used for
secondary prevention of stroke in
ESRD patients with AF
Anticoagulants should be continued
even in patients with high HASBLED
score (3 or more) but needs close
monitoring at more frequent intervals

In patients with AF and LASO, OAC only is
preferred over OAC+Antiplatelets if there is
complete occlusion of the carotid artery
In patients with AF and LASO, OAC +
Antiplatelets may be beneficial compared to
OAC alone if there is moderate to severe
stenosis of the carotid artery

In patients with stroke and AF who
underwent recent carotid artery stenting,
NOAC + P2Y12 inhibitor is preferred over
triple therapy or DAPT or OAC alone
In patients with lacunar stroke and AF, OAC
alone may not be sufficient to prevent small
vessel stroke. NOAC plus antiplatelets may be
required along with lifestyle modification and
control of diabetes and hypertension

In patients with stroke and SDH, resumption of
antithrombotic therapy may be attempted within
2-14 days after SDH. Resume early if thrombotic
risk high and bleeding risk low. Resume late if
thrombotic risk low and bleeding risk high.
In stroke patients with low EF (less than 30%) who
are in sinus rhythm, anticoagulation reduces
stroke risk at the expense of bleeding risk

Surgical/Endovascular Intervention
 Carotid endarterectomy for TIA or nondisabling stroke
within 6 months and ipsilateral 70-99% (50-69% in
selected cases) extracranial carotid stenosis
 Carotid stenting if surgical risk is high
 Procedure should be done ideally within 2 weeks of the
event (CEA preferred over CAS if within 1 week)

LA appendage closure in ischemic stroke/TIA
with nonvalvular AF if there is
contraindication for lifelong anticoagulation.
Surgery in ischemic stroke/TIA and native
left-sided valve endocarditis with mobile
vegetations more than 10mm in length.
PFO closure in 18-60 years old patients with
nonlacunar ischemic stroke of undetermined
cause and high risk anatomic features of PFO

Resection of left-sided cardiac tumor in patients with
stroke/TIA
Endovascular intervention in patients with ischemic
stroke/TIA due to extracranial carotid/vertebral artery
dissection if recurrent events despite antithrombotics
Carotid stenting/endarterectomy in patients with
carotid web or fibromuscular dysplasia and ischemic
stroke on the same side refractory to medical
management

THANK YOU
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