Tailored Approach to Secondary Prevention After Stroke

Secondary prevention of stroke involves identifying and then addressing the underlying contributory pathophysiologic mechanism(s) for a given index stroke. The conventional risk factors for secondary stroke are mostly “conventional” by definition and have been known for decades, with pivotal clinical trial or observational study data showing that management of these conditions results in lower occurrence of recurrent cerebrovascular events. Nonetheless, challenges and controversies remain. For proven therapeutic modalities, routine and consistent translation of clinical trial data to clinical practice is uneven, and when it does occur there are questions that arise, which were not answered by the trials including when to start certain risk factor modification therapies after a stroke, which treatments apply to what stroke subtypes, level of treatment intensity, single agent vs. class effects, possible pleiotropic effects of some drugs, and the need to tailor treatment based on demographics (e.g., age, race). Major conventional risk factors for recurrent stroke include hypertension, dyslipidemia, diabetes, and adverse lifestyle practices including smoking, unhealthy diets, and sedentary living. Since there are several contributors to stroke risk and differences in severity across stroke survivors, avenues for averting future stroke need be tailored to the needs of the individual patient based upon their personal risk factors and circumstances. In this chapter, we focus primarily on the traditional management of atherosclerotic stroke. We discuss the established conventional risk factors including current information on various proven therapies and strategies for addressing them. We include case vignettes that exemplify important issues in conventional stroke risk factor management and discuss our approach to thinking through them.