Perspective:

The following are 10 points to remember about secondary prevention after ischemic stroke or transient ischemic attack (TIA):

1. Worldwide, stroke is the second most common cause of death after myocardial infarction (MI), and is a leading cause of acquired disability.

2. Patients with stroke are at high risk for subsequent vascular events, including recurrent stroke (highest risk), MI, and death from vascular causes. Because the risk of stroke is highest in the early period after the acute event, prompt initiation of tailored prevention strategies is essential.

3. Investigations (including brain imaging and arterial and cardiac assessment) are warranted promptly after a TIA or stroke to determine the cause and guide interventions to reduce subsequent risk.

4. Aggressive risk factor management and lifestyle advice are essential for all patients.

5. In secondary prevention, three principal strategies are appropriate for nearly all patients: blood pressure lowering, cholesterol lowering with statins, and antiplatelet therapy (except in patients in whom anticoagulant therapy is indicated).

6. Blood pressure is the most important modifiable risk factor in both primary and secondary prevention of stroke. Whether the benefits of blood pressure lowering depend on the particular class of antihypertensive drugs or simply on the antihypertensive effect of all such drugs remains controversial, although most of the evidence appears to support the latter.

7. Cholesterol lowering with statin drugs, which is effective in primary stroke prevention, has also proved effective in secondary prevention after stroke or TIA.

8. Unless anticoagulation is indicated, patients should receive antiplatelet therapy for secondary stroke prevention. Low doses of aspirin (ranging from 75-325 mg per day) appear to be as effective as higher doses in reducing the risk of stroke, with a lower risk of gastrointestinal toxic effects.

9. Effective secondary prevention strategies for selected patients include carotid revascularization for high-grade carotid stenosis and anticoagulation therapy for atrial fibrillation.

10. Atrial fibrillation causes at least 15% of cases of ischemic stroke. Dose-adjusted warfarin has been the mainstay of therapy. Newer oral anticoagulant strategies, which do not require monitoring, are now available and are likely to replace warfarin in many cases, although they are more costly.