Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Secondary prevention strategies for patients who have experienced a stroke involve a multi-faceted approach, including medication management, control of underlying conditions, and ongoing support.
- Antiplatelet Therapy: For patients who have experienced an ischaemic stroke or transient ischaemic attack (TIA), antiplatelet treatment with clopidogrel 75 mg daily is recommended, unless contraindicated NICE NG128. If clopidogrel is contraindicated or not tolerated, a combination of aspirin 75 mg daily and modified-release dipyridamole 200 mg twice daily should be offered NICE NG128. Aspirin 300 mg daily is offered immediately for suspected TIA, unless contraindicated NICE NG128. For people with disabling ischaemic stroke who are in atrial fibrillation, aspirin 300 mg is given for the first two weeks before considering anticoagulation treatment NICE NG128.
- Anticoagulation: Routine anticoagulation treatment is not recommended for acute stroke NICE NG128. However, full-dose anticoagulation (initially heparin, then warfarin with an international normalised ratio of 2 to 3) is offered to people diagnosed with cerebral venous sinus thrombosis, including those with secondary cerebral haemorrhage, unless there are comorbidities that preclude its use NICE NG128. For stroke secondary to acute arterial dissection, either anticoagulants or antiplatelet agents can be offered NICE NG128. For people with ischaemic stroke and symptomatic proximal deep vein thrombosis or pulmonary embolism, anticoagulation treatment is preferred over aspirin, unless there are other contraindications NICE NG128.
- Statin Treatment: Immediate initiation of statin treatment is not recommended in people with acute stroke NICE NG128. However, statin treatment should be continued in patients who are already receiving statins at the time of an acute stroke NICE NG128.
- Blood Pressure Management: Antihypertensive strategies are important for the prevention of secondary stroke Wang et al. 2025. For people with acute intracerebral haemorrhage, rapid blood pressure lowering may be considered under specific conditions, aiming to reach a systolic blood pressure of 140 mmHg or lower while ensuring the magnitude drop does not exceed 60 mmHg within one hour of starting treatment NICE NG128. General guidance on hypertension in adults is also relevant for secondary prevention NICE NG236.
- Blood Glucose Control: Maintaining a blood glucose concentration between 4 and 11 mmol/litre is important for people with acute stroke NICE NG128. Optimal insulin therapy, which can be achieved by the use of intravenous insulin and glucose, should be provided to all adults with type 1 diabetes with threatened or actual stroke NICE NG128. General guidance on type 2 diabetes in adults is also relevant for secondary prevention NICE NG236.
- Ongoing Review and Support: Health and social care needs, along with the needs of their carers, should be reviewed at 6 months and then annually, covering participation in activities of everyday life to ensure that people's goals are met NICE NG236. Referral to community participation programmes can be considered to support involvement in social activities, peer support, and leisure pursuits NICE NG236. Information regarding transport and driving, including DVLA requirements, should also be provided NICE NG236.