Secondary Prevention and Risk Factor Management
Antiplatelet and anticoagulant strategy
Noncardioembolic ischemic stroke: aspirin 81-325 mg, clopidogrel, or extended-release dipyridamole plus aspirin. For minor stroke (NIHSS 3 or less) or high-risk TIA, dual antiplatelet therapy with aspirin plus clopidogrel for 21-90 days reduces early recurrence, then transition to single therapy. Atrial fibrillation: anticoagulate with a direct oral anticoagulant in preference to warfarin (except with mechanical valves or moderate-to-severe mitral stenosis), typically starting within 4-14 days depending on infarct size and hemorrhage risk. Never combine therapeutic warfarin with antiplatelet therapy unless there is a separate indication.
Vascular risk factors
High-intensity statin regardless of baseline LDL. Blood pressure target below 130/80 mmHg once stable. Tight glycemic control and screening for diabetes. Smoking cessation, alcohol moderation, weight management, and physical activity. Screen for obstructive sleep apnea, especially in patients with AF or recurrent events.
Carotid disease
Carotid endarterectomy is indicated for symptomatic stenosis of 70-99% when perioperative risk is acceptable, ideally within two weeks of the index event; consider it for 50-69%. Carotid stenting is an alternative in selected patients.
Traps: DAPT is not for cardioembolic stroke and is not indefinite. DOACs are inappropriate for mechanical valves. A normal LDL does not exempt the patient from statin therapy. Recurrent stroke on aspirin should prompt a re-examination of mechanism, not simply a higher dose.
Rule of thumb: minor stroke or high-risk TIA = dual antiplatelet for three weeks, then single agent.