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HelixTalk Episode #98 - Stroke Me Once, Shame on You; Stroke Me Twice ... Let's Talk Prevention!

Date posted: July 9, 2019, 6:00 am

In this episode, we review guideline recommendations and recent evidence for secondary prevention of stroke, including risk factor modification, anticoagulant therapy (in patients with atrial fibrillation), and antiplatelet therapy (in patients with noncardioembolic stroke).


Key Concepts

  1. Risk factor modification is an important component of secondary prophylaxis of stroke.  Modifiable risk factors for stroke include: hypertension, dyslipidemia, diabetes, obesity, physical activity, smoking, alcohol, and carotid artery stenosis.
  2. Among patients with a stroke likely due to atrial fibrillation (cardioembolic stroke), anticoagulation with direct oral anticoagulants (DOACs) or warfarin is typically considered.  DOACs are preferred over warfarin in most patients by the 2019 Atrial Fibrillation guidelines.
  3. Among patients with a stroke likely due to atherosclerosis (noncardioembolic stroke), antiplatelet therapy with aspirin, aspirin/dipyridamole, or clopidogrel is typically considered.
  4. In noncardioembolic stroke, the combination of aspirin with clopidogrel is not commonly done; however, if it is considered, the duration of combination antiplatelet therapy is usually limited to several weeks (e.g., 21 days).


  • Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Mar;49(3):e46-e110.k
  • January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. 2019 Jan 28:CIR0000000000000665.
  • Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Jul;45(7):2160-236.