Top Things to Know: 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack

Published: May 24, 2021

  1. Specific recommendations for prevention strategies often depend on the ischemic stroke/TIA subtype. Therefore, new in this guideline is a section describing recommendations for the diagnostic workup after ischemic stroke, to define ischemic stroke etiology (when possible) and identify targets for treatment to reduce the risk of recurrent ischemic stroke. Recommendations are now grouped by etiologic subtype.
  2. Management of vascular risk factors remain extremely important in secondary stroke prevention, including (but not limited to) diabetes, smoking cessation, lipids, and especially hypertension. Intensive medical management, often performed by multidisciplinary teams, is usually best, with goals of therapy tailored to the individual patient.
  3. Lifestyle factors, including healthy diet and physical activity, are important for preventing a second stroke. Low salt and/or Mediterranean diets are recommended for stroke risk reduction. Stroke patients are especially at risk for sedentary and prolonged sitting behaviors, and they should be encouraged to perform physical activity in a supervised and safe manner.
  4. Changing patient behaviors, such as diet, exercise, and medication adherence, requires more than just simple advice or a brochure from their physician. Programs that utilize theoretical models of behavior change, proven techniques, and multidisciplinary support are needed.
  5. Antithrombotic therapy, including antiplatelet or anticoagulant agents, is recommended for nearly all stroke patients without contraindications. With very few exceptions, the combination of antiplatelets and anticoagulation treatment is typically not indicated for secondary stroke prevention. Dual antiplatelet therapy is not recommended long term; and, short term, dual antiplatelet therapy is only recommended in very specific patients including those with early arriving minor stroke and high-risk TIA or severe symptomatic intracranial stenosis.
  6. Atrial fibrillation (AF) remains a common and high-risk condition for a second ischemic stroke. Anticoagulation is usually recommended if the patient has no contraindications. Heart-rhythm monitoring for occult AF is usually recommended if no other cause of stroke is discovered.
  7. Extracranial carotid artery disease is an important and treatable cause of stroke. Patients with severe stenosis ipsilateral to a non-disabling stroke or TIA who are candidates for intervention should have the stenosis treated, likely relatively early after their ischemic stroke. The choice between carotid endarterectomy and carotid artery stenting should be driven by specific patient comorbidities and features of their vascular anatomy.
  8. Patients with severe intracranial stenosis in the vascular territory of ischemic stroke or TIA should not receive angioplasty and stenting as a first-line therapy for preventing recurrence. Aggressive medical management of risk factors, and short-term dual anti-platelet therapy is preferred.
  9. There have been several studies evaluating secondary stroke prevention of patent foramen ovale (PFO) closure since the previous guideline in 2014. It is now considered reasonable to percutaneously close PFOs in selected patients: younger age with non-lacunar stroke or no other cause at any age.
  10. Patients with embolic strokes of uncertain source (ESUS) should not be treated empirically with anticoagulants or ticagrelor, as it was found to be of no benefit.


Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC Jr, Turan TN, Williams LS. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association [published online ahead of print May 24, 2021]. Stroke. doi: 10.1161/STR.0000000000000375