Secondary stroke prevention: recent developments

Secondary stroke prevention is of great importance since, after a stroke or transient ischemic attack (TIA), the risk is high not only for a new stroke but also for any cardiovascular event. Secondary stroke prevention includes the investigation of pathogenesis, physical activity and nutritional recommendations, and medical treatment. Medical treatment is further divided into antihypertensive, hypolipidemic, antidiabetic and antithrombotic therapy. In this brief review, we discuss antithrombotic, hypolipidemic and antidiabetic therapy, focusing on recent interesting developments. In addition to established antiplatelet regimens, there exist data supporting the use of ticagrelor and cilostazol in specific patient groups, while the combination of aspirin plus rivaroxaban appears very promising. Although the combination of aspirin plus clopidogrel is contraindicated for long-term administration, when given only during the first three weeks after the acute episode, in patients with mild ischemic stroke or high-risk TIA, is superior to aspirin monotherapy. Triple antiplatelet therapy has no place in the secondary prevention of stroke. The anticoagulants failed when administered to patients with embolic stroke of undetermined source (ESUS). Besides statins, other hypolipidemic agents, such as ezetimibe and PCSK-9 inhibitors, seem to have a role in the secondary prevention of stroke. Concerning antidiabetics, pioglitazone remains the drug of choice, while GLP-1 receptor agonists also appear to provide some protection. In contrast, no benefit is derived from DPP-4 inhibitors and SGLT-2 inhibitors.