Stroke Prevention

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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

See also: Stroke written for patients

Prevention of stroke may be classified as:

  • Primary prevention, if there is no previous history of stroke or transient ischaemic attack (TIA).
  • Secondary prevention, if there has been such an event.

See also separate Prevention of Cardiovascular Disease and Cardiovascular Risk Assessment articles. For tertiary prevention, see also separate Cerebrovascular Event Rehabilitation article.

  • Well-documented and modifiable risk factors for stroke include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation (AF), dyslipidaemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity - especially truncal obesity[1].
  • Less well-documented or potentially modifiable risk factors include the metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, obstructive sleep apnoea, migraine headaches, hyperhomocysteinaemia, elevated lipoprotein(a), elevated lipoprotein-associated phospholipase, and hypercoagulability[1].
  • After a stroke or TIA, there is a high risk of stroke and of other serious vascular events. Medical treatments with clear evidence of benefit include[2]:
    • Lowering blood pressure after all types of stroke or TIA.
    • Lowering blood cholesterol with a statin after ischaemic stroke or TIA.
    • Antiplatelet treatment after ischaemic stroke or TIA.
  • Use an appropriate cardiovascular risk assessment tool (eg, Joint British Societies' (JBS2) risk calculator) to assess cardiovascular disease (CVD) risk[4]:
    • CVD risk should be calculated as 10-year risk of fatal and non-fatal stroke, including TIA, + 10-year risk of coronary heart disease (CHD).
    • CHD risk includes the risks of death from CHD, and non-fatal CHD, including silent myocardial infarction (MI), angina and coronary insufficiency (acute coronary syndrome).
  • The QRISK®2 calculator is gaining acceptance and may be more relevant to UK populations[5].
  • The ETHRISK® calculator is more appropriate in British black and minority ethnic groups[6].

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Lifestyle factors[3]

  • Dietary advice:
    • Advise eating at least five portions of fruit and vegetables per day.
    • Advise eating at least two portions of fish per week, including a portion of oily fish.
    • Advise people to eat a diet in which the total fat intake is 30% or less of total energy intake, saturated fats are 10% or less of total energy intake, dietary cholesterol is less than 300 mg/day, and saturated fats are replaced by monounsaturated and polyunsaturated fats.
    • Advise pregnant women to limit their intake of oily fish to two portions a week.
    • Do not routinely recommend omega-3 fatty acid supplements or plant sterols and stanols for primary prevention.
  • Physical activity:
    • Advise people to take 30 minutes of at least moderate-intensity exercise a day at least five days a week.
    • Encourage people who cannot manage this to exercise at their maximum safe capacity.
    • Recommend exercise that can be incorporated into everyday life, such as brisk walking, using stairs and cycling.
    • Tell people that they can exercise in bouts of 10 minutes or more throughout the day.
    • Take into account the person's needs, preferences and circumstances.
    • Agree goals and provide written information about the benefits of activity and local opportunities to be active.
  • Weight management:
    • Offer people who are overweight or obese advice and support to work towards achieving and maintaining a healthy weight.
  • Alcohol consumption[7]:
    • Advise men and women to limit alcohol intake to no more than 14 units a week.
    • Advise everyone to avoid binge drinking.
  • Smoking cessation:
    • Advise all people who smoke, to stop.
    • If people want to stop:
      • Offer support and advice.
      • In addition, provide medication to help with smoking cessation when indicated.

Drug treatment

See also separate Atrial Fibrillation article for more information about the prevention of strokes in people with AF. AF is responsible for 25% of all strokes[8].


  • Screen for hypertension and treat appropriately according to National Institute for Health and Care Excellence (NICE) guidelines[9].

Antithrombotic treatment

  • Following acute MI: anticoagulation is appropriate in those who are at increased risk of thromboembolism, including those with a large anterior MI, left ventricular aneurysm or thrombus, paroxysmal tachyarrhythmias, chronic heart failure or a history of thromboembolic events[4].
  • Anticoagulation is indicated for other cardiovascular risk factors for thromboembolism - eg, prosthetic valves, rheumatic heart disease and AF. Warfarin instead of antiplatelet treatment should be used for patients who have AF and no contra-indications to anticoagulation[1].


  • Aspirin produces a 12% proportional reduction in serious vascular events, mainly due to a 20% reduction in non-fatal MI. There was no net effect on stroke and vascular mortality[10].
  • If low-dose aspirin is used in primary prevention, the balance of risk and benefits should be discussed with the patient.
  • The risk of gastrointestinal bleeding probably outweighs the small benefit in stroke prevention unless the risk of stroke is particularly high.

Lipid-lowering drugs
NICE recommends statin therapy as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD[3].

Atrial fibrillation (AF)[11]

See also separate Atrial Fibrillation article for more information about the prevention of strokes in people with AF. AF is responsible for 25% of all strokes[8].

  • All patients with AF should be assessed for their risk of stroke and the need for thromboprophylaxis balanced with the patient's risk of bleeding.
  • NICE recommends using the CHA2DS2-VASc assessment tool for stroke risk and the HAS-BLED tool for bleeding risk prior to and during anticoagulation.
  • Risk factors for stroke included in CHA2DS2-VASc include prior ischaemic stroke, transient ischaemic attacks or thromboembolic events, heart failure, left ventricular systolic dysfunction, vascular disease, diabetes, hypertension, females and patients over 65 years.
  • Patients with a very low risk of stroke (CHA2DS2-VASc score of 0 for men or 1 for women) do not require any antithrombotic therapy for stroke prevention.
  • Oral anticoagulation should be offered to patients with confirmed diagnosis of atrial fibrillation in whom sinus rhythm has not been successfully restored within 48 hours of onset, patients who have had or are at high risk of recurrence of AF (eg, structural heart disease, prolonged history of AF longer than 12 months), a history of failed attempts at cardioversion, and patients with a greater risk of stroke than risk of bleeding.
  • Oral anticoagulation is with a vitamin K antagonist (eg, warfarin or, in non-valvular AF, with apixaban, dabigatran etexilate, rivaroxaban or edoxaban.
  • Anticoagulants are also indicated during cardioversion procedures.
  • Aspirin is less effective than warfarin and the modest benefit is offset by the risk of bleeding. Therefore, aspirin should not be offered as monotherapy for stroke prevention in AF.
  • If anticoagulant treatment is contra-indicated or not tolerated, left atrial appendage occlusion can be considered.
  • All patients should have an individualised strategy for stroke prevention that should be implemented within a maximum of seven days of acute stroke or TIA.
  • All patients should be given appropriate advice on lifestyle factors as described for primary prevention, including smoking cessation, physical activity, diet, weight control and avoiding excess alcohol.
  • All patients should receive regular review and treatment of risk factors for vascular disease for the rest of their lives after a stroke with inclusion on a stroke register and a minimum of annual follow-up.
  • Blood pressure: see separate Management of Hypertension article.
  • Antithrombotic treatment:
    • If there is a history of persistent or paroxysmal AF in a non-haemorrhagic stroke, consider anticoagulation first-line:
      • Anticoagulation should be started in every patient with persistent or paroxysmal AF (valvular or non-valvular) unless contra-indicated[4].
      • Anticoagulants should not be used for patients without persistent or paroxysmal AF unless there is a major source of cardiac embolism.
      • Anticoagulation is indicated for other cardiovascular risk factors for thromboembolism - eg, prosthetic valves[1].
      • Anticoagulants should not be started until brain imaging has excluded haemorrhage and usually not until 14 days have passed from the onset of an ischaemic stroke.
    • Patients with TIAs not being anticoagulated should be on modified-release dipyridamole in combination with aspirin (modified-release dipyridamole alone if aspirin is not tolerated)[13].
    • Patients with ischaemic stroke (not due to AF) should be on clopidogrel (only use modified-release dipyridamole in combination with aspirin if clopidogrel is not tolerated)[14]. Clopidogrel is also the preferred treatment option in patients with peripheral arterial disease or multivascular disease[13].
    • For patients post-MI, an option including aspirin is preferred (use clopidogrel only, if aspirin is not tolerated).
  • Anti-lipid agents:
    • Treatment with a statin should be given to all patients with ischaemic stroke or TIA unless contra-indicated[3].

Carotid endarterectomy has been the standard in atherosclerotic stroke prevention but carotid artery stenting has emerged as a less invasive alternative for revascularisation[15]. See also the separate Carotid Artery Stenosis article.

  • Carotid endarterectomy:
    • Carotid endarterectomy is of some benefit for patients with 50-69% symptomatic stenosis and is very beneficial for 70-99% stenosis without near-occlusion[16].
    • Benefit in patients with carotid near-occlusion is marginal in the short term and uncertain in the long term[16].
    • Carotid endarterectomy should be performed as soon as the patient is fit for surgery, preferably within two weeks of a TIA[12].
    • Carotid endarterectomy for asymptomatic carotid stenosis reduces the risk of any stroke by approximately 30% over three years. However, the absolute risk reduction is small and there is a 3% peri-operative stroke or death rate[17].
  • Carotid angioplasty and stenting:
    • Stenting with the use of an embolic protection device is a less invasive revascularisation strategy than endarterectomy in carotid artery disease. For patients with severe carotid artery stenosis and co-existing conditions, carotid stenting with the use of an embolic protection device appears to be as safe and as effective as carotid endarterectomy[18].
    • Endovascular treatment and carotid endarterectomy appear to have similar early risks of death or stroke and similar long-term benefits in the treatment of carotid artery stenosis[17].
    • The efficacy of carotid artery stenting compared with endarterectomy has not yet been fully established[19].
  • NICE recommendations following acute stroke or TIA[12]:
    • People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50-99% according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria, or 70-99% according to the European Carotid Surgery Trialists' (ECST) Collaborative Group criteria, should:
      • Be assessed and referred for carotid endarterectomy within one week of onset of stroke or TIA symptoms.
      • Undergo surgery within a maximum of two weeks of onset of stroke or TIA symptoms.
      • Receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).
    • People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according to the ECST criteria, should:
      • Not undergo surgery.
      • Receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).
  • The Scottish Intercollegiate Guidelines Network (SIGN) recommends that all patients with carotid artery territory stroke (without severe disability) or TIA should be considered for carotid endarterectomy as soon as possible after the index event. Carotid endarterectomy should be considered in all male patients with a carotid artery stenosis of 50-99% (by NASCET method) and all female patients with a carotid artery stenosis of 70-99%. Carotid endarterectomy should be performed as soon as the patient is stable and fit for surgery, ideally within two weeks of an event[20].

Further reading & references

  1. Meschia JF, Bushnell C, Boden-Albala B, et al; Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Dec;45(12):3754-832. doi: 10.1161/STR.0000000000000046. Epub 2014 Oct 28.
  2. Sudlow C; Preventing further vascular events after a stroke or transient ischaemic attack: an update on medical management. Pract Neurol. 2008 Jun;8(3):141-57.
  3. Lipid modification - cardiovascular risk assessment and the modification of blood lipids for the prevention of primary and secondary cardiovascular disease; NICE Clinical Guideline (July 2014)
  4. Report of the Joint British Societies for the Prevention of Cardiovascular Disease; JBS3, 2014
  5. QRISK®2 - Cardiovascular Risk Assessment Calculator
  6. ETHRISK®. A modified Framingham CHD and CVD risk calculator for British black and minority ethnic groups
  7. Alcohol Guidelines Review – Report from the Guidelines development group to the UK Chief Medical Officers; Department of Health, January 2016
  8. Ahmad Y, Lip GY; Stroke Prevention in Atrial Fibrillation: Where are We Now? Clin Med Insights Cardiol. 2012;6:65-78. Epub 2012 Feb 23.
  9. Hypertension: management of hypertension in adults in primary care; NICE Clinical Guideline (August 2011)
  10. Baigent C, Blackwell L, Collins R, et al; Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009 May 30;373(9678):1849-60.
  11. British National Formulary; NICE Evidence Services (UK access only)
  12. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management; NICE Clinical Guideline (July 2008)
  13. Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events; NICE Technology Appraisal Guidance, December 2010
  14. National clinical guidelines for stroke (fourth edition); Royal College of Physicians (2012)
  15. Skerritt MR, Block RC, Pearson TA, et al; Carotid endarterectomy and carotid artery stenting utilization trends over time. BMC Neurol. 2012 Mar 29;12(1):17.
  16. Rerkasem K, Rothwell PM; Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev. 2011 Apr 13;(4):CD001081.
  17. Chambers BR, Donnan GA; Carotid endarterectomy for asymptomatic carotid stenosis. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001923.
  18. Hopkins LN, Myla S, Grube E, et al; Carotid artery revascularization in high surgical risk patients with the NexStent Catheter and the Filterwire EX/EZ: 1-year results in the CABERNET trial. Cardiovasc Interv. 2008 Jun 1;71(7):950-60.
  19. Ederle J, Dobson J, Featherstone RL, et al; Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010 Mar 20;375(9719):985-97. Epub 2010 Feb 25.
  20. Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention; Scottish Intercollegiate Guidelines Network - SIGN (December 2008)

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Colin Tidy
Current Version:
Peer Reviewer:
Dr Hannah Gronow
Document ID:
2808 (v25)
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