Summary

Comprehensive AHA/ASA guideline on secondary prevention of ischemic stroke and TIA, organized by etiologic subtype with new sections on diagnostic evaluation and systems of care. Emphasizes intensive vascular risk factor management (BP <130/80, LDL-C <70 mg/dL), antithrombotic therapy tailored to mechanism, short-term DAPT for minor stroke/high-risk TIA, anticoagulation for AF, and PFO closure in selected patients age 18–60. Replaces 2014 guidelines and adds ESUS, carotid web, FMD, and health equity sections.

Key Recommendations

Treat neurologically stable patients with prior stroke/TIA to a BP goal <130/80 mm Hg using diuretics, ACE inhibitors, or ARBs; start antihypertensives when BP >130/80.
Use high-intensity statin (atorvastatin 80 mg or rosuvastatin 20 mg) targeting LDL-C <70 mg/dL in patients with atherosclerotic stroke/TIA; add ezetimibe then PCSK9 inhibitor if needed.
Recommend Mediterranean diet (with olive oil or nuts) and reduced sodium intake (≥1 g/d reduction) for stroke risk reduction.
Long-term oral anticoagulation (preferring DOAC over warfarin) is recommended for nonvalvular AF; use warfarin for moderate-severe mitral stenosis or mechanical valves.
For minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4) presenting within 24 hours, give DAPT with aspirin + clopidogrel for 21–90 days, then single antiplatelet; do not continue DAPT long-term.
For symptomatic severe (70–99%) carotid stenosis ipsilateral to nondisabling stroke/TIA, perform CEA (preferred) or CAS within 2 weeks if perioperative stroke/death risk <6%.
For severe symptomatic intracranial stenosis (70–99%), use aggressive medical management with DAPT for 90 days plus risk factor control; do not use angioplasty/stenting as first-line.
Percutaneous PFO closure is reasonable in patients age 18–60 with nonlacunar cryptogenic stroke and high-risk PFO features after multidisciplinary evaluation.
Do not empirically anticoagulate or use ticagrelor in patients with embolic stroke of undetermined source (ESUS).
Screen all stroke/TIA patients for OSA; treat with CPAP if diagnosed to improve sleepiness and BP control.
Screen for diabetes with HbA1c after ischemic stroke; in patients with T2D and ASCVD, add GLP-1 receptor agonist or SGLT2 inhibitor to metformin; pioglitazone reduces stroke/MI risk in nondiabetic insulin-resistant stroke patients (IRIS trial).
Use icosapent ethyl 2 g twice daily in patients with ASCVD, triglycerides 135–499 mg/dL, and LDL-C 41–100 mg/dL on statin to reduce recurrent vascular events.

Thresholds & Doses

BP target: <130/80 mm Hg for neurologically stable patients with prior stroke/TIA; initiate antihypertensives when BP >130/80.
LDL-C target: <70 mg/dL in atherosclerotic stroke (TST trial); add ezetimibe then PCSK9 inhibitor (evolocumab, alirocumab) if needed.
High-intensity statin doses: atorvastatin 80 mg daily or rosuvastatin 20 mg daily.
Aspirin dose: 81–325 mg daily for secondary prevention.
Warfarin target INR: 2.0–3.0 generally; 2.5–3.5 for mechanical mitral valve or aortic mechanical valve with prior stroke/TIA.
DAPT duration: 21 days (CHANCE) to 90 days (POINT) of aspirin + clopidogrel for minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4) starting <24 hours from onset.
Clopidogrel loading: 300 mg (CHANCE) or 600 mg (POINT), then 75 mg daily.
Ticagrelor regimen (THALES): 180 mg load then 90 mg twice daily + aspirin for 30 days.
Carotid revascularization: indicated for 70–99% symptomatic stenosis; reasonable for 50–69%; perioperative stroke/death risk must be <6%; perform within 2 weeks.
PFO closure age criteria: 18–60 years with nonlacunar cryptogenic stroke and high-risk PFO features.
Delay anticoagulation after large cardioembolic stroke (NIHSS >15 or large infarct territory) for ~14 days; TIA patients may start earlier.
HbA1c target: <7% for most adults with diabetes; 7–8% or 8–9% acceptable in elderly with limited life expectancy.
Sodium reduction: 1 g/d reduction associated with 20% cardiovascular event reduction; DASH targets ~1.5–2.4 g/d.
Physical activity: 40-min sessions, 3–4 times/week of moderate-vigorous aerobic activity; interrupt sitting every 30 min with 3-min light activity.
Triglyceride thresholds: moderate hypertriglyceridemia 175–499 mg/dL; severe ≥500 mg/dL (risk of pancreatitis).
Icosapent ethyl dose: 2 g twice daily (REDUCE-IT).
OSA diagnosis threshold: AHI ≥5 with symptoms or ≥15 without symptoms.
Weight loss target: 5–10% body weight produces meaningful vascular risk factor improvement.
Aortic plaque thickness threshold: ≥4 mm associated with increased recurrent stroke risk.
LV thrombus anticoagulation duration: ~3 months with warfarin (INR 2.0–3.0).
Alcohol limits: heavy drinking defined as >4 drinks/day or >14/week (men), >3/day or >7/week (women); >60 g/d associated with recurrent stroke.
Bioprosthetic valve anticoagulation: warfarin INR 2.0–3.0 for 3–6 months post-op, then aspirin 75–100 mg.
Cilostazol dose: 200 mg/day (studied in Asian populations with ICAS/lacunar stroke).
Intracranial atherosclerosis BP target: SBP <140 mm Hg (caution with <120 mm Hg early).

Citations

Top 10 Take-Home Messages — summary of major recommendations and changes from 2014 guideline
Section 3 (Diagnostic Evaluation) — ECG, vessel imaging, echocardiography, prolonged cardiac monitoring for cryptogenic stroke
Section 4.2 (Hypertension) — BP target <130/80 mm Hg supported by RESPECT, PAST-BP, SPS3, PODCAST meta-analysis
Section 4.3 (Hyperlipidemia) — SPARCL and TST trials supporting LDL-C <70 mg/dL with high-intensity statin; Table 5 very high-risk criteria
Section 4.3.2 — REDUCE-IT trial supporting icosapent ethyl for hypertriglyceridemia
Section 5.1.1 (Intracranial atherosclerosis) — SAMMPRIS, CHANCE, WASID supporting DAPT and medical management over stenting
Section 5.1.2.1 (Extracranial carotid) — NASCET, ECST, CREST supporting CEA preference and timing within 2 weeks
Section 5.4.1 (Atrial fibrillation) — RE-LY, ROCKET AF, ARISTOTLE, ENGAGE AF-TIMI 48 supporting DOACs over warfarin
Section 5.4.5 (PFO) — CLOSE, RESPECT, REDUCE, DEFENSE-PFO trials supporting closure in selected patients
Section 5.18 (ESUS) — NAVIGATE ESUS and RESPECT ESUS negative trials of anticoagulation
Section 5.19 / Figure 6 — POINT and CHANCE trials supporting short-term DAPT for minor stroke/high-risk TIA
Section 4.6 (OSA) — SAVE trial and CPAP recommendations
Section 4.4 (Glucose) — IRIS trial supporting pioglitazone in insulin-resistant nondiabetic stroke patients