Prevention of ischemic stroke

David Goldemund M.D.
Updated on 25/03/2024, published on 02/02/2024

  • primary stroke prevention – interventions and measures taken to reduce the risk of stroke in asymptomatic individuals
  • secondary stroke prevention  – interventions taken to reduce the risk of recurrent ischemic stroke in individuals who have already suffered a stroke or TIA; the treatment is based on the cause of the previous ischemic stroke and takes into account individual vascular risk factors

Stroke prevention involves:

  • initial vascular risk stratification (to assess an individual’s likelihood of experiencing a cardiovascular event) – analyze risk factors + personal medical history (including prior stroke or another cardiovascular event)
  • management of vascular risk factors
  • antithrombotic therapy
    • antiplatelet agents – aspirin, clopidogrel, ticagrelor, or their combinations (DAPT) are commonly prescribed
    • anticoagulants – for those with cardioembolic risk factors (most commonly atrial fibrillation)
  • surgical and endovascular procedures
    • carotid endarterectomy or angioplasty with stenting on extracerebral and cerebral arteries
    • PFO closure, LAA closure, pulmonary AV shunt occlusion, RF ablation, cardiac surgery, etc.
  • regular monitoring and strict adherence to treatment are crucial

For an overview of vascular risk factors, see here and here

Cardiovascular disease risk predictors

Arterial hypertension (HTN)

Other risk factors

Anti-XI inhibitors

Anti-XI inhibitors, also known as factor XI inhibitors, are a novel class of anticoagulants that target factor XI, a component of the intrinsic coagulation pathway. While they have primarily been investigated for their potential to prevent venous thromboembolism (VTE) and reduce the risk of thrombosis without increasing the risk of bleeding, there is emerging interest in their role in cardiovascular prevention, including stroke prevention

  • milvexian is a peroral factor XIa inhibitor
    • AXIOMATIC-SSP  – milvexian, added to dual antiplatelet therapy, did not substantially reduce the composite outcome of symptomatic ischemic stroke and did not meaningfully increase the risk of major bleeding
    • ongoing stroke trial LIBREXIA
  • osocimab
  • ibisomab

Anti-inflammatory drugs

Inflammation plays a significant role in the development and progression of atherosclerosis

  • colchicine
    • by targeting inflammation, colchicine may help reduce the inflammatory burden on blood vessels, potentially slowing the progression of atherosclerosis and reducing the risk of stroke
    • the CLEAR trial investigated the effect of colchicine on markers of inflammation and lipid profile in patients with a history of ischemic stroke/TIA. While the primary endpoints were changes in inflammatory markers and lipid profile, the study also reported a reduction in recurrent vascular events, including stroke, in patients treated with colchicine compared to placebo
  • beyond colchicine, other anti-inflammatory agents and interventions targeting specific inflammatory pathways are being studied for their potential to reduce inflammation-related stroke risk
    • interleukin-1 (IL-1) inhibitors (canakinumab and anakinra)
    • tumor necrosis factor-alpha (TNF-α) inhibitors (such as infliximab and etanercept)
    • P-selectin inhibitors (inclacumab and crizanlizumab)
      • P-selectin is a cell adhesion molecule involved in the recruitment of leukocytes to sites of inflammation
    • CCR2 inhibitors
      • chemokine receptor 2 (CCR2) is involved in the recruitment of monocytes to sites of inflammation
    • low-dose methotrexate (CIRT trial)

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Prevention of ischemic stroke