By Kateriine Orav, Department of Neurology, North Estonia Medical Center, Tallinn, Estonia

 As vast resources are invested into acute stroke treatment we should not forget that about 90% of strokes are attributable to ten common, potentially modifiable risk factors.1

With emerging evidence on more effective stroke prevention strategies there remains a considerable gap between risk factor control recommended by guidelines and real-world stroke prevention.  Boehme et al. found that adequate control of the five most relevant risk factors combined (hypertension, hypercholesterolemia, atrial fibrillation, smoking and overweight) might have prevented ≈1 of 2 strokes. In their study, 80% of TIA and ischemic stroke patients had at least one indaequately treated risk factor. Alarmingly patients with recurrent strokes showed even more inadequately treated risk factors than patients with first-ever events. The authors contributed these finding to the absence of standardized post-acute treatment follow-up visits in the study area.2 The ESO/SAFE survey identified significant gaps in secondary prevention across Europe, with limited specialist follow-up, poor levels of adherence to medications and uneven availability of advanced investigations such as prolonged cardiac monitoring. Only 54% of countries reported having national strategies that incorporated secondary prevention.3

What should be done?

The 2019 update of recommendations for the establishment of stroke systems by the American Stroke Association also points out that a barrier to improving secondary prevention is the lack of structure in the paths that stroke patients and their caregivers experience. Therefore, the guidelines recommend that support systems are necessary to ensure that all patients have appropriate follow-up with specialized stroke services when needed and primary care arranged on discharge.4


Can support programmes help?

A 2018 Cochrane meta-analysis found that organizational interventions may be associated with improved blood pressure control but there was no clear evidence for other risk factors or a reduced incidence of cardiovascular events. However, several of the included studies demonstrated improved medication adherence among the intervention group patients. Multidisciplinary team members were usually involved in the studies where an intervention was associated with an improved outcome on secondary prevention and often included a combination of patient education and regular monitoring. The benefits of a multidisciplinary team may be associated with a collective consideration of the whole patient due to a variation in knowledge, specialisation and experience.5

More recently, the STROKE-CARD trial found that an easily implementable stroke follow-up programme by a multidisciplinary stroke team reduced cardiovascular risk and improved health-related quality of life and functional outcome one year after ishemic stroke and TIA.6 A randomized controlled study reported by Ahmadi et al. evaluated a multicomponent support programme for secondary prevention in TIA and minor stroke patients which led to 8-17% higher rates of patients who achieved various secondary prevention targets (including blood pressure, LDL-levels, physical activity and smoking cessation).7

The recently published study by Ullberg et al. evaluated the feasibility of a comprehensive and structured three-month follow up programme in community dwelling stroke survivors using a modified Post-stroke checklist. The nurse-led interview was followed by multi-disciplinary team meetings. Stroke-related health problems were present in 93% of patients. Secondary prevention problems were highly prevalent necessitating interventions in 62% of patients. The study concluded that follow-up of stroke patients using a post-stroke checklist was feasible and highly relevant. We will eagerly wait for data of the 12-month follow-up.8

To conclude, organized stroke care in the postacute period is essential to improve secondary prevention in stroke patients. However, as secondary prevention programmes can be resource intensive, we need a better understanding of which aspects of different interventions actually work. With an increasing burden of stroke in Europe effective prevention strategies are more important than ever.9


  1. O’Donnell MJ, Chin SL, Rangarajan S, et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. 2016 Aug 20;388(10046):761-75.
  2. Boehme C, Toell T, Mayer L, et al. The dimension of preventable stroke in a large representative patient cohort. 2019 Dec 3;93(23):e2121-e2132.
  3. Webb A, Heldner MR, Aguiar de Sousa D, et al. ESO-SAFE Secondary Prevention Survey Steering Group. Availability of secondary prevention services after stroke in Europe: An ESO/SAFE survey of national scientific societies and stroke experts. Eur Stroke J. 2019 Jun;4(2):110-118.
  4. Adeoye O, Nyström KV, Yavagal DR, et al. Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update. Stroke. 2019 Jul;50(7):e187-e210.
  5. Bridgwood B, Lager KE, Mistri AK, et al. Interventions for improving modifiable risk factor control in the secondary prevention of stroke. Cochrane Database Syst Rev. 2018;5(5):CD009103.
  6. Willeit P, Toell T, Boehme C, et al. STROKE-CARD study group. STROKE-CARD care to prevent cardiovascular events and improve quality of life after acute ischaemic stroke or TIA: A randomised clinical trial. EClinicalMedicine. 2020;25:100476.
  7. Ahmadi M, Laumeier I, Ihl T, et al. A support programme for secondary prevention in patients with transient ischaemic attack and minor stroke (INSPiRE-TMS): an open-label, randomised controlled trial. Lancet Neurol. 2020;19(1):49-60.
  8. Ullberg T, Mansson K, Berhin I, et al. Comprehensive and Structured 3-month Stroke Follow-up Using the Post-stroke Checklist (The Struct-FU study): A Feasibility and Explorative Study. Journal of Stroke and Cerebrovascular Diseases, 2021;30(2)
  9. Wafa HA, Wolfe CDA, Emmett E, et al. Burden of Stroke in Europe: Thirty-Year Projections of Incidence, Prevalence, Deaths, and Disability-Adjusted Life Years. Stroke. 2020;51(8):2418-2427.