What to Do After a Stroke & Prevention

Having a stroke or TIA means your brain has already given you one warning. The most important thing you can do after that warning is make sure it does not happen again. Research consistently shows that the majority of second strokes are preventable — and the most powerful tools available are not surgical procedures but the medications you take every day and the lifestyle choices you make.

This page summarizes the key areas of medical management recommended by the American Heart Association and American Stroke Association (AHA/ASA) for patients who have had a stroke or TIA. Each section explains what the target is, which treatments are typically used, and why it matters for your brain health.

The Bottom Line:  Up to 80 percent of recurrent strokes are preventable. The combination of well-controlled blood pressure, appropriate antithrombotic medication, statin therapy, and healthy lifestyle changes reduces your risk of a second stroke more than any single intervention alone.

Blood Pressure Control

Many patients require more than one medication to reach goal blood pressure. This is entirely normal — high blood pressure is a chronic condition that typically needs ongoing management. Your care team will select medications based on your stroke type, kidney function, other health conditions, and how well you tolerate each drug.

Commonly recommended blood pressure medication classes include:

• ACE inhibitors / ARBs: ACE inhibitors (e.g., lisinopril) or ARBs (e.g., losartan) — often first choice, particularly beneficial for patients with diabetes or kidney disease
• Thiazide diuretics: Thiazide-type diuretics (e.g., chlorthalidone, hydrochlorothiazide) — frequently used in combination
• Calcium channel blockers: Calcium channel blockers (e.g., amlodipine) — effective and well-tolerated

Lifestyle changes that lower blood pressure and should be part of every patient's plan:

• Low-sodium diet: Reduce sodium intake to less than 2,300 mg per day (about 1 teaspoon of salt)
• Exercise: Regular aerobic exercise — at least 150 minutes per week of moderate activity
• Limit alcohol: Limit alcohol — no more than one drink per day for women, two for men
• Weight management: Maintain a healthy weight — even modest weight loss (5–10 lbs) measurably lowers blood pressure

Do You Qualify for the Lower Target?  Many patients with stroke plus diabetes, hypertension, older age, or a prior cardiac event will qualify as 'very high risk' under the new 2026 guidelines — meaning their LDL target is now < 55 mg/dL rather than < 70 mg/dL. Ask your neurologist or primary care provider which category applies to you, and whether your current therapy is sufficient to reach that goal.

Note for Hemorrhagic Stroke Patients:  Important note for hemorrhagic stroke: The relationship between statins and intracerebral hemorrhage (ICH) is more complex. For patients whose stroke was a bleed rather than a clot, statin therapy should be discussed individually with your neurologist, as the risks and benefits differ from ischemic stroke.

Antithrombotic Therapy: Preventing Clots

Antithrombotic therapy — medications that prevent blood clots from forming — is recommended for virtually all patients who have had an ischemic stroke or TIA. The specific medication depends on what caused your stroke. This is one reason why a thorough stroke workup — including heart monitoring, vascular imaging, and blood tests — is so important before or shortly after discharge.

Do Not Combine Without a Reason:  An important principle: antiplatelet therapy and anticoagulation are generally not combined in stroke prevention unless there is a specific, well-defined reason (such as a recent coronary stent alongside a definite cardiac source of embolism). Combining them without clear indication significantly increases bleeding risk without additional stroke protection.

Antiplatelet Therapy — For Most Non-Cardioembolic Strokes

If your stroke was caused by plaque disease, small vessel changes, or no clearly identified source (cryptogenic), you will typically be prescribed an antiplatelet agent. Antiplatelet medications prevent platelets in the blood from clumping together and forming clots.

• Aspirin: 81-325 mg daily — the most widely used antiplatelet, inexpensive, well-studied, and appropriate for long-term use in most patients
• Clopidogrel (Plavix): 75 mg daily — an alternative to aspirin that works through a different mechanism. Often preferred for patients who cannot tolerate aspirin or who had their stroke while already on aspirin
• Ticagrelor (Brilinta): Similar to clopidogrel but works faster and more powerfully — sometimes used instead of clopidogrel in the short-term after a minor stroke or TIA.
• Aspirin + dipyridamole (Aggrenox): A combination of low-dose aspirin and extended-release dipyridamole — effective for long-term secondary prevention in selected patients

Dual Antiplatelet Therapy After Minor Stroke/TIA:  After a minor ischemic stroke or high-risk TIA, short-term dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel for 21 to 90 days significantly reduces the risk of early recurrent stroke. After this short window, single antiplatelet therapy is continued long-term — combining both agents long-term increases bleeding risk without additional stroke benefit.

Anticoagulation — For Cardioembolic Stroke
If your stroke was caused by a clot from the heart — most commonly due to atrial fibrillation (AFib) — anticoagulation is recommended rather than antiplatelet therapy. Anticoagulants work differently from antiplatelet agents: they interrupt the clotting cascade itself, providing stronger protection against cardiac emboli.

• Direct oral anticoagulants (DOACs) — preferred: Direct oral anticoagulants (DOACs) — apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), or edoxaban (Savaysa) — are preferred over warfarin for most patients with atrial fibrillation. They are as or more effective than warfarin, carry a lower risk of brain bleeding, and do not require regular blood monitoring.
• Warfarin: Warfarin (Coumadin) remains the treatment of choice for patients with a mechanical heart valve or antiphospholipid antibody syndrome, as DOACs have not been shown to be safe in these specific conditions.

Atrial Fibrillation (AFib) Management

Atrial fibrillation — an irregular heart rhythm in which the heart's upper chambers quiver instead of beating normally — is the most common cardiac cause of ischemic stroke. When the heart beats irregularly, blood can pool in the left atrial appendage (a small pouch in the left upper chamber) and form clots. These clots can travel to the brain, causing a large, often devastating stroke.

If you have AFib that was identified as the cause of your stroke, or if AFib is discovered during your stroke workup, anticoagulation is one of the most important treatments you will receive.

• DOAC anticoagulation: As above — apixaban, rivaroxaban, dabigatran, edoxaban. Choice depends on kidney function, other medications, dosing preference, and cost. Your cardiologist or neurologist will select the right agent for you.
• Rate control: The goal is generally to keep the heart rate in a normal range. Rate control medications (beta-blockers, calcium channel blockers, digoxin) do not eliminate AFib but prevent the heart from beating too fast during AFib episodes.
• Rhythm management: Some patients are candidates for procedures to restore or maintain normal heart rhythm — cardioversion (electrical reset of heart rhythm) or catheter ablation (a procedure that targets the abnormal electrical pathways). These are usually coordinated by your cardiologist.
• Left atrial appendage closure: For patients who cannot safely take anticoagulants, closure of the left atrial appendage (the most common site of clot formation in AFib) with a device such as the Watchman may be considered. This requires a separate consultation and is not appropriate for all patients. UNM Cardiology proudly offers this option and work closely with the stroke neurologist to ensure this is a right fit for a patient.

What If AFib Wasn't Found Yet?  Not all AFib is constant. 'Paroxysmal AFib' — AFib that comes and goes — can be difficult to detect with a standard ECG. If your stroke workup has not identified a clear cause, you may be sent home with a long-term heart monitor to look for intermittent AFib over weeks to months. If AFib is detected, anticoagulation will typically be recommended.

Diabetes and Blood Sugar Management

For stroke patients with diabetes or pre-diabetes, several classes of medications have shown cardiovascular benefit beyond blood sugar control:

• GLP-1 receptor agonists: GLP-1 receptor agonists (such as semaglutide / Ozempic, liraglutide / Victoza) have demonstrated significant reductions in cardiovascular events including stroke in patients with type 2 diabetes and established cardiovascular disease. Weight loss is an additional benefit.
• SGLT-2 inhibitors: SGLT-2 inhibitors (such as empagliflozin / Jardiance, dapagliflozin / Farxiga) reduce heart failure hospitalizations and cardiovascular death in patients with type 2 diabetes. They also lower blood pressure and promote weight loss.
• Metformin: Metformin remains an important first-line medication for type 2 diabetes and has a long track record of safety and cardiovascular neutrality.

Intensive blood sugar control should be balanced carefully — very aggressive lowering (HbA1c below 6%) has not been shown to reduce stroke risk and may increase hypoglycemia risk, particularly in older patients.

Smoking Cessation

• Nicotine replacement therapy (NRT): Nicotine replacement therapy (patches, gum, lozenges, nasal spray) doubles quit rates compared to willpower alone and is safe for most patients after stroke
• Varenicline (Chantix): Varenicline (Chantix) is the most effective single pharmacotherapy for smoking cessation — significantly more effective than NRT alone. It requires a prescription.
• Bupropion: Bupropion (Wellbutrin / Zyban) is an antidepressant that also reduces nicotine cravings. An option for patients who cannot use varenicline.
• Behavioral support: Brief counseling from a clinician, combined with pharmacotherapy, significantly improves quit rates. [Link to UNMH or NM smoking cessation resources]

Secondhand Smoke:  Secondhand smoke also increases stroke risk. If you live with a smoker, encouraging them to quit — or at minimum ensuring your home is smoke-free — is an important part of your own stroke prevention.

Physical Activity and Exercise

Moderate-intensity aerobic activity means exercise that raises your heart rate and makes you breathe harder but still allows you to carry on a conversation — such as brisk walking, swimming, cycling, or light jogging. Spreading activity across multiple days is preferable to concentrating it all in one or two sessions.

• Resistance/strength training: 2–3 sessions per week of exercises that strengthen major muscle groups complement aerobic activity and further reduce cardiovascular risk
• For patients with stroke deficits: If you have physical deficits from your stroke, work with your physical therapist to develop a safe, graduated exercise program tailored to your abilities. Even small amounts of regular activity are beneficial.
• Reduce sedentary time: Sitting for prolonged periods is independently associated with increased cardiovascular risk. Break up long periods of sitting with short movement breaks throughout the day.

Diet, Weight, and Nutrition

Key dietary principles recommended by the AHA/ASA after stroke:

• Mediterranean-style diet: Vegetables, fruits, whole grains, legumes, fish, and olive oil as primary food sources. Associated with reduced stroke risk in large population studies.
• DASH diet: Emphasizes vegetables, fruits, whole grains, low-fat dairy, lean protein, and limits saturated fats and sodium. Specifically designed to lower blood pressure.
• Reduce sodium: Aim for less than 2,300 mg of sodium per day — about 1 teaspoon of salt. Even modest sodium reduction noticeably lowers blood pressure over time.
• Limit saturated and trans fats: Limit saturated fat (red meat, full-fat dairy, tropical oils), trans fats, and processed/ultra-processed foods, which raise LDL and promote inflammation.
• Increase fish intake: Fatty fish (salmon, mackerel, sardines) two or more times per week provides omega-3 fatty acids with cardiovascular benefit.
• Moderate alcohol consumption: One drink per day maximum for women; two for men. Heavy or binge drinking raises blood pressure and increases stroke risk.

Sleep Apnea Screening and Treatment

Obstructive sleep apnea (OSA) — a condition in which breathing repeatedly stops and starts during sleep — is present in up to 70 percent of stroke patients and is significantly underdiagnosed. OSA contributes to high blood pressure (especially resistant hypertension), irregular heart rhythms, and oxidative stress on blood vessel walls. Untreated sleep apnea dramatically increases the risk of recurrent stroke and worsens neurological recovery after stroke.

All stroke and TIA patients should be screened for sleep apnea. If a sleep study confirms OSA, treatment with CPAP (continuous positive airway pressure) — a mask worn during sleep that keeps the airway open — is recommended. Consistent CPAP use lowers blood pressure, improves daytime alertness, and supports recovery from stroke.

Signs of Sleep Apnea:  If you snore loudly, are told you stop breathing during sleep, wake feeling unrefreshed, or are excessively sleepy during the day — tell your care team. A sleep study can be arranged to evaluate for sleep apnea.

Patent Foramen Ovale (PFO) — When the Heart Has a Small Opening

A patent foramen ovale (PFO) is a small hole between the upper chambers of the heart that normally closes shortly after birth. In approximately 25 percent of adults, this opening persists. In most people it causes no problems. However, in younger patients (typically under 60) who have had a cryptogenic stroke — meaning no other cause has been identified despite a thorough workup — a PFO may have allowed a small clot from the venous system to cross into the arterial circulation and travel to the brain.

Whether to close a PFO with a catheter-based procedure is a decision that requires careful individualization. The AHA/ASA recommends PFO closure in adults up to age 60 with a cryptogenic stroke and a PFO, provided a comprehensive search for other stroke causes has been completed.

• Medical option: Antiplatelet therapy (aspirin or clopidogrel) if closure is not performed
• PFO closure: Catheter-based closure with a small plug device — for eligible patients age ≤60 with confirmed cryptogenic stroke after thorough evaluation. UNM Cardiology team works closely with the stroke team to ensure the right patients are offered this procedure.

Individualized Decision:  Not every PFO requires closure. A thorough discussion with your neurologist and cardiologist about the size of the PFO, the presence of an atrial septal aneurysm, your age, and whether all other stroke causes have been ruled out is essential before making this decision.

Your Medical Management Goals at a Glance

Your Care Team at UNMH

Managing all of these risk factors together is a lot to take on. At UNMH, you will not do it alone. Your stroke care team — including your vascular neurologist, primary care provider, and specialists in cardiology, endocrinology, and rehabilitation — work together to build a comprehensive prevention plan tailored to your specific stroke type, risk factors, and lifestyle.

Before you leave the hospital after a stroke, you should have: a clear list of all new medications and why you are taking them; target values for your blood pressure, cholesterol, and blood sugar; a follow-up appointment within one to two weeks; and a referral for any additional workup still needed (such as extended heart monitoring or sleep study).