Therapy For Secondary Stroke Prevention Research Articles

Antithrombotic therapy in primary and secondary stroke prevention of cardiac patients and in acute stroke

Primary vascular prevention: the prevalence of cardiogenic stroke will increase in the future. All patients with atrial fibrillation but without any ischemic stroke, must undergo a rigorous risk evaluation, which is crucial for pharmacotherapy. Atrial fibrillation is an important risk factor for stroke, therefore patients with atrial fibrillation should be anticoagulated (except those without other risk factors). Even patients over 75 years with atrial fibrillation could be anticoagulated if the INR is properly controlled. The authors review also the role of anticoagulation in patients suffering from myocardial infarction or valve diseases. Acute stroke: The new European stroke guideline does not recommend the use of conventional or fractionated heparin in the first three days of acute stroke, but aspirin therapy is recommended. Long-term anticoagulation is needed only if cardiac source of emboli can be verified, the patient has good compliance, and the risk of hemorrhagic complication is low (INR: 2-3). Otherwise, antiplatelet therapy is recommended. Some authors recommend early anticoagulation in special cases (high risk of embolisation, left atrial/ventricular thrombus, arterial dissection or surgical intervention for a severe arterial stenosis). Caution is needed in patients with large infarct, uncontrolled hypertension and microbleeds on MRI. Secondary prevention: Antiplatelet therapy is recommended for every post-stroke patient, but for those with cardiac source of emboli anticoagulation is recommended.

Evaluation and management of stroke

In contrast to myocardial infarction, stroke is a heterogeneous disease with multiple different causes. Determination of stroke mechanism is critical to choosing optimal therapy to prevent recurrence. This article reviews the diagnostic approach to stroke and prognostic and treatment implications of specific stroke mechanisms. Data on the role of antiplatelet and anticoagulant therapy in secondary stroke prevention, as well as the role of these agents and thrombolytic therapy in acute stroke treatment are reviewed. Situations of particular relevance to the practicing hematologist-stroke in the young, patients with multiple recurrent strokes, patients with abnormal hypercoagulable laboratory testing, and treatment of intracerebral hemorrhage following thrombolytic therapy-are discussed.

Antiplatelets for Stroke Prevention

Marc Fisher MD Kennedy Lees MD Section Editors Indirect comparisons of CAPRIE, ESPS-2, and MATCH trials led many stroke experts to favor the combination of aspirin and extended-release dipyridamole (ASA/ERD) over clopidogrel as the preferred antiplatelet therapy for secondary stroke prevention.1–3 The Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) study, a 2×2 factorial, double-blind, event-driven, active and placebo-controlled study of ASA/ERD versus clopidogrel, and the angiotensin receptor blocker, telmisartan, versus placebo in 20 332 patients with a recent ischemic stroke was performed to evaluate the 2 antiplatelet agents directly. No clear winner can be declared, but ASA/ERD, the presumptive favorite, has been bruised and clopidogrel’s role in stroke prevention has been partly restored. A rematch between these rivals appears unlikely. PRoFESS demonstrated that the risks of recurrent stroke or the composite of stroke, myocardial infarction, or vascular death are similar with ASA/ERD and clopidogrel.4 However, increased risks of nonfatal hemorrhagic stroke and side effects leading to discontinuation of therapy were seen with ASA/ERD. Treatment with either ASA/ERD or clopidogrel did not seem to afford neuroprotection. Disability due to stroke and cognitive decline was not different between the 2 antiplatelets.5 There was no interaction between the treatment benefit of the antiplatelets and telmisartan in any outcome measure. A few editorials have already attempted to explain “What went …

Impact of deep vein thrombosis assessed by venous ultrasonography in patients with stroke and patent foramen ovale

Introduction: Appropriate therapeutic management for secondary stroke prevention (SSP) in stroke patients and patent foramen ovale (PFO) remains uncertain. Assumption of paradoxical embolism (PDE) supposes a venous thrombotic source. Diagnosis of deep vein thrombosis (DVT) of lower extremity/pelvis veins (LEPV) not only strengthens the hypothesis of PDE, simultaneously determine the therapy for SSP. The aim of this study was to assess the frequency of DVT detected by sonography in a cohort of stroke patients diagnosed of PFO. The study might help to understand which factors are associated with the diagnosis of DVT in order to optimize the diagnostic management.

Acetylsalicylic acid + extended-release dipyridamole combination therapy for secondary stroke prevention

Background: Approximately 25% of strokes are recurrent. Antiplatelet therapy is indicated for the prevention of recurrent stroke in patients with a history of noncardioembolic minor stroke or transient ischemic attack (TIA). Although clinicians may choose acetylsalicylic acid (ASA) as first-line therapy for secondary prevention, clinical guidelines and evidence from trials suggest that ASA may not be the most effective strategy. Objective: The purpose of this review was to discuss results from clinical trials that have compared the efficacy of ASA monotherapy versus ASA + extendedrelease dipyridamole in secondary stroke prevention. Methods: Relevant randomized experimental and clinical studies in patients with a history of minor stroke or TIA of noncardioembolic etiology were identified using a search of the US National Library of Medicine database, with no limits on publication dates. The primary search terms used were secondary stroke prevention, antiplatelet therapy, acetylsalicylic acid, ASA, aspirin, aspirin + extended-release dipyridamole, and combination therapy. Results: Early trials of dipyridamole monotherapy or ASA + dipyridamole involved small numbers of patients and found no significant treatment differences. Two major trials that compared ASA monotherapy, dipyridamole monotherapy, and ASA + dipyridamole were identified: the Second European Stroke Prevention Study (ESPS-2) and the European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT). Efficacy measurements in ESPS-2 found that stroke relative risk reductions were 18% ( P = 0.013), 16% ( P = 0.039), and 37% ( P < 0.001), respectively, compared with placebo for a relative risk reduction of 23.1% ( P = 0.006) favoring the combination over ASA monotherapy. In ESPRIT, patients who received ASA + dipyridamole had a 20% relative risk reduction versus ASA monotherapy for the composite end point of death from all vascular causes, nonfatal stroke, nonfatal myocardial infarction, or major bleeding complications. In ESPS-2, headache was 5% more common with dual therapy compared with ASA monotherapy. ESPRIT found that combination treatment was not associated with a higher complication rate than ASA monotherapy, but that the rate of withdrawal due to adverse events was higher in the group that received the combination. Conclusion: Based on the results from these 2 large, randomized trials, ASA + dipyridamole was more effective than ASA monotherapy as first-line therapy for secondary stroke prevention in these patients with a history of minor stroke or TIA of noncardioembolic etiology.

A Review of Therapeutic Strategies for Risk Reduction of Recurrent Stroke

Although cardiovascular disease (CVD) is a major source of morbidity and mortality in the United States, a relatively small percentage of deaths related to CVD result from ischemic stroke. However, the impairment and costs associated with stroke are large--and largely preventable. Large-scale trials have demonstrated benefit with antihypertensive therapy for secondary prevention, showing significantly reduced rates of stroke and cardiovascular events. Statins have shown efficacy in primary stroke prevention, and one trial showed reduced incidence of stroke and cardiovascular events in patients with recent stroke or transient ischemic attack (TIA). The merits of antiplatelet therapy in primary and secondary stroke prevention have been demonstrated across numerous trials and meta-analyses. Trials assessing aspirin plus clopidogrel or aspirin plus extended-release dipyridamole for preventing secondary stroke have produced somewhat contradictory findings. This review discusses the relationship between CVD and risk of secondary stroke or TIA and summarizes secondary prevention strategies, focusing on antiplatelet agents, to provide guidance for the practicing cardiologist. Certain combination therapies appear to be more effective for secondary prevention of stroke or TIA than therapy with single antiplatelet agents. The choice of agents may be important, based on results of several trials. The ongoing, large-scale, comparative Prevention Regimen for Effectively Avoiding Second Strokes (PR. FESS) trial should provide cardiologists with more definitive recommendations.

Antiplatelet therapy in cerebrovascular disease: implications of Management of Artherothrombosis with Clopidogrel in High-risk Patients and the Clopidogrel for High Artherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance studies' results for cardiologists.

Cardiovascular disease is prevalent among patients with stroke; thus, cardiologists frequently treat patients at high risk for stroke. Results from recent clinical trials of antiplatelet medications, given alone or in combination, may be of special interest to cardiologists. The MATCH study demonstrated no significant difference between clopidogrel alone and clopidogrel plus aspirin in reducing risk of vascular events after stroke or transient ischemic attack. A 1.3% increased risk of major bleeding was associated with clopidogrel plus aspirin. In CHARISMA, clopidogrel plus aspirin did not reach statistical significance vs. placebo plus aspirin in reducing incidence of myocardial infarction (MI), stroke, or death from cardiovascular causes in patients with stable atherothrombotic disease; clopidogrel was associated with an increase in moderate bleeding. These results suggest that clopidogrel plus aspirin may be inappropriate as first-line therapy for secondary stroke prevention. In patients with established cardiovascular disease at risk for MI or other vascular events, physicians must weigh the benefits and risks before choosing this therapy. Selection of an antiplatelet agent must be based on patient history, including previous MI and stroke, susceptibility to bleeding, and other high-risk factors (e.g. advanced age and diabetes). Aspirin plus extended-release dipyridamole may be more effective than clopidogrel for preventing stroke in high-risk patients. This article strives to put MATCH and CHARISMA results into context by providing an overview of antiplatelet therapy, including relevant clinical trial results, a review of current practice guidelines, and a summary of an ongoing study that will improve clinical decision making.

Cost–effectiveness of antiplatelet therapy for secondary stroke prevention

Antiplatelet therapy is recommended over anticoagulants for the secondary prevention of vascular death in patients with noncardioembolic ischemic stroke or transient ischemic attack based upon the 2006 American Heart Association/American Stroke Association guidelines for the prevention of stroke and the National Stroke Association guidelines for the management of transient ischemic attack. Aspirin is commonly used as a cornerstone antiplatelet agent considering its mild but definite prevention benefit and low costs. Other antiplatelet strategies that are currently recommended include extended-release dipyridamole plus low-dose aspirin (Aggrenox®, Asasantin®) and clopidogrel. In this brief review, we evaluate the cost–effectiveness of antiplatelet agents for secondary stroke prevention to better understand the socioeconomical value of the recommended agents.

Statin Therapy for Secondary Stroke Prevention: Evidence Catches Up to Practice

Current approaches for the secondary prevention of ischemic stroke include the aggressive use of antithrombotic therapy, particularly antiplatelet agents, and carotid endarterectomy for eligible patients. Blood pressure lowering with angiotensin converting enzyme inhibitors and diuretics in hypertensives, glucose control to a hemoglobin A1C of less than 7% in diabetics, and statin therapy in patients with hyperlipidemia and/or cardiovascular disease are also important measures forsecondary prevention of stroke. Support for the routine use of statin therapy in all patients with ischemic stroke, regardless of lipid profile or a history of cardiovascular disease, has been, until recently, of debate. Clinical evidence found in studies such as the SPARCL trial and the Heart Protection Study now support the routine use of statin therapy in all ischemic stroke patients. This article focuses on the potential and proven benefits of statins in ischemic stroke.

PRoFESS Expected Implications for Oral Antiplatelet Therapy in Secondary Stroke Prevention Therapy

PRoFESS Expected Implications for Oral Antiplatelet Therapy in Secondary Stroke Prevention Therapy

Immediate Anticoagulation for Acute Stroke in Atrial Fibrillation

HomeStrokeVol. 37, No. 12Immediate Anticoagulation for Acute Stroke in Atrial Fibrillation Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBImmediate Anticoagulation for Acute Stroke in Atrial FibrillationNo, but …. Stephen M. Davis and Geoffrey A. Donnan Stephen M. DavisStephen M. Davis From the National Stroke Research Institute (G.A.D.), and the Royal Melbourne Hospital (S.M.D.), Victoria, Australia. Search for more papers by this author and Geoffrey A. DonnanGeoffrey A. Donnan From the National Stroke Research Institute (G.A.D.), and the Royal Melbourne Hospital (S.M.D.), Victoria, Australia. Search for more papers by this author Originally published26 Oct 2006https://doi.org/10.1161/01.STR.0000248917.58920.9cStroke. 2006;37:3056Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 26, 2006: Previous Version 1 We all accept that full anticoagulation is highly effective, proven therapy for the great majority of patients with atrial fibrillation (AF) for the prevention of recurrent stroke. This controversy relates chiefly to the timing of anticoagulation in the acute stroke setting, the agent and mode of administration.It is useful to track the path of the use of heparin over the past 25 years. Many of us based a practice of acute intravenous heparin in AF patients on the trial of the Cerebral Embolism Study Group (1983),1 which concluded that the immediate anticoagulation of embolic stroke was effective and apparently safe, yet based on only 45 randomized patients. Clearly, conclusions based on such small numbers would not be reached a quarter of a century later, where trial methodology is so much more sophisticated.Two major influences then led to guidelines that immediate anticoagulation is not warranted. First, Sandercock and others, in much larger randomized trials, showed that there was a substantially lower risk of early recurrent embolism than previously thought.2,3,4 Second, these trials did show an overall benefit for a policy of acute anticoagulation. However, none of these trials used a monitored anticoagulation protocol. Interestingly, in an earlier heparin controversy in our series, we pointed out that there had been no adequate trial of APTT-monitored intravenous heparin in acute ischemic stroke. Sadly, as indicated by Chamorro, this remains the case.5 Furthermore, we are not convinced that there is bioequivalence between different anticoagulation agents and mode of administration.So, what do we do in this evidence-light zone? In the great majority of patients with AF, we do not use full anticoagulation in any form in the acute stroke setting and would generally commence warfarin within a few days of symptom onset. In exceptional circumstances, such as recurrent embolism or echocardiographic evidence of left atrial or ventricular thrombus, we would immediately anticoagulate.Our final word: the reality is that heparin is still widely used around the world in this setting. We don’t believe that this controversy will die without an adequately powered trial of monitored anticoagulation in high-risk patients with AF and acute stroke.DisclosuresNone.FootnotesCorrespondence to Geoffrey A. Donnan, National Stroke Research Institute, Austin Health, 300 Waterdale Rd, Heidelberg Heights, Victoria, Australia 3081. E-mail [email protected]References1 Cerebral Embolism Study Group. Immediate anticoagulation of embolic stroke: a randomized trial. Stroke. 1983; 14: 668–676.CrossrefMedlineGoogle Scholar2 Saxena R, Lewis S, Berge E, Sandercock PA, Koudstaal PJ. Risk of early death and recurrent stroke and effect of heparin in 3169 patients with acute ischemic stroke and atrial fibrillation in the International Stroke Trial. Stroke. 2001; 32: 2333–2337.CrossrefMedlineGoogle Scholar3 The TOAST investigators. Low molecular weight heparinoid, Org 10172 (danaparoid), and outcome after acute ischemic stroke. JAMA. 1998; 279: 1265–1272.CrossrefMedlineGoogle Scholar4 Berge E, Abdelnoor M, Nakstad PH, Sandset PM. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial Lancet. 2000; 355: 1205–1210.Google Scholar5 Chamorro A, Busse O, Obach V, Toni D, Sandercock P, Reverter JC, Cervera A, Torres F, Dávalos A. The rapid anticoagulation prevents ischemic damage study in acute stroke - final results from the writing committee. Cerebrovasc Dis. 2005; 19: 402–404.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Csiba L and Kovács K Antithrombotic therapy in primary and secondary stroke prevention of cardiac patients and in acute stroke, Orvosi Hetilap, 10.1556/oh.2009.28414, 150:5, (195-202) December 2006Vol 37, Issue 12 Advertisement Article InformationMetrics https://doi.org/10.1161/01.STR.0000248917.58920.9cPMID: 17068309 Manuscript receivedJuly 10, 2006Manuscript acceptedAugust 11, 2006Originally publishedOctober 26, 2006 Keywordsatrial fibrillationPDF download Advertisement

Immediate Anticoagulation for Acute Stroke in Atrial Fibrillation

Immediate Anticoagulation for Acute Stroke in Atrial Fibrillation

Antithrombotic Therapy in Secondary Stroke Prevention

Ischemic stroke is a major cause of morbidity and mortality. The choice of antithrombotic therapy is largely dependent on the type of stroke. In this article, the authors focus on the secondary prevention of stroke, providing evidence from the literature. The mechanism of action of each of the antithrombotic drugs is discussed. Anticoagulation with warfarin for cardioembolic stroke, particularly atrial fibrillation, is strongly recommended, while no clear advantage for warfarin over aspirin exists for ischemic stroke secondary to atherothrombotic or patent foramen ovale. Combination therapies of aspirin plus warfarin do not offer any additional therapeutic benefit and carry an increased risk of hemorrhage. Aspirin and clopidogrel present similar risks for stroke recurrence. The combination of aspirin with extended-release dipyridamole has a lower risk of stroke than aspirin alone and does not enhance the risk of hemorrhage. Finally, some recommendations and future perspectives are included.

Dipyridamole/aspirin combination in secondary stroke prevention: effects on absolute myocardial blood flow and coronary vascular resistance

In the European Stroke Prevention Study (ESPS 2), oral administration of a fixed combination of 200 mg extended-release dipyridamole and 25 mg aspirin (twice daily) after ischemic stroke or transient ischemic attack, significantly reduced the risk of stroke compared to placebo as well as compared to aspirin or dipyridamole alone. However, the i.v. application of dipyridamole over 4 - 6 min is known to increase myocardial blood flow up to 6-fold, and thereby potentially provoke ischemic wall motion abnormalities in patients with coronary artery disease. We therefore assessed the cardiac side effects of the dipyridamole/aspirin combination on absolute myocardial blood flow (MBF) and coronary vascular resistance (CVR). MBF and CVR were measured using 150-water positron emission tomography in 24 patients after stroke or transient ischemic attack, before and 6.7 +/- 1.9 days after starting the dipyridamole/aspirin combination (Aggrenox) therapy. Resting MBF increased by 39% (max. 112%), from 0.92 +/- 0.13 (ml x g(-1) x min(-1)) at baseline to 1.28 +/- 0.27 (ml x g(-1) x min(-1)) under ongoing dipyridamole/aspirin combination therapy (p < 0.0005). CVR consecutively decreased from 105.3 +/- 16.9 to 74.1 +/- 16.5 (mmHg x ml(-1) x g x min) (p < 0.0005). The relative increase in MBF correlated negatively with the body surface area. No correlation was found between relative MBF increase and duration of dipyridamole/aspirin combination therapy (range 4 - 10 days). Orally administered dipyridamole/aspirin combination therapy in secondary stroke prevention increases MBF and decreases CVR significantly. These cardiac side effects of the dipyridamole/aspirin combination should be taken into account in stroke patients with proven or suspected coronary artery disease, particularly in combination with a small body surface area.

Changing attitudes to the management of ischaemic stroke between 1997 and 2004: a survey of New Zealand physicians

In 1997, a survey of New Zealand physicians' opinions on the management of stroke was carried out. Since then, there have been a number of advances in stroke therapy. We have repeated the 1997 survey to assess changes in physicians' opinions on stroke management. A questionnaire was sent to 293 physicians responsible for patients admitted with acute stroke to hospitals throughout New Zealand. It included questions on the management of acute stroke and secondary prevention and was based on the 1997 questionnaire. Responses were received from 211 physicians of whom 174 (82%) managed patients with an acute stroke. The number of respondents who thought that stroke units were efficacious has increased (57% in 1997 to 89%, P < 0.001). The use of aspirin acutely (P < 0.001) and intravenous tissue plasminogen activator (P = 0.006) has also increased. In 2004, antihypertensive therapy for secondary stroke prevention would be commenced if the blood pressure was 150/90 by 98% of respondents and 140/90 by 70% of respondents. In 2004, a statin would be commenced if the total cholesterol level was 4.0 mmol/L by 56% of respondents and 5.0 mmol/L by 91% of respondents. This survey has shown important changes in the management of ischaemic stroke over the past 7 years.

Aspirin resistance in secondary stroke prevention

We investigated the platelet function in stroke patients treated with aspirin [acetylsalicylic acid (ASA)] for secondary stroke prevention during a follow-up period of 1 year. In this prospective study 291 patients with first initiated aspirin therapy (300 mg/day) for secondary stroke prevention were included. Platelet aggregation measurements were performed 24 h, 3, 6, and 12 months after starting medication. Twenty-one of 291 patients (7.2%) were identified as primary ASA-non-responders (initial insufficient platelet inhibition) and 4.1% as secondary ASA-non-responders (insufficient platelet inhibition during follow-up). There were no significant differences between ASA-responders and ASA-non-responders concerning age, gender, risk factors, and stroke characteristics. Aspirin resistance in stroke patients is not uncommon. The clinical usefulness of routine platelet function tests needs to be proved by further trials.

Development and application of Model of Resource Utilization, Costs, and Outcomes for Stroke (MORUCOS): An Australian economic model for stroke

To outline the development, structure, data assumptions, and application of an Australian economic model for stroke (Model of Resource Utilization, Costs, and Outcomes for Stroke [MORUCOS]). The model has a linked spreadsheet format with four modules to describe the disease burden and treatment pathways, estimate prevalence-based and incidence-based costs, and derive life expectancy and quality of life consequences. The model uses patient-level, community-based, stroke cohort data and macro-level simulations. An interventions module allows options for change to be consistently evaluated by modifying aspects of the other modules. To date, model validation has included sensitivity testing, face validity, and peer review. Further validation of technical and predictive accuracy is needed. The generic pathway model was assessed by comparison with a stroke subtypes (ischemic, hemorrhagic, or undetermined) approach and used to determine the relative cost-effectiveness of four interventions. The generic pathway model produced lower costs compared with a subtypes version (total average first-year costs/case AUD$ 15,117 versus AUD$ 17,786, respectively). Optimal evidence-based uptake of anticoagulation therapy for primary and secondary stroke prevention and intravenous thrombolytic therapy within 3 hours of stroke were more cost-effective than current practice (base year, 1997). MORUCOS is transparent and flexible in describing Australian stroke care and can effectively be used to systematically evaluate a range of different interventions. Adjusting results to account for stroke subtypes, as they influence cost estimates, could enhance the generic model.

Patent Foramen Ovale and Stroke: Prognosis and Treatment in Young Adults

A patent foramen ovale (PFO) is found with increased frequency in patients with stroke of undetermined origin but the significance and therapeutic implications of this observation remain unclear. Several lines of evidence suggest a role for the PFO in stroke pathophysiology for some cryptogenic stroke patients, such as those whose PFO is accompanied by a prothrombotic state, atrial septal aneurysm, or lower extremity/pelvic DVT. Diagnostic evaluation of the patient with cryptogenic stroke and PFO is directed at identifying these subgroups. Appropriate therapy for primary and secondary stroke prevention in a subject with a PFO remains unclear given current uncertainties as to the pathophysiological significance of PFO. Additional studies are needed, such as those focused on lower extremity veins or the cardiac interatrial septum, to guide therapy in specific stroke subpopulations.

1323 Dual antiplatelet therapy in secondary stroke prevention: a community hospital experience

1323 Dual antiplatelet therapy in secondary stroke prevention: a community hospital experience

In-Hospital Initiation of Secondary Stroke Prevention Therapies Yields High Rates of Adherence at Follow-up

The Stroke PROTECT (Preventing Recurrence Of Thromboembolic Events through Coordinated Treatment) program systematically implements, at the time of acute transient ischemic attack (TIA) or ischemic stroke admission, 8 medication/behavioral secondary prevention measures known to improve outcome in patients with cerebrovascular disease. The objective of this study was to determine if the high utilization rates previously demonstrated at hospital discharge were maintained at 90 days after discharge. Data were prospectively collected on consecutively encountered ischemic stroke and TIA patients admitted to a university hospital stroke service beginning September 1, 2002. PROTECT interventions were initiated before hospital discharge in all PROTECT-target (underlying stroke mechanism large vessel atherosclerosis or small vessel disease) and PROTECT-ACS (At-risk for Coronary Sequelae) patients. Adherence to program goals was assessed 3 months after discharge. During the period from September 2002 to August 2003, 144 individuals met criteria for PROTECT intervention. Of the 130 patients (90%) with available day 90 follow-up data, mean age was 72 (range, 37 to 95), and 63% were male. Adherence rates in patients without specific contraindications were 100% for antithrombotics, 99% for statins, 92% for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 80% for thiazides. Awareness of the importance of calling 911 in response to stroke was 87%. Adherence to diet and exercise guidelines were 78% and 70%, respectively. Of the 24 smokers, tobacco cessation was maintained in 20 (83%). High rates of adherence to PROTECT therapies were maintained at 90 days after hospital discharge.