Preventing further strokes

After a stroke, doctors generally recommend taking an antiplatelet (a specific type of anticoagulant). These drugs are only recommended if you don't have atrial fibrillation though. Antiplatelets make it harder for the platelets in your blood to stick to blood vessel walls and to each other. This can prevent new blood clots from forming and blocking vessels in the brain. Antiplatelets normally contain one of the following active ingredients:

• Acetylsalicylic acid: This drug can be found in painkillers like Aspirin.
• Clopidogrel and ticagrelor: These medications also prevent blood clots.

The doctor will talk to you about your medication options. After minor strokes, acetylsalicylic acid can be combined with clopidogrel or ticagrelor. The treatment starts immediately after the stroke and lasts for around two to four weeks. After that, it’s usually enough to take just one of these medications on a permanent basis.

Antiplatelets can have side effects. They slow down blood clotting, which can increase the likelihood of bleeding. Most bleeding is only light and harmless. More serious effects, like bleeding in the stomach, are rare. Antiplatelets can also cause stomach ulcers. Because of this, it sometimes makes sense to take additional medication to protect the stomach (known as proton pump inhibitors or PPIs).

People with high blood pressure have a higher risk of stroke. Taking medication to reduce blood pressure decreases the risk of having another stroke. Blood pressure should average out at between 120/70 mmHg and 140/90 mmHg over the day.

Studies have shown that blood pressure medications have the following effects during the first few years after a stroke:

• 10 out of 100 people who did not take blood pressure medication had another stroke.
• 8 out of 100 people who took blood pressure medication had another stroke.

Another advantage of blood pressure medication is that it reduces the risk of heart attacks and kidney disease.

Most people are advised to take medication to lower their cholesterol levels after a stroke – commonly these are statins. These drugs protect and stabilize blood vessel walls, which helps prevent blood clots. They also lower the risk of heart attack.

Several types of statins have been approved for use in Germany. So if you don't tolerate a particular type you can switch to another one. But most people tolerate these drugs quite well. One possible side effect is muscle pain or muscle weakness. This is very uncommon, though.

Other kinds of medicine can reduce cholesterol levels too. If statins aren't effective enough on their own, you can take one of the other medications as well.

Atrial fibrillation is the most common kind of constantly irregular heartbeat, and usually isn't immediately life-threatening. In the long term, though, it increases your risk of a stroke. So most people who have atrial fibrillation are advised to take medication to prevent strokes.

Oral anticoagulants can greatly reduce the risk of strokes. There are two different types:

• Direct oral anticoagulants (DOACs), also known as “novel oral anticoagulants” (NOACs)
• Vitamin K antagonists, also known as coumarins – these include the active ingredients phenprocoumon (known by the brand name “Marcumar”) and warfarin

Depending on the active ingredient, you take anticoagulant tablets one or two times per day.

Direct anticoagulants are probably slightly more effective than vitamin K antagonists and they don’t cause bleeding as often. So they are usually the preferred option. But if someone is taking a vitamin K antagonist and is doing well on it, there's no medical reason for them to switch to a DOAC.

The most common side effect of anticoagulants is minor bleeding, like nosebleeds or bleeding gums. Larger-scale bleeding – in the stomach or bowel, for instance – is rare. The most serious side effect of anticoagulants is a brain hemorrhage. But the risk of that happening is very low. The number of strokes anticoagulants prevent is much higher than the number of brain hemorrhages they cause.

Strokes are often trigged by very narrow blood vessels (stenosis) due to deposits on the walls of the blood vessels in the brain or the carotid arteries in the neck. Deposits in a carotid artery (carotid artery stenosis) can be removed by surgery. The surgery is usually done within the first two weeks of the stroke happening. Research shows that the procedure can considerably decrease the risk of having another stroke.

Stents are sometimes used to keep the blood vessel open. These tiny wire mesh tubes prevent vessels from becoming narrow or blocked again. Inserting a stent in a narrowed carotid artery prevents strokes and can be an alternative to removing vessel deposits.

Placing stents in narrowed blood vessels in the brain, on the other hand, is only recommended in rare cases. This is because research shows that the procedure is associated with significant risks. For example, it can lead to brain hemorrhages, which can cause strokes themselves. Doctors will only consider this approach if someone has a very narrow blood vessel that can't be treated effectively any other way (like with the usual medication). Before having this kind of procedure, the possible risks and benefits need to be weighed very carefully.

An active lifestyle strengthens the heart and blood vessels. Exercise and sports can have a positive effect on cholesterol and blood pressure. Exercise and sports can also help you lose weight, strengthen your muscles and bones and improve your general level of fitness and wellbeing. Depending on how fit you are and what activities you enjoy, Nordic walking, jogging, cycling and swimming are good options. Strength training and exercises to improve balance and coordination are also suitable.

Recommendations include

• do some form of moderate physical activity on at least four days per week (a total of at least 150 minutes) and
• train all large muscle groups twice a week (strength training).

Staying active is important even if your mobility is very limited due to a stroke. It is definitely a good idea to spend as little time as possible sitting and lying down. Getting up regularly and taking at least a few, small steps can make a difference. You can do simple mobility and strengthening exercises even when you’re in bed. Family members and nursing staff can assist you. Physical and occupational therapy can also help you improve your strength and mobility.

In Germany, local sports clubs run regular rehabilitation exercise classes for people who’ve had a stroke. These Rehasport classes include things like aerobics, active games, and swimming. Statutory health insurers cover the costs of Rehasport if a doctor has prescribed it.

Smokers have a higher risk of stroke. This is because smoking damages the walls of the blood vessels, which makes blood clots more likely. Giving up smoking has other health benefits too, like preventing lung disease. Various forms of help are available for people who want to quit. They include telephone helplines and special courses. Nicotine replacement therapy can also help you quit smoking.

There is little research on how diet and weight loss affect the risk of having another stroke. But people who have an increased risk of blood vessel disease (vascular disease) can benefit from making changes if they have very little variety in their diet. The recommendation is to eat a balanced diet, for instance a “Mediterranean diet” – in other words, a diet full of vegetables, fruits, legumes, nuts, olive oil, whole grain products, fish, and poultry. According to a number of recommendations, this type of diet contains a good mix of nutrients.

A low-salt diet leads to less water being stored in the body, which can lower blood pressure. The recommended daily intake for salt is less than 6 grams. It is possible to stick to that by not adding salt to everything you eat, for example, and not eating too many ready-made salty meals.

People who are very overweight (obese) can benefit from losing weight. The more severe their obesity and the longer it lasts, the higher the risk of a heart attack or stroke. However, it is unclear to what extent weight loss after a first stroke reduces the risk of having another stroke. Family doctors can advise you about diet and other ways to lose weight, but you can also seek professional dietary advice.

Dietary supplements containing omega-3 fatty acids (like fish oil capsules) are marketed as being “good for heart health.” Several studies have investigated whether they prevent strokes but were unable to find any effect.

People with a high risk of stroke are advised to limit the amount of alcohol they drink. That is because alcohol can increase the risk of strokes and other illnesses. Alcohol raises your blood pressure. But it’s not possible to say exactly how much alcohol is “too much” for people who have had a stroke.