Secondary stroke prevention: more questions than answers

Advances in the clinical management of acute stroke in the past decade have led to more people surviving and living with less disability after stroke than before. However, secondary strokes, which are often more severe than the incident stroke, remain prevalent. In The Lancet Neurology, Christopher Schwarzbach and colleagues present the results of the SANO trial, 1 Schwarzbach CJ Eichner FA Rücker V et al. The structured ambulatory post-stroke care program for outpatient aftercare in patients with ischaemic stroke in Germany (SANO): an open-label, cluster-randomised controlled trial. Lancet Neurol. 2023; (published online July 14.)https://doi.org/10.1016/S1474-4422(23)00216-8 Summary Full Text Full Text PDF PubMed Google Scholar a large, cluster-randomised trial that tested the effectiveness of a secondary prevention programme for reducing recurrent stroke rate. The research team are to be congratulated on a rigorously conducted trial. The trial had neutral findings with no difference in rate of recurrent stroke identified between control and intervention groups (odds ratio 1·00 [95% CI 0·58 to 1·73]). Large secondary prevention trials in Europe (INSPiRE-TMS) 2 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: 49-60 Summary Full Text Full Text PDF PubMed Scopus (56) Google Scholar and India (SPRINT INDIA) 3 Kate MP Arora D Verma SJ et al. Secondary prevention by structured semi-interactive stroke prevention package in India (SPRINT INDIA) study protocol. Int J Stroke. 2020; 15: 109-115 Crossref PubMed Scopus (3) Google Scholar have also reported neutral results. It is tempting to conclude that comprehensive secondary prevention services do not work; however, it is important to carefully consider the details.