“One in ten stroke patients experience another stroke within five years"

431 Norwegian patients who had suffered a stroke were followed up three years after their initial hospitalisation through an NTNU study.

Most patients reported that they were still taking the medications they had been prescribed.

Nevertheless, fewer than half had achieved the treatment targets for both blood pressure and cholesterol.

“One in ten patients who have had a stroke experience another stroke within five years. And the second stroke is often worse than the first. Therefore, following up on these patients is crucial,” says resident doctor Erlend Fagerli.

At the same time, research shows that 80 per cent of recurrent strokes can be avoided with optimal prevention and follow-up of patients after the first stroke. 

Lowering blood pressure and reducing levels of harmful LDL cholesterol are most important.

LDL is a type of lipoprotein, meaning a transport medium for fats in the blood. In everyday terms, the cholesterol in LDL particles is known as the 'bad' cholesterol. 

The risk of another stroke is high

Strokes affect approximately 9,000 people in Norway each year. Nearly 5,000 people experience a 'mini-stroke', called transient ischemic attack (TIA). This is a temporary disruption of blood flow to the brain that causes stroke-like symptoms, but no lasting damage. 

The risk of having another stroke is roughly the same for individuals who have had either a cerebral infarction (ischemic stroke) or a TIA.

Fagerli is particularly struck by the fact that many people do not reach the targets for blood pressure treatment.

Three years after having a stroke, only 42 per cent of patients have managed to lower their blood pressure to an optimal level. This is despite the fact that more than nine out of ten patients continued taking the blood pressure medications they were prescribed after their hospital stay.

Lowering blood pressure is crucial

“Blood pressure is the most important factor when it comes to stroke risk. If there's one thing you should do, it's to get your blood pressure under control,” says Fagerli.

The study also shows that most of the patients with high blood pressure were only taking one single type of blood pressure medication.

“When someone has had a stroke, it's very important for them to lower their blood pressure, and combining different blood pressure medications can help achieve that. It can therefore be better to take two different medications at a slightly lower dose rather than a high dose of just one single medication,” says Fagerli.

More medicine gives better results

The study shows a similar tendency for treating high cholesterol. 

Despite the fact that four out of five patients are still taking their prescribed cholesterol medications, only about half manage to lower the level of harmful LDL cholesterol to the desired level.

“We see that patients on higher doses of cholesterol-lowering medication are more likely to reach their treatment target. We also observed that patients with multiple illnesses more often achieved their targets than patients with fewer other illnesses. It often takes two different cholesterol-lowering medications to reach the treatment targets,” he says.

Menopause has a negative impact

The study also showed a difference between men and women when it comes to cholesterol. 

The women had higher levels of harmful LDL cholesterol than men and were less likely to reach the treatment target.

“This may be connected to the fact that LDL cholesterol levels rise after menopause. Other studies also show that women often receive lower doses of cholesterol-lowering medications, which might be part of the explanation,” says Fagerli.

An alliance between doctor and patient

The conclusion is that risk factors after a stroke are still not being adequately followed up. This is despite the fact that many patients take their medications and follow the advice they are given. 

Fagerli also points out that they lack data on why patients do not reach their targets.

“That's a limitation of the study. For example, we don't know why the patients were not given higher doses of medication. There are often good reasons for that,” he says.

Fagerli emphasises that the follow-up of stroke patients is complex.

“Each patient is different, and medications, dosages, and needs vary. Sometimes it may be due to patients not continuing their follow-up, or the doses being too low. Other times, it has to do with the patient’s personal preferences. It's complex,” he says.

Perhaps the patient does not want to take multiple medications. Fagerli feels it is important that patients understand why their doctor wants them to reach the treatment targets.

“This is to avoid another stroke or other cardiovascular events. We want there to be an alliance between the doctor and the patient, and that they collaborate to achieve the treatment targets," he says.

Check your blood pressure

So what should you do if you have had a stroke and are unsure whether you are being followed up adequately?

“Good follow-up is crucial. Most patients receive a check-up at the hospital within three months, but after that, follow-up is left to the GP and the patient. Blood pressure and cholesterol should be measured regularly,” says Fagerli.

If you have had a stroke, you are a high-risk patient.

“If, after a while, you still have slightly high blood pressure or slightly elevated cholesterol levels, it should be followed up,” he says.

He also emphasises that lifestyle changes can be important.

In this study, the researchers found no clear correlation between physical activity and control of blood pressure or cholesterol. 

"Nevertheless, adapted and regular physical activity can be considered a treatment target in itself and is recommended for everyone who has had a TIA or cerebral infarction. Three out of four participants in our study were not physically active enough, based on the Norwegian Directorate of Health’s definition,” says Fagerli.

Reference:

Fagerli et al. Three-year adherence to secondary prevention and vascular risk control after ischemic stroke, European Stroke Journal, 2025. DOI: 10.1177/239698732513292

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Read the Norwegian version of this article on forskning.no

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