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The risk for recurrent stroke following a stroke or transient ischemic attack (TIA) is high. Prevention of a secondary event is a priority, as the associated morbidity and mortality are great. Antiplatelet agents have been shown to reduce this risk, but the choice of treatment modality depends on a number of factors, including the underlying cause of the stroke and the patient's comorbidities. For example, a cardioembolic stroke is best treated with anticoagulants, whereas one of noncardioembolic origin requires antiplatelet therapy. A number of challenging patient scenarios are explored in this article, and appropriate medical management is discussed, with the goal of examining the most recent trial data and information in the context of an actual case. Eight sample cases are presented: stroke prevention in a patient with recent stent placement, low ejection fraction, intracranial stenosis, carotid stenosis, atherosclerosis of the aortic arch, symptomatic coronary artery disease, antiplatelet failure, and stroke prevention in a patient already on warfarin. Journal of Hospital Medicine 2008;3(4 Suppl):S20–S28. © 2008 Society of Hospital Medicine.

A systems approach to stroke care is a multidisciplinary team strategy with the goal of reducing stroke risk. This strategy may start with community-based primary prevention education. For individuals who experience stroke, the inpatient component of a stroke system is designed to integrate evidence-based acute treatment and secondary prevention strategies. A key component to stroke systems care is the use of standardized, evidence-based treatment protocols. During the acute (or subacute) phase of care, the team must be prepared to prevent stroke progression, prevent complications of stroke, manage comorbidities, and reduce the risk of secondary stroke. Hospitalists may take a leadership role both in establishing stroke systems protocols at their institutions and in providing inpatient care for stroke patients. The objective of this article is to review the components of inpatient stroke systems, with a focus on care of patients with noncardioembolic ischemic stroke. Methods to minimize common barriers to establishing stroke systems programs are also presented. Journal of Hospital Medicine 2008;3(4 Suppl):S29–S35. © 2008 Society of Hospital Medicine.

Transient ischemic attack (TIA) carries a substantial short-term risk for stroke, which is a leading cause of disability and death in the United States. Despite the existing evidence-based guidelines for secondary prevention of stroke, variability in the assessment, diagnostic testing, and treatment of patients with TIA in actual clinical practice remains. Identification of stroke etiology via radiological examination is of paramount importance for the appropriate treatment of patients after TIA or stroke. Management of ischemic stroke or TIA includes lifestyle modifications, reduction of modifiable risk factors (eg, hypertension, diabetes, and elevated cholesterol), and appropriate therapeutic treatments. Antiplatelet therapy is the cornerstone of secondary prevention of stroke; guidelines for its use for noncardioembolic cases have been developed from a solid evidence base. Additional therapeutic approaches include HMG-CoA reductase inhibitors (statins), antihypertensives, and anticoagulants. The results of ongoing large trials will further clarify the role of specific antiplatelet agents for the secondary prevention of stroke in patients with noncardioembolic ischemic stroke

Stroke is a prevalent and often devastating condition that is likely to affect a growing proportion of the United States population in the coming decades. Individuals who have experienced a stroke or transient ischemic attack are at elevated risk for recurrent events, which are frequently more severe. Therefore, secondary prevention has become the focus of much clinical research and widespread initiatives to deliver evidence-based care. Hospitalists are in a unique position to contribute substantially to these efforts. The 4 articles in this supplement are a call to action for hospital-based physicians. They are based on the conclusions of a panel of hospitalists, neurohospitalists, vascular neurologists, and neurointensivists who met for a roundtable discussion in March 2007. This, the first of the 4 articles, discusses the opportunity for hospitalists to take a leadership role in creating stroke systems of care that integrate secondary stroke prevention with inpatient treatment of acute stroke. The articles that follow will summarize the consensus of roundtable participants on stroke care best practices and their implementation. Journal of Hospital Medicine 2008;3(4 Suppl):S1–S5. © 2008 Society of Hospital Medicine.