The highest-risk window for a recurrent vascular event is the first weeks after the index stroke, and much of that risk is modifiable with decisions that should be settled before discharge rather than punted to the outpatient setting. This checklist is organized around the questions a covering team, a nurse, or the patient is most likely to ask in the hours after the bed empties: what blood thinner and for how long, what the blood pressure should run, whether the statin is high enough, and when — if there is atrial fibrillation — to start anticoagulation. The goal is not a longer note; it is a note where every one of those answers is explicit. This page is for clinician education and does not replace individualized judgment; antithrombotic choice, anticoagulation timing, and targets vary by mechanism, bleeding risk, and local protocol.

Antithrombotic plan and duration.

Write down the agent and the stop date, not just “continue aspirin.” For most non-cardioembolic ischemic stroke or TIA, a single antiplatelet agent is the long-term plan. In qualifying minor ischemic stroke (NIHSS ≤3) or high-risk TIA, short-course dual antiplatelet therapy reduces early recurrence: in POINT, clopidogrel plus aspirin started within 12 hours lowered major ischemic events compared with aspirin alone but increased major hemorrhage, with benefit concentrated early and harm accruing later — the basis for limiting DAPT to roughly the first 21 days before stepping down to monotherapy.3,5 The 2021 AHA/ASA secondary-prevention guideline frames antiplatelet selection, DAPT eligibility, and duration in the same risk-benefit terms.1 If the mechanism is cardioembolic, the plan is anticoagulation, not an antiplatelet — document which, and the start date.

Bedside pearl

Put the DAPT stop date in the discharge instructions and the after-visit summary, not only the note. The recurrence benefit is front-loaded and the bleeding risk is back-loaded, so an open-ended “take both” order is how a 21-day course quietly becomes a 21-month one.

Blood pressure, lipids, and glucose.

These three are the durable workhorses of secondary prevention, and each needs a target on the page. For blood pressure, a long-term goal of <130/80 mm Hg is reasonable for most patients after the hyperacute period, with the caveat that how fast you get there depends on the mechanism and the acute course — document the target and who owns titration.1 For lipids, start a high-intensity statin — atorvastatin 80 mg or rosuvastatin 20–40 mg — unless contraindicated; SPARCL showed that high-dose atorvastatin reduces recurrent stroke after a recent stroke or TIA, establishing intensive statin therapy as standard.2 For glucose, an A1c <7% is a reasonable target for most patients, individualized for frailty, hypoglycemia risk, and life expectancy.1

  • Blood pressure: long-term goal <130/80 mm Hg for most; name the agent and who titrates.1
  • Lipids: atorvastatin 80 mg or rosuvastatin 20–40 mg unless contraindicated; document baseline LDL and the rationale if a lower-intensity regimen is used.2
  • Glucose: A1c <7% for most; individualize and arrange follow-up for diabetes management.1

Atrial fibrillation: anticoagulation choice and timing.

When the mechanism is atrial fibrillation, two decisions must be documented: the agent (a direct oral anticoagulant is preferred over warfarin for most non-valvular AF) and the start timing. ELAN compared earlier versus later initiation of a DOAC after acute ischemic stroke with AF and did not show that earlier starting increased the composite of recurrent ischemia, systemic embolism, major bleeding, or death — supporting earlier initiation in selected patients rather than a rigid fixed delay.4 Timing has historically been tied to infarct size (the “1-3-6-12 day” heuristic) and hemorrhagic transformation risk; trials such as ELAN and OPTIMAS6 have pushed the field toward earlier, more individualized starts. Document the chosen day, the infarct-size reasoning, and any hold for hemorrhagic transformation.

Pitfall

Discharging a patient with newly detected AF on an antiplatelet alone with a vague “start anticoagulation as outpatient.” If no one owns the start date, the DOAC is often never started. Name the agent, the calendar date, and the responsible clinician before the patient leaves.

Rehab disposition.

Disposition should follow function and tolerance for therapy, not bed availability. The common tiers are home with outpatient therapy for patients with mild deficits and adequate support; acute inpatient rehabilitation for patients who can tolerate intensive multidisciplinary therapy (often framed around roughly three hours per day) and have rehabilitation potential; skilled nursing facility for those who need a lower-intensity, longer runway; and long-term acute care (LTACH) for medically complex patients, such as those requiring prolonged ventilator weaning. Document the deficits driving the choice, the therapy recommendations (PT/OT/SLP), and any dysphagia precautions so the receiving team is not guessing.

Follow-up and patient teaching.

Close the loop with concrete appointments rather than instructions to “call to schedule.” A practical chain is a primary-care visit within about two weeks for medication reconciliation and blood-pressure follow-up, a stroke or neurology clinic visit at roughly 4–6 weeks, and outpatient PT/OT/SLP as indicated. Confirm the patient or caregiver can recite BE-FAST (Balance, Eyes, Face, Arm, Speech, Time to call emergency services), understands why each medication matters — especially the antithrombotic and statin — and knows their target numbers for blood pressure and A1c. Teaching that the patient can repeat back is worth more than a stack of handouts they will not read.