Moving the Needle on Stroke Recurrence in Patients With Limited Access to Care: Eva Mistry, MD

Roughly 1 in 4 strokes in the United States each year occurs in a person who has already had a stroke. The 2021 American Heart Association/American Stroke Association (AHA/ASA) guideline on secondary prevention emphasizes that this risk can be reduced through etiology-driven antithrombotic therapy and aggressive vascular risk factor management. Treating hypertension to an office target below 130/80 mm Hg is described as possibly the single most important intervention.¹

Stroke has been characterized as a disease of disparities, with marked racial and ethnic inequities in incidence, treatment, and outcomes. A 2023 AHA scientific statement found that most interventions tested to date have targeted proximate determinants such as medication adherence and health literacy. Few have addressed upstream barriers such as income, housing, food security, and access to care, and few have focused on rehabilitation and recovery.²

Social and environmental determinants of health are increasingly recognized as shaping both functional recovery and secondary prevention after stroke. A 2026 AHA scientific statement reviewed how the conditions in which stroke survivors live, work, and age influence their outcomes. The statement outlined actionable strategies, including screening for upstream factors, using policy levers, and applying implementation science frameworks to bring evidence-based practices into real-world settings.³

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"I say this frequently, if we just made some moderate amount of improvement in hypertension control in the population, we would make such big changes in both primary and secondary stroke prevention."

To discuss these disparities, NeurologyLive^® spoke with Eva Mistry, MD, professor of neurology, vice chair of research, and division director of vascular neurology at the University of Cincinnati. In the conversation, Mistry described the barriers that underserved patients face immediately after a stroke. These include limited access to the most appropriate post-acute facility, insufficient rehabilitation to reach full recovery, and difficulty obtaining secondary prevention medications.

Mistry noted that gaps in medication access extend across antiplatelet agents, direct oral anticoagulants, antihypertensives, and lipid-lowering therapies, with each recurrent stroke adding to disability, morbidity, mortality, and caregiver burden. She emphasized that clinicians are increasingly considering social determinants of health, from prescribing medications covered by a patient’s insurance to connecting patients with resources before discharge. She also highlighted telehealth as an important tool for expanding access to acute stroke expertise in rural hospitals and, increasingly, outpatient care.

Mistry urged clinicians to treat the whole patient by addressing risk factors such as hypertension beyond antithrombotic management and involving family members when poststroke cognitive changes complicate patient education. She stressed that the remaining burden of stroke continues to fall disproportionately on certain populations, making these disparities an ongoing priority for the field.

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REFERENCES
1. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021;52(7):e364-e467. doi:10.1161/STR.0000000000000375
2. Towfighi A, Boden-Albala B, Cruz-Flores S, et al. Strategies to Reduce Racial and Ethnic Inequities in Stroke Preparedness, Care, Recovery, and Risk Factor Control: A Scientific Statement From the American Heart Association. Stroke. 2023;54(7):e371-e388. doi:10.1161/STR.0000000000000437
3. Nelson SE, El Husseini N, Bahouth MN, et al. Social and Environmental Determinants of Stroke Functional Outcome and Strategies to Reduce Inequities: A Scientific Statement From the American Heart Association. Stroke. 2026;57(6):e219-e235. doi:10.1161/STR.0000000000000520