NeuroVoices: Eva Mistry, MD, on Addressing Secondary Stroke Prevention Gaps in Underserved Populations

Stroke remains one of the leading causes of death and long-term disability in the United States, and a substantial share of that burden is preventable.¹ Secondary stroke prevention centers on controlling modifiable risk factors, along with consistent use of antiplatelet or anticoagulant therapy.² Since a prior stroke is among the strongest predictors of a future one, the period following an initial event may represent a critical window for intervention, and even modest improvements in risk factor control at the population level can meaningfully reduce recurrent stroke and its downstream disability.

That window is not equally accessible to everyone. Studies have shown that social determinants of health are associated with meaningful disparities in stroke incidence, care processes, and outcomes.³ Underserved and rural populations in particular face compounding barriers such as reduced access to rehabilitation services and specialty follow-up, higher rates of uncontrolled hypertension and diabetes, and structural obstacles such as transportation, insurance limitations, and distance from stroke centers.

These barriers do not simply raise the risk of a second stroke; they also deepen the disability, caregiving burden, and socioeconomic strain that follow one. In a new iteration of NeuroVoices, stroke expert Eva Mistry, MD, professor of neurology at the University of Cincinnati, unpacked the specific challenges underserved patients face after a stroke. In the conversation, she talked about why closing these gaps matters for secondary prevention, and where she's seen real movement toward more equitable care, particularly in telehealth.

NeurologyLive: What are the unique challenges that underserved populations face following a stroke?

Eva Mistry, MD: The challenges that the underserved population faces following a stroke are manifold. I would probably just start with some immediate ones, just going out of the hospital. Resource challenges can include not being able to go to a facility that is the best for them to recover from their stroke. Sometimes underinsured populations can have access issues in terms of rehabilitation, how much rehabilitation they need to get to be able to get the full recovery, or as much recovery from their stroke as possible. That's one piece of it.

Continuing the line of access to care issues, I think access to medications that are important for them to take in order to prevent a second stroke, and that can include, of course, antiplatelet therapies, sometimes novel anticoagulants, but also sometimes basic things such as controlling blood pressure, or having access to medications to reduce the lipids and things like that, can really be challenging for underserved patients, and that leads to suboptimal management from a secondary stroke prevention standpoint.

Why is addressing these disparities such an important part of secondary stroke prevention?

I think the people who are underserved do carry a large burden of secondary stroke. Every time somebody has a recurrent stroke, that increases their disability, morbidity, and mortality exponentially. Each insult to the brain can exponentially reduce their chances of having a recovery, and so it is important to prevent these events from happening.

It increases the burden overall on society in the form of increased caregiving, where families that are already stretched thin can face a lot more of that burden caring for a family member who's disabled from a first or second stroke than families who have the resources to outsource some of that caregiving. So that adds a lot of secondary socioeconomic burden that is also carried disproportionately by the families of patients who are underserved.

How has the landscape of care evolved to better meet the needs of these patients?

I think from a clinical community standpoint, it's just the fact that we are now more and more aware of social determinants of health, knowing that this is an issue people should actively keep in mind when they're seeing their patients, in order to do simple things such as prescribe medications that their insurance is going to cover. If their insurance won't cover it, find them resources while they're still in the hospital, before they're discharged, so they're not left to figure it out by themselves once they're back out in the community. There's, of course, a lot more work to do about this awareness. We're not there yet, but I have definitely seen an increased active thinking on the clinician's part about these various things that could determine somebody's health outside of just their stroke.

One tangible improvement, I would say, is access to more telehealth, and this addresses some access to care disparities in patients who live in rural areas, for example. One tangible thing where we've seen this effect is acute stroke care, access to neurology specialists, even in rural hospitals, by telehealth, so that they can get timely decision making and timely care. Now that telehealth has expanded into outpatient settings as well, I think that has really moved the needle. Again, there is so much more work to do in all areas, and there are many more than what I mentioned, but we're at least thinking about them, and I hope that we will continue to make leaps of improvement in the future.

What advice would you give to clinicians who may be managing these patients over time?

I think the one advice for clinicians is to look at the patient as a whole. Sometimes we do tend to, as stroke neurologists specifically, manage their stroke, and that means different things. I feel like even in our group, different stroke clinicians sometimes take ownership of managing things that are directly affecting their stroke such as antithrombotic, anticoagulant, antiplatelet medications, but we should really be taking ownership of other risk factors that really affect the chances of this patient having another stroke.

Hypertension is number one. 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. So really thinking about the patient as a whole and addressing all the things that contribute to their stroke and secondary stroke, rather than the single episode that is in front of us, I think is important.

Then, it can be especially challenging to educate poststroke patients about their health condition, just from cognitive aspects that many strokes carry. The patients can sometimes have challenges taking ownership of their own health conditions, so clinicians need to recognize that and involve family members, or do your best to educate the patient and come down to their level so that they can take ownership of their health. I think that is also an important aspect to keep in mind.

Why does this remain such a timely topic in the neurology community?

I will say it has always been timely. We're just waking up to it now. I think it is going to remain timely. The data suggests that although we're continuing to do better in terms of stroke incidence and secondary stroke incidence at the population level, nationally, the remaining burden is disproportionately borne by a certain group of the population. We always need to make sure that we're aware of it. Moving everybody along with us, and leaving no one behind, is really important. I think we should always be aware of it, but it's good that we are putting an increasing emphasis on it now.

Transcript edited for clarity. Click here to view more NeuroVoices.

REFERENCES
1. Palaniappan LP, Allen NB, Almarzooq ZI, et al. 2026 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation. 2026;153(9):e275-e906. doi:10.1161/CIR.0000000000001412
2. 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
3. Kapral MK. Social determinants of health and stroke care and outcomes: SEQUINS lecture 2025. Equity Neurosci. 2026;2(3):100065. doi:10.1016/j.neuros.2026.100065