Stroke is the second leading cause of death worldwide and the leading cause of death in China, where one-fifth of the world’s population resides (1, 2). The overall stroke recurrence rate for patients at 3, 6, and 12 months and within 5 years after onset is 12.3, 15.5, and 17.7%, > 40%, respectively (3, 4). Ischemic stroke (IS) and transient ischemic attack (TIA) are the most common types of strokes. Approximately 10–17% patients with IS or TIA have a risk of recurrent stroke in the first year after the onset of symptoms (1–4).

Effective secondary prevention measures, including lifestyle improvements and prevention of risk factors, can reduce IS recurrence and mortality (5–8). According to recent studies, it is possible to prevent up to 90% of strokes by addressing and treating 10 modifiable stroke risk factors, half of which are related to making lifestyle modifications (9, 10). A study conducted by China’s third National Stroke Registry (CNSR-III) found that only 34.9% of patients adhered to guideline-based secondary prevention. Patients who followed the guidelines for secondary prevention had a lower rate of stroke recurrence compared to those who did not (11). Moreover, studies from other countries have indicated that more than one-third to one-half of patients fail to follow long-term strategies for secondary prevention (12, 13).

The incidence of IS varies regionally, with different regions within a country having different incidence and recurrence rates of stroke owing to differences in race, geographical location, and living habits (13–16). China’s southwest region, home to a population of 249 million, contributes 13.3% to China’s GDP. Previous epidemiological investigations on stroke have reported the incidence and mortality rates of IS in southwest China to be 154.6/100,000 and 103.8/100,000, respectively (17). However, despite the high prevalence of stroke in this region, there is a dearth of studies focusing on the investigation and intervention of secondary prevention for patients with IS in southwest China. This study aimed to investigate the cognition and compliance status of secondary prevention in patients with IS in southwest China and explore the factors affecting compliance with secondary prevention 1 year after discharge.

According to the investigation of several of Grade III and A general hospitals in Chengdu and Chongqing, we found that the awareness and adherence to secondary prevention measures among patients with IS are not high. Additionally, whether or not patients have children did not significantly impact their compliance. Furthermore, no difference was observed in the prevalence of risk factors between patients with one or two of the three cardiovascular diseases (hypertension, diabetes, and hyperlipidemia) and those with all three.

Although these patients had already experienced an IS, their adherence to secondary prevention was low. A previous study from the Chinese National Stroke Registry-II (CNSR-II) found that the compliance rates with antiplatelet, hypoglycemic, and antihypertensive drugs were 57.58, 63.68, and 61.90%, respectively, 1 year after discharge (1, 7). The results of the Adherence eValuation After ischemic stroke–Longitudinal (AVAIL) study showed that the regimen persistence for secondary prevention medications at 12 months was 65.6% (19). The patients surveyed in our study in 2023 had relatively high medication compliance compared with the CNSR-II study in 2018, which may be owing to the recent health education related to IS. Nonetheless, adherence in western China is lower than that in developed countries. In the AVAIL study, the 12-month persistence was the highest for antihypertensive medications (87.9%), followed by those of antiplatelet (87.1%), diabetes (82.3%), and lipid-lowering (77.6%) medications (19). Other studies, such as Preventing Recurrence of Thromboembolic Events through Coordinated Treatment reported that antithrombotic and statin use was maintained at 98 and 99%, respectively at 1-year follow-up (20). Another study conducted in eastern Canada showed that patients with stroke had a self-reported persistence of 90% for all categories of stroke-prevention medications (21). Our 1-year follow-up results were similar to that of the Riks-Stroke Register (22) in Sweden, which found that persistence by medication category at 2 years post-discharge (56% for statins and 74% for antihypertensive drugs). Taking strong measures for the health education of secondary prevention of AIS is essential.

Age and type of medical insurance affect outpatient follow-up. Similarly, previous studies have found that age and type of medical insurance are factors that affect the medication compliance of patients with IS after discharge (23–25). Our study also found that the proportion of follow-up visits by patients with the NCMS insurance type was higher than that of other insurance types. Chronic disease management in community hospitals has ensured that patients with hypertension, diabetes, and IS are treated with special medical insurance, and the reimbursement ratio is high. However, this may be related to the insurance type of Urban Residents’ Basic Medical Insurance (URBMI) and UEBMI, in which people can visit a pharmacy to buy drugs without registering at a hospital. However, living with children did not promote regular follow-up. This could be attributed to the high work pressure and lack of time among young people to care for patients. Previous studies have shown the significance of caregivers in patient compliance after discharge (26, 27). Therefore, it is crucial to prioritize health education for patients’ families in the future. Furthermore, we observed a lesser focus on lifestyle improvements to prevent recurrent IS compared to regular outpatient follow-up. The cost of improving one’s lifestyle is much lower than healthcare costs. Thus, greater emphasis should be placed on high-value lifestyle interventions, which are consistently reasonable and effective for patients with IS (28–32). Alongside enhancing patients’ medication compliance, it is important to strengthen lifestyle and health education.

Consistent with previous studies, most patients with a history of hypertension and hyperlipidemia in this study had regular follow-up (19, 33). Patients with one or two of the three risk factors had a lower risk of IS recurrence than those with IS having the above three risk factors; however, these patients did not closely monitor their risk factors in our study. Hypertension, hyperglycemia, and dyslipidemia have an evident tendency to aggregate and usually occur in pairs or triplets in the same patient, forming a “two-high” or “three-high” coexistence (34–36). Patients with “three-high” coexistence have an exponentially increased risk of IS recurrence, however, the implementation of “three-high” co-management can produce good health and economic benefits (37, 38). Strengthening secondary prevention interventions for patients with IS at three high levels is essential.

Our findings were based on a real-world study of the cognition and compliance status of secondary prevention measures in patients with IS in southwest China. However, it is important to note that our study had certain limitations. First, we could not analyze the education level of the patients. Second, we did not categorize the type of ischemic stroke in the patients. Third, data collection needs to be more comprehensive, including indicators such as whether the patient is experiencing a first-time stroke, severity of the IS, and functional prognosis of the patients in future research. Fourth, our analyses primarily focused on correlations rather than causal inference; hence, our findings may be susceptible to confounding bias. Fifth, owing to our large sample size, we can explain the secondary prevention of some patients with IS in China. However, there is indeed a lack of generalizability. In the future, an even larger sample size is needed to better investigate the secondary prevention of ischemic stroke in China.

The recurrence rate of ischemic stroke is high; however, nearly one-third of patients do not perform secondary prevention per the guidelines, particularly for lifestyle improvement. In the future, strengthening the secondary prevention of health publicity for patients with ischemic stroke and their families is essential.