Building Systems That Prevent the Next Stroke

Stroke prevention is entering a consequential period of change as health systems face growing expectations to translate emerging evidence into safer, coordinated, and equitable care. New antithrombotic approaches, improved identification of recurrent risk, and greater attention to vulnerable transitions of care are expanding opportunities to improve outcomes.^1-3 Progress, however, continues to require disciplined evaluation, thoughtful implementation, and sustained collaboration across neurology, cardiology, emergency medicine, primary care, nursing, rehabilitation, pharmacy, and community services.

Health-system pharmacists are positioned at the intersection of these efforts. Through formulary review, protocol development, risk assessment, medication optimization, education, reconciliation, and follow-up, they connect evidence with practice and help ensure that clinical innovation is matched by operational readiness. Their perspective across inpatient, ambulatory, specialty, and community settings enables them to anticipate implementation barriers, support shared decision-making, and reinforce prevention strategies as patients move among clinicians, facilities, and home.

This leadership is especially important after an ischemic stroke or transient ischemic attack, when recurrent risk intersects with complex regimens, comorbidities, changing function, and multiple handoffs.^1,3,5 A sound discharge plan can falter if indications are unclear, access is delayed, follow-up is fragmented, or patients and caregivers do not understand the treatment regimen. Pharmacists close these gaps by confirming that therapy aligns with the suspected stroke mechanism and risk profile, addressing modifiable cardiovascular risks, identifying interactions and adherence barriers, and ensuring that the next care team receives an accurate medication list and monitoring plan. These vital actions transform prevention from a recommendation into a coordinated process.

The articles in this supplement reflect that responsibility. As opposed to simply treating prevention as one prescribing decision or a task confined to 1 setting, the articles examine the connected clinical and operational choices that shape a patient’s journey. The issue begins with the OCEANIC-STROKE trial (NCT05686070), reviewing topline findings presented in February at the International Stroke Conference in 2026 and considering what asundexian (Bayer HealthCare) may mean for future stroke prevention.² The discussion addresses its mechanism, efficacy, bleeding profile, regulatory status, and the questions pharmacists should follow as this new drug class approaches potential approval.^2,4

Pharmacy leaders and health care professionals must interpret the evidence carefully, compare novel and established therapies, and anticipate safeguards, education, monitoring, and interdisciplinary alignment needed for responsible adoption. Moving the conversation from evidence appraisal to health-system preparedness, pharmacy and therapeutics committees may need to determine where emerging agents belong within anticoagulation pathways, define patient-selection criteria, revise protocols and order sets, and address educational needs before implementation. Early engagement among clinical specialists, medication-safety leaders, informatics, nursing, physicians, case management, and pharmacy operations can prevent fragmented decisions. Advance preparation also helps define outcomes, clarify accountability, and align future formulary decisions with both the evidence and the realities of care delivery.

Vigilance and continuity matter most as patients move through each stage of care. This third article examines how clinical markers and screening approaches can identify the risk of recurrent ischemic stroke or transient ischemic attack, and reinforces pharmacists’ role in counseling patients on modifiable cardiovascular risk factors.¹ Continuity can be lost easily, and health-system and community pharmacists can collaborate through medication reconciliation, rehabilitation-center coordination, and patient navigation to help minimize errors and sustain care.^3,5

Having a checklist can help translate evidence into a practical guide for multidisciplinary rounds and clinical questions that sharpen therapeutic decisions. Together, the resources connect emerging evidence and formulary planning with risk recognition, transitions of care, and bedside application. My hope is that this issue advances informed discussion, encourages proactive preparation, and equips pharmacists to lead with clinical rigor and practical insight. Across every setting, our role is not simply to manage medications, but to build reliable systems around patients so prevention remains safe, understandable, and sustainable throughout the continuum of care.

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. Sharma M, Dong Q, Hirano T, et al. OCEANIC-STROKE phase 3 findings: asundexian for prevention of recurrent ischemic stroke after noncardioembolic ischemic stroke or high-risk transient ischemic attack. Presented at: International Stroke Conference; February 4-6, 2026; New Orleans, LA.

3. The Joint Commission. Transitions of care: managing medications. Quick Safety. Issue 26. April 2022. Accessed October 16, 2026. https://digitalassets.jointcommission.org/api/public/content/f2bc2df2b9f145859c01e8941e70b282?v=413a59d6

4. New drug applications for asundexian accepted by the US Food and Drug Administration under priority review and by Japan’s Ministry of Health, Labour and Welfare. News release. Bayer. May 19, 2026. Accessed October 13, 2026. https://www.bayer.com/media/en-us/new-drug-applications-for-asundexian-accepted-by-us-food-and-drug-administration-under-priority-review-and-by-japans-ministry-of-health-labour-and-welfare/

5. Care transitions/medication reconciliation. American Society of Health-System Pharmacists. Accessed October 13, 2026. https://www.ashp.org/-/media/assets/pharmacy-educators/docs/Care-Transitions-Medication-Reconciliation.pdf?rev=45c4540cb592431c84f400a5845dfa1d&hash=D8E5299B11BB0213C9384E8BD7ED803E