Management of vascular risk factors remains extremely important in secondary stroke preven- tion, including (but not limited to) diabetes, smok- ing cessation, lipids, and especially hypertension. Intensive medical management, often performed by multidisciplinary teams, is usually best, with goals of therapy tailored to the individual patient. 3. Lifestyle factors, including healthy diet and physi- cal activity, are important for preventing a second stroke. Low-salt and Mediterranean diets are rec- ommended for stroke risk reduction. Patients with stroke are especially at risk for sedentary and prolonged sitting behaviors, and they should be encouraged to perform physical activity in a super- vised and safe manner. 4. Changing patient behaviors such as diet, exercise, and medication compliance requires more than just simple advice or a brochure from their physician. Programs that use theoretical models of behavior change, proven techniques, and multidisciplinary support are needed. 5. Antithrombotic therapy, including antiplatelet or anticoagulant agents, is recommended for nearly all patients without contraindications. With very few exceptions, the combination of antiplatelets and anticoagulation is typically not indicated for sec- ondary stroke prevention. Dual antiplatelet therapy is not recommended long term, and short term, dual *AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guidelines Liaison. AAN Representative. AHA Stroke Council Scientific Statement Oversight Committee Members, see page e436. 2021 American Heart Association, Inc. CLINICAL STATEMENTS AND GUIDELINES Kleindorfer antiplatelet therapy is recommended only in very specific patients, including those with early arriv- ing minor stroke and high-risk transient ischemic attack or severe symptomatic intracranial stenosis. 6. Atrial fibrillation remains a common and high- risk condition for second ischemic stroke. Anticoagulation is usually recommended if the patient has no contraindications. Heart rhythm monitoring for occult atrial fibrillation is usu- ally recommended if no other cause of stroke is discovered. 7. 