In this nationally representative sample of US adults with stroke, fewer than 10% met guideline recommendations for all risk factors with an overall stable trend, suggesting that efforts aimed at glycemia, blood pressure, and lipid control and smoking cessation could be improved to reduce the burden of recurrent stroke.
Key Findings
Results
Fewer than 10% of US adults with prior stroke met guideline recommendations for all four vascular risk factors across the entire study period from 1999 to 2023.
The four risk factors assessed were hyperglycemia, hyperlipidemia, hypertension, and smoking.
Guideline-recommended targets were defined as HbA1c <6.5% without diabetes or <7.0% with diabetes, LDL cholesterol <70 mg/dL, blood pressure <130/80 mm Hg, and nonsmoking.
The overall trend in meeting all four guideline targets was stable across the study period.
Data were drawn from 1999 through 2023 National Health and Nutrition Examination Surveys (NHANES) participants with self-reported stroke.
Results
Age-standardized mean HbA1c increased significantly among US adults with prior stroke from 1999 to 2023.
Mean HbA1c increased from 5.7% (95% CI, 5.5–5.9) in 1999–2002 to 6.0% (95% CI, 5.7–6.3) in 2021–2023.
This increase was statistically significant (P-trend = 0.04).
The prevalence of meeting glycemia guidelines decreased from 90.7% (95% CI, 85.9%–95.6%) in 1999–2002 to 83.9% (95% CI, 70.2%–97.5%) in 2021–2023 (P-trend = 0.03).
Results
Age-standardized mean LDL cholesterol decreased significantly among US adults with prior stroke from 1999 to 2023.
Mean LDL decreased from 125.9 mg/dL (95% CI, 119.4–132.4) in 1999–2002 to 115.6 mg/dL (95% CI, 107.8–123.5) in 2021–2023 (P-trend < 0.001).
Despite this decrease, the proportion meeting the guideline target of LDL <70 mg/dL remained low, increasing from only 5.1% (95% CI, 0%–11.0%) in 1999–2002 to 13.6% (95% CI, 6.9%–20.4%) in 2021–2023 (P-trend = 0.002).
Even in the most recent epoch, fewer than 14% of stroke survivors met the LDL guideline target.
Results
Blood pressure control among US adults with prior stroke was largely stable over the 24-year study period.
Age-standardized mean blood pressure did not show a significant trend across epochs from 1999 to 2023.
The prevalence of meeting the blood pressure guideline target of <130/80 mm Hg was also stable over the study period.
The guideline threshold used was blood pressure <130/80 mm Hg.
Results
The prevalence of meeting smoking guidelines was stable over the study period among US adults with prior stroke.
Nonsmoking was the criterion used for meeting smoking guidelines.
No statistically significant trend in smoking cessation prevalence was observed across the six epochs from 1999 to 2023.
Smoking was one of four modifiable risk factors assessed in this nationally representative sample.
Methods
The study analyzed trends across six epochs using NHANES data spanning 1999 to 2023 among participants with self-reported stroke.
Epochs were defined as 1999–2002, 2003–2006, 2007–2010, 2011–2014, 2015–2020, and 2021–2023.
Age-standardized mean HbA1c, LDL, and blood pressure and prevalence of meeting each recommended target were calculated for each epoch.
The sample was described as nationally representative of US adults with stroke.
Stroke status was based on self-report.
What This Means
This research suggests that among American adults who have had a stroke, the control of key risk factors that can lead to a second stroke has remained persistently poor over a 24-year period from 1999 to 2023. Using a nationally representative health survey, researchers tracked how well stroke survivors managed four major risk factors: blood sugar, cholesterol, blood pressure, and smoking. Despite these being well-known and treatable contributors to recurrent stroke, fewer than 1 in 10 stroke survivors met the recommended targets for all four risk factors at any point during the study.
The picture was mixed across individual risk factors. Blood sugar control actually worsened over time, with average HbA1c levels rising and fewer people meeting glycemic targets by the most recent period. Cholesterol levels did improve on average, but the proportion of stroke survivors reaching the stricter guideline target of LDL below 70 mg/dL remained very low — only about 1 in 7 people in the most recent years. Blood pressure control and smoking rates showed no meaningful improvement over the entire study period.
This research suggests there are significant, persistent gaps in secondary stroke prevention across the United States. Despite advances in medical treatments and updated guidelines, the majority of stroke survivors are not achieving recommended targets for the risk factors most likely to cause another stroke. These findings highlight the need for stronger efforts in healthcare systems, public health programs, and clinical care to help stroke survivors better manage these modifiable risk factors and reduce the likelihood of a recurrent, potentially more disabling stroke.
Andres W, Rothstein A, Abbruzzese S, Stulberg E, Law C, Murthy S, et al.. (2026). Trends in Vascular Risk Factor Control Among US Adults With Prior Stroke: 1999 to 2023.. Journal of the American Heart Association. https://doi.org/10.1161/JAHA.125.046500