9.4 Management of other risk factors		COR	LOE
Revised	Smoking cessation is recommended for patients who had an IS or TIA with a smoking history.	I	A
	Results from a prospective cohort study in China suggested that smoking increased the risk of recurrent stroke in patients with stroke and TIA.270 The Nanjing Stroke Registry Study showed that, after adjusting for major covariates, persistent smokers still had a higher likelihood of stroke recurrence when compared with non-smokers (HR 1.93, 95% CI 1.43 to 2.61).271 There was a strong dose–response relationship between the amount of smoking and the risk of recurrent stroke.271
New recommendation	Regardless of smoking history, patients with IS or TIA should avoid exposure to smoking environments and passive smoking.	I	B
	Data obtained from the US National Health and Nutrition Examination Surveys have shown that high exposure to secondhand smoke was associated with higher odds of previous stroke (OR 1.46). There was a dose-dependent relationship between exposure to secondhand smoke and all-cause mortality after stroke.272
Revised	For patients with IS or TIA who smoke, comprehensive smoking cessation measures, including medication and behavioural interventions, are recommended.	I	A
	Some meta-analyses and RCTs have shown that drug combination therapy is the most effective and safe way to quit smoking.273–275 In particular, standard doses of varenicline combined with nicotine replacement therapy significantly improve the rate of sustained smoking cessation.273 274 276
Revised	For patients with IS or TIA who have not quit drinking, alcohol consumption should be moderate. A daily alcohol intake of ≤2 standard units for men and ≤1 standard unit for non-pregnant women may be considered reasonable.	IIa	B
	The EPIC-CVD study showed that the HRs of non-fatal stroke and fatal stroke (both ischaemic and haemorrhagic) were 1.04 (95% CI 1.02 to 1.07) and 1.05 (95% CI 0.98 to 1.13) with an increase of 12 g daily alcohol intake above the baseline alcohol intake (24 g/day for men and 10 g/day for women), respectively.273
New recommendation	It is recommended that healthcare professionals screen exercise capacity in patients who had a chronic IS with movement disorders, formulate personalised exercise plans and provide supervision.	I	B
	Currently, most of the evidence for physical activity in the secondary prevention of stroke comes from patients with incomplete loss of motor capacity.277 For patients unable to engage in regular physical activity, individualised exercise programmes should be developed based on their exercise endurance, stage of recovery, environment, available social support and exercise preferences.278 Some preliminary trial results suggest that aerobic exercise after the acute phase can improve cardiovascular health and reduce cardiovascular disease risk after adequate pre-exercise screening in patients with movement disorders.279
New recommendation	For patients who had an IS or TIA with a good functional capacity, it is recommended engaging in moderate-intensity exercises, such as brisk walking, for at least three to four times per week (10 min/session), or aerobic exercises like brisk walking or jogging for at least two times per week (20 min/session) after the acute phase.	I	B
	The 3-year follow-up data from 227 patients in the drug treatment group of the SAMMPRIS trial showed that the risk of IS recurrence was 6.7 times higher for those with substandard physical activity levels (no or no regular moderate exercise (brisk walking or slow cycling ≥10 min) or vigorous exercise (jogging or brisk cycling ≥20 min)).240 More physical activity was associated with a 40% reduction in the risk of composite endpoint events (IS, MI, vascular death).
New recommendation	Aerobic exercise is not recommended for patients who had a subacute IS with moderate severity (NIHSS score of 5–12).	III	B
	The PHYS-STROKE study found that for patients who had a stroke with NIHSS scores of 5–12, combined aerobic exercise with standard rehabilitation treatment increased the risk of stroke recurrence.280 281
New recommendation	In overweight or obese patients with IS or TIA, weight reduction can reduce the risk of ASCVD.	I	B
	Currently, some RCTs which involve patients with diabetes have shown that weight control could significantly reduce SBP, glucose, TG and the incidence of cardiovascular events.281–283
New recommendation	For obese patients with IS or TIA, multiple lifestyle adjustments or behaviour strategies should be employed based on individual circumstances to achieve the goals of weight management.	I	B
	A meta-analysis involving 122 RCTs and 2 observational studies showed that lifestyle adjustment and behavioural intervention could help lose weight safely and effectively.284
New recommendation	For patients with IS or TIA, it is recommended following a diet with appropriate calorie and nutrient intake, which includes increased consumption of whole grains, legumes, fruits, vegetables and low-fat dairy products while decreasing the intake of saturated and trans fats. Additionally, there should be a moderate reduction in sodium intake and an increase in potassium intake. The practical use of potassium-containing salt substitutes is encouraged as it can contribute to lowering blood pressure and reducing the risk of stroke recurrence.	I	B
	Cohort studies have shown that increased intake of nuts, olive oil and fruits can reduce stroke risk by 28%, 31% and 52.3%.270 285 One RCT study from China confirmed that reducing sodium intake and increasing potassium intake also reduced stroke risk (HR 0.86, 95% CI 0.77 to 0.96, p=0.006).286
New recommendation	Assessing nutritional risk promptly upon hospital admission is recommended for patients who had an IS or TIA. Individualised nutrition plans with targeted interventions should be implemented for patients identified with nutritional risk, along with regular screening.	IIb	B
	The study based on the Third China National Stroke Registry data found that moderate-to-severe malnutrition risk was associated with an increased risk of long-term death and major disability in patients with IS (OR 2.25, 95% CI 1.75 to 2.90, for controlling nutritional status score; OR 2.10, 95% CI 1.63 to 2.69, for geriatric nutritional risk index; OR 3.36, 95% CI 2.33 to 4.84, for prognostic nutritional index).287 The EFFORT study found that compared with standard hospital diets, individualised nutritional support therapy reduced the risk of 30-day adverse endpoint events by 21% (OR 0.79, 95% CI 0.64 to 0.97) and death by 35% (OR 0.65, 95% CI 0.47 to 0.91).288
Unchanged	Routine screening for obstructive sleep apnoea in patients with recent IS is not recommended.	III	B
Revised	The association between oral contraceptives and stroke needs further confirmation through prospective studies. Oral contraceptives may be linked to various types of strokes, especially in patients with hypertension. Long-term and high-dose use of oral contraceptives is not recommended, particularly in individuals with hypertension.	III	B
	A study examined the association between self-reported oral contraceptive and hormone replacement therapy use and stroke risk in 257 194 women from the UK Biobank, and found an increased rate of any stroke (HR 2.49, 95% CI 1.44 to 4.30) and IS (HR 1.93, 95% CI 1.05 to 3.57).289 A dose–response meta-analysis involving 6 cohort studies and 12 case–control studies showed that longer and higher doses of oral hormonal contraceptives were associated with an increased risk of IS, with ORs 1.24 (95% CI 1.04 to 1.49) and 1.20 (95% CI 1.17 to 1.22), respectively.290
Reworded	The relationship between drug use and stroke requires further investigation. Acute drug use in the previous 24 hours may be a risk factor for stroke occurrence and poor prognosis.	III	C
Reworded	For patients with recent IS or TIA and mild-to-moderate homocysteine elevation, supplementation with folate, vitamin B6 and vitamin B12 could effectively lower homocysteine levels. There is insufficient evidence to support homocysteine level reduction as a strategy for reducing the risk of stroke recurrence.	IIb	B