In spite of the considerable benefits to interventions for modifiable vascular disease risk factors, evidence indicates most ischemic strokes continue to be associated with poorly controlled lifestyle behaviors and medical conditions. In their nested cohort study of the Post-Stroke Disease Management STROKE-CARD trial, Drs. Boehme et al. found that 4 out of 5 patients with ischemic stroke had at least 1 inadequately managed lifestyle behavior or vascular comorbidity. Surprisingly, patients who had a prior stroke were even more likely to have 1 inadequately managed risk factor—which the authors attribute to the more extensive recommendations for secondary stroke prevention (e.g., antithrombotic and statin use) when compared to primary prevention. While the study highlights the failure of primary prevention strategies across stroke patients, it was limited in that only 8 risk factors were assessed. As Dr. Kelly indicates, chronic kidney disease (CKD) is one important vascular risk factor that was not addressed in this study. While CKD may not necessarily be a modifiable risk factor (in the sense that hypertension and body mass index may be modifiable), the presence of CKD may be a limiting factor for certain pharmacologic interventions for primary or secondary prevention. Using an admission glomerular filtration rate (GFR) cutoff of <60 mL/min/1.73 m2 as a threshold for CKD, the investigators subsequently reported no difference in the proportion of patients with at least one inadequately managed risk factor with or without CKD. Dr. Goldstein also responds to the investigators' comment that risk factor modification among diabetic patients has unclear benefits for stroke risk reduction. Dr. Goldstein emphasizes that these patients show a clear benefit if blood pressure and dyslipidemia are managed appropriately, and if antithrombotic use is initiated among diabetics at high risk of vascular events. The investigators then returned to their source data and found that diabetic patients—although representing only 9.9% of patients who were undertreated based on measures of glycemic control—were particularly undertreated for other comorbid vascular risk factors when compared to non-diabetic patients. This study adds to the growing literature that indicates a significant gap in practice-based recommendations and clinical practice when it comes to stroke prevention.