When optimally managed, patients with stroke are less likely to have further vascular events. We aimed to identify factors associated with optimal use of secondary prevention therapies in long-term survivors of stroke. METHODS: We carefully documented discharge medications at baseline and self-reported use of medications at annual follow-up in the Northeast Melbourne Stroke Incidence Study (NEMESIS). We defined optimal medication use when patients reported taking (1) antihypertensive agents and (2) statin and antithrombotic agents (ischemic stroke only). Logistic regression was used to assess factors associated with optimal medication use between 2 and 10 years after stroke. RESULTS: We recruited 1241 patients with stroke. Optimal prescription at discharge from hospital was the most important factor associated with optimal medication use at each time point: odds ratio (OR), 32.2 (95 confidence interval [CI], 13.6-76.1) at 2 years; OR, 7.86 (95 CI, 4.48-13.8) at 5 years (425 of 505 survivors); OR, 6.04 (95 CI, 3.18-11.5) at 7 years (326 of 390 survivors); and OR, 2.62 (95 CI, 1.19-5.77) at 10 years (256 of 293 survivors). Associations were similar in men and women. The association between optimal prescription at discharge and optimal medication use at each time point was greater in those who were not disadvantaged, particularly women. CONCLUSIONS: Prescription of medications at hospital discharge was the strongest predictor of ongoing medication use in survivors of stroke, even at 10 years after stroke. Ensuring that patients with stroke are discharged on optimal medications is likely to improve their long-term management, but further strategies might be required among those who are disadvantaged.