Objective:To determine whether TIA or ischemic stroke patients with co-existing cardiovascular disease (i.e. history of coronary or peripheral artery disease) are still at high risk of recurrent ischemic events despite current secondary prevention guideline. Methods: In a population-based study in Oxfordshire, United Kingdom (Oxford Vascular Study), we studied consecutive patients with TIA or ischemic stroke for 2002-2014. Patients were treated according to current secondary prevention guidelines and we determined risks of coronary events, recurrent ischemic stroke, and major bleeding stratified by the presence of co-existing cardiovascular disease. Results: Among 2555 patients (9148 patient-years of follow-up), those (n=640; 25.0%) with co-existing cardiovascular disease (449 coronary only; 103 peripheral only; 88 both) were at higher 10-year risk of coronary events than those without (22.8%; 95%CI 17.4-27.9; versus 7.1%, 5.3-8.8; p<0.001, age-and sex-adjusted HR=3.07, 2.24-4.21) and of recurrent ischemic stroke (31.5%, 25.1-37.4; versus 23.4%, 20.5-26.2; p=0.0049, age-and sex-adjusted HR=1.23, 0.99-1.53), despite similar rates of use of antihrombotic and lipid-lowering medication. However, in patients with non-cardioembolic TIA/stroke, risk of extracranial bleeds was also higher in those with co-existing cardiovascular disease, particularly in patients aged <75 years (8.1%, 2.8-13.0; versus 3.4%, 1.6-5.3; p=0.0050; age-and sex-adjusted HR=2.71, 1.16-6.30), although risk of intracerebral hemorrhage was not increased (age-and sex-adjusted HR=0.36, 0.04-2.99). Conclusions: As in older studies, TIA/stroke patients with co-existing cardiovascular disease still remain at high risk of recurrent ischemic events despite current management. More intensive lipid-lowering might therefore be justified, but benefit from increased antithrombotic treatment might be offset by the higher risk of extracranial bleeding.