© 2018 American Academy of Neurology. Objective To determine black-white differences in 1-year recurrent stroke and 30-day case fatality after a recurrent stroke in older US adults. Methods We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries with fee-for-service health insurance coverage who were hospitalized for ischemic stroke between 1999 and 2013. Hazard ratios for recurrent ischemic stroke and risk ratios for 30-day case fatality comparing blacks to whites were calculated with adjustment for demographics, risk factors, and competing risk of death when appropriate. Results Among 128,789 Medicare beneficiaries having an ischemic stroke (mean age 80 years [SD 8 years], 60.4% male), 11.1% were black. The incidence rate of recurrent ischemic stroke per 1,000 person-years for whites and blacks was 108 (95% confidence interval [CI], 106-111) and 154 (95% CI 147-162) , respectively. The multivariable-adjusted hazard ratio for recurrent stroke among blacks compared with whites was 1.36 (95% CI 1.29-1.44). The case fatality after recurrent stroke for blacks and whites was 21% (95% CI 21%-22%) and 16% (95% CI 15%-18%), respectively. The multivariable-adjusted relative risk for mortality within 30 days of a recurrent stroke among blacks compared with whites was 0.82 (95% CI 0.73-0.93). Conclusion The risk of stroke recurrence among older Americans hospitalized for ischemic stroke is higher for blacks compared to whites, while 30-day case fatality after recurrent stroke remains lower for blacks. Glossary CI = confidence interval; HR = hazard ratio; ICD-9-CM = International Classification of Diseases, 9th edition, clinical modification; NOMAS = Northern Manhattan Study; PRoFESS = Prevention Regimen for Effectively Avoiding Second Strokes; PROGRESS = Perindopril Protection Against Recurrent Stroke Study; REGARDS = Reasons for Geographic and Racial Differences in Stroke; RR = relative risk; SPARCL = Stroke Prevention by Aggressive Reduction in Cholesterol Levels; VISP = Vitamin Intervention for Stroke Prevention.