Transient ischemic attack secondary prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]Maryam Hadipour, M.D.[3]

Overview[edit | edit source]

The secondary prevention strategies for recurrent transient ischemic stroke and ischemic stroke may include the lifestyle modification and treatment of modifiable risk factors.

Secondary prevention[edit | edit source]

The secondary prevention strategies for recurrent transient ischemic stroke and ischemic stroke may include the following:^[1][2][3]

Life style modification for secondary prevention[edit | edit source]

Life style modification measures which may help reduce the risk of recurrent stroke and prevent complications may include:

• Increased physical activity->10 min of exercise such as walking, running, bicycling or swimming >3 times/wk
• Eating healthy balanced diet. Mediterranean diets are recommended for stroke risk reduction.
• Smoking cessation
• Decreased alcohol intake
• Controlling diseases that are risk factors, including diabetes, hyperlipidemia, and hypertension.

Treatment of modifiable risk factors[edit | edit source]

Blood pressure[edit | edit source]

• BP control to less than 130/80mm Hg with an angiotensin inhibitor alone or in combination with a diuretic or angiotensin receptor blocker^[4]

Diabetes mellitus[edit | edit source]

• Diabetes control with fasting blood glucose level <126mg/dl or HbA1C < 7% or < 7%-8%^[4]

Hyperlipidemia[edit | edit source]

• Initiation of statin for hyperlipidemia with goal LDL level<70mg/dL (Please note that the previous guideline suggested LDL level < 110mg/dL or < 90mg/dL but it is now suggested to use highest tolerable dose of statins and PCSK-9 inhibitors to reach the LDL < 70mg/dL level, if tolerable).^[4]

Antithrombotic stroke[edit | edit source]

• Long term antiplatelet therapy with aspirin, dipyrimadole plus aspirin, clopidogrel or aspirin alone^{[1][3][5][6][4]}
• Anticoagulation not required

Cardioembolic stroke[edit | edit source]

• Anticoagualtion for atrial fibrillation with Vit K antagonist or NOACs.
• If intolerant to anticoagulation, aspirin 325 mg or clopidogrel 75 mg (if aspirin intolerant)^[3]

TIA with ongoing non Q wave MI or unstable angina[edit | edit source]

• Use of aspirin(75 mg-100mg) in combination with clopidogrel (75 mg) may be beneficial.^[3]
• An ECG is suggested to perform on any patient, presenting with MI or recurrent TIA or stroke, in order to rule out AF.^[4]

Other situations[edit | edit source]

• Patients having history of TIA undergoing endartectomy may benefit from aspirin (25 to 325mg) before surgery.^[3]
• Because patients with symptomatic high-grade cervical carotid stenosis are candidates for revascularization, it is appropriate to screen for stenosis in any patient who may have such stenosis. Initial testing for carotid stenosis should be done with a noninvasive test such as CTA, MRA, or ultrasonography rather than digital subtraction angiography.^[4]

Secondary prevention for specific causes of transient ischemic stroke^[7][edit | edit source]

For AHA/ASA guidelines for the secondary prevention of transient ischemic stroke, please click here

References[edit | edit source]

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