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]

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

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

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.

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

• 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]

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

• 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]

• 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]

• 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]

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

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