What is the treatment for a transient ischemic attack (TIA) in the emergency department (ED)?

From the Guidelines

The treatment of minor stroke or transient ischemic attack (TIA) in the emergency department should focus on rapid assessment, early intervention, and secondary prevention, with immediate antiplatelet therapy, typically with aspirin 160-325mg, as recommended by the American College of Chest Physicians 1.

Key Components of Treatment

• Immediate antiplatelet therapy with aspirin 160-325mg, as this has been shown to be effective in reducing the risk of subsequent major stroke 1
• Urgent neuroimaging with CT or MRI to rule out hemorrhage and assess for large vessel occlusion
• Blood pressure management with a goal of <140/90 mmHg, though acute lowering should be gradual to avoid cerebral hypoperfusion
• Statins should be initiated promptly, typically high-intensity atorvastatin 40-80mg daily, regardless of baseline cholesterol levels
• Blood glucose should be monitored and hyperglycemia treated
• Patients with atrial fibrillation typically need anticoagulation, usually starting 1-2 weeks after the event

Discharge Criteria

• Most minor stroke/TIA patients can be discharged if they have access to rapid outpatient follow-up within 24-48 hours, stable neurological status, and adequate home support
• Early intervention during the high-risk period following a TIA/minor stroke significantly reduces the risk of subsequent major stroke, which is highest in the first days to weeks after the initial event 1

Recent Guidelines

• The Canadian Stroke Best Practice Recommendations update 2015 emphasizes the importance of rapid assessment and treatment, including the use of endovascular therapy for patients with acute ischemic stroke and proximal arterial occlusion 1
• The 2018 update of the Canadian Stroke Best Practice Recommendations for secondary prevention of stroke highlights the importance of rapid transient ischemic attack clinics and urgent evaluation by stroke specialists in reducing the risk of recurrent stroke 1

From the Research

Treatment of Minor Stroke Transient in the Emergency Department

• The treatment of minor stroke transient in the emergency department is a topic of ongoing debate, with various studies investigating the optimal treatment methods 2, 3, 4, 5, 6.
• According to a systematic review and network meta-analysis, dual antiplatelet therapy based on aspirin and clopidogrel offers balanced efficacy and safety, positioning it as a potentially optimal treatment for minor stroke 2.
• Another study found that the addition of clopidogrel to aspirin for patients with transient ischemic attack (TIA) or minor ischemic stroke (IS) appeared to significantly reduce the risk of IS recurrence, but with a possible increase in the risk of bleeding compared with aspirin alone 3.
• A review of medical management for secondary stroke prevention highlights the use of short-term dual antiplatelet therapy after minor stroke and TIA, as well as the importance of antihypertensive therapy, antithrombotic therapy, cholesterol-lowering therapy, and glycemic control 4.
• An updated systematic review and meta-analysis of randomized clinical trials found that dual antiplatelet therapy with clopidogrel and aspirin was associated with significantly lower rates of any stroke and ischemic stroke, but also with increased risks of intracranial bleeding and major bleeding 5.
• An overview of systematic reviews and meta-analyses found that clopidogrel plus aspirin was more effective than aspirin alone in reducing the risk for recurrent stroke, but increased major bleeding events, particularly with combined therapy regimens lasting more than 1 month 6.

Key Findings

• Dual antiplatelet therapy with aspirin and clopidogrel may be an optimal treatment for minor stroke 2.
• The addition of clopidogrel to aspirin reduces the risk of IS recurrence, but increases the risk of bleeding 3.
• Short-term dual antiplatelet therapy is recommended after minor stroke and TIA 4, 5.
• Dual antiplatelet therapy increases the risk of intracranial bleeding and major bleeding, particularly with long-term use 5, 6.

Treatment Options

• Aspirin plus clopidogrel: offers balanced efficacy and safety for minor stroke 2.
• Aspirin alone: may be associated with a lower risk of bleeding, but less effective in reducing IS recurrence 3.
• Dual antiplatelet therapy: recommended for short-term use after minor stroke and TIA, but may increase the risk of bleeding with long-term use 4, 5, 6.