From the Guidelines
For a patient presenting to the emergency department with a minor stroke or transient ischemic attack (TIA) that occurred 6 days ago, the most appropriate treatment is to start with antiplatelet therapy, such as aspirin 50mg daily plus sustained-release dipyridamole 200mg twice daily, for the secondary prevention of stroke and other vascular events. This recommendation is based on the guidelines for the management of transient ischemic attacks, which suggest that daily long-term antiplatelet therapy should be prescribed immediately for patients who have sustained a noncardioembolic TIA 1.
Key Considerations
- The combination of aspirin and sustained-release dipyridamole is a reasonable option for patients with TIA as first choice to reduce the risk for stroke 1.
- Clopidogrel may be slightly more effective than aspirin in the prevention of further vascular events, and can be prescribed as first choice or when aspirin alone or aspirin in combination with dipyridamole is not tolerated 1.
- Oral anticoagulation is not recommended for noncardioembolic TIA, as there is no documented evidence of a higher benefit compared with antiplatelet therapy, and the risk for cerebral hemorrhagic complications is higher at an INR range greater than 3.0 1.
Additional Recommendations
- Patients with cardioembolic TIA, such as those with persistent or paroxysmal atrial fibrillation, should receive long-term oral anticoagulation with a target INR of 2.5 (range, 2.0-3.0) 1.
- Aspirin or clopidogrel can be recommended after a cardioembolic TIA associated with nonvalvular atrial fibrillation, but only if oral anticoagulation cannot be administered 1.
- Antiplatelet therapy is recommended after a TIA associated with patent foramen ovale if anticoagulation is not deemed indicated 1.
Important Notes
- The patient should undergo urgent diagnostic workup, including brain imaging, carotid imaging, ECG, and cardiac monitoring, to identify the stroke etiology.
- Blood pressure management and lipid-lowering therapy should also be considered as part of the overall treatment plan.
From the Research
Treatment of Minor Stroke
- The treatment of minor stroke, also known as transient ischemic attack (TIA), typically involves antiplatelet therapy to reduce the risk of recurrent ischemic stroke 2.
- Aspirin is recommended as the initial treatment to prevent recurrent ischemic stroke, while clopidogrel is recommended as an alternative monotherapy and in patients allergic to aspirin 2.
- Statins are also effective in decreasing cardiovascular events through lipid lowering and pleiotropic effects, and are recommended for the prevention of recurrent events in patients with a previous cerebrovascular event 3.
Management of Minor Stroke in the Emergency Department
- Patients who experience a stroke while on statins should not discontinue statins, and statins are associated with better survival and improved functional outcome when administered during the acute phase of stroke in statin-naive patients 3.
- The use of statins is not associated with an increased risk of intracranial bleeding in primary prevention studies, but there may be an increased incidence of non-fatal hemorrhagic stroke with high dose statins in patients with a previous cerebrovascular event 3, 4.
- High-dose atorvastatin combined with aspirin can effectively reduce inflammatory cytokine levels in serum and reduce carotid intima-media thickness and plaque area, but may cause blood glucose abnormality 5.
Safety and Efficacy of Statin Therapy
- The benefits of statin therapy far outweigh any real or perceived risks, and statins are safe and effective in both primary and secondary prevention of cardiovascular disease 6.
- The potential harmful effects of statin therapy on muscle and liver have been known for some time, but new concerns have emerged regarding the risk of new-onset diabetes mellitus, cognitive impairment, and haemorrhagic stroke associated with the use of statins 6.