How long should a patient with a Transient Ischemic Attack (TIA) take aspirin (acetylsalicylic acid)?

Duration of Aspirin Therapy After Transient Ischemic Attack (TIA)

For patients with a transient ischemic attack (TIA), aspirin therapy should be continued indefinitely as long-term secondary prevention unless contraindicated. 1

Initial Management of TIA

When a patient presents with a TIA:

1. Immediate initiation of aspirin:

   • Start aspirin 160-325 mg as a loading dose after ruling out intracranial hemorrhage 1
   • For patients who cannot swallow, rectal aspirin (325 mg) or enteral tube administration (81 mg) can be used 1

2. Short-term dual antiplatelet therapy (DAPT) consideration:

   • For high-risk TIA (ABCD2 score ≥4): Consider DAPT with aspirin plus clopidogrel for 21-30 days 1, 2
   • DAPT reduces early recurrent stroke risk by approximately 24% compared to aspirin alone but increases bleeding risk 2

Long-term Aspirin Therapy

After the initial management phase:

• Duration: Aspirin should be continued indefinitely 1
• Dosage: 81-100 mg daily is recommended for long-term maintenance 1
• Alternative options if aspirin is not tolerated:
  • Clopidogrel 75 mg daily
  • Aspirin/extended-release dipyridamole 25/200 mg twice daily 1

Clinical Considerations and Caveats

• Early benefit is substantial: Aspirin reduces 6-week risk of recurrent ischemic stroke by approximately 60% and disabling/fatal stroke by about 70%, with greatest benefit in TIA or minor stroke patients 3

• Bleeding risk: Lower maintenance doses (81 mg) are preferred over higher doses to minimize bleeding complications while maintaining efficacy 1, 4

• Special populations:

  • For patients with intracranial atherosclerotic stenosis (50-99%): Continue aspirin indefinitely 1
  • For patients with extracranial carotid stenosis: Aspirin should be continued regardless of whether carotid endarterectomy is performed 1

• Common pitfall: Discontinuing aspirin prematurely increases risk of recurrent stroke. The evidence clearly supports indefinite continuation for secondary prevention 1

Monitoring and Follow-up

• Regular assessment for bleeding complications
• Evaluate medication adherence at each visit
• Consider periodic reassessment of stroke risk factors

Remember that the evidence strongly supports lifelong aspirin therapy after TIA for optimal secondary prevention of stroke, with the dosage generally maintained at 81-100 mg daily for long-term use.