What is the most appropriate next step in managing a clinically stable 72-year-old man with a resolved Transient Ischemic Attack (TIA) and no other medical illnesses?

Management of Transient Ischemic Attack in a 72-Year-Old Man

Aspirin should be immediately initiated as the most appropriate next step in managing this 72-year-old man with a resolved transient ischemic attack (TIA). 1

Rationale for Antiplatelet Therapy

TIAs represent unstable conditions with a high risk of recurrent stroke—up to 10% within the first week of symptom onset. The patient's presentation with right-sided weakness that resolved within 10 minutes is classic for a TIA, requiring prompt intervention to prevent a potentially devastating stroke.

Key considerations:

• The patient has experienced a transient neurological deficit that has fully resolved
• He is clinically stable with normal vital signs
• He has no other medical illnesses that would contraindicate antiplatelet therapy

Evidence-Based Approach

The American Academy of Neurology and American Heart Association recommend immediate initiation of antiplatelet therapy for non-cardioembolic TIAs 1. Since this patient has no history suggesting cardioembolism, antiplatelet therapy is the appropriate first-line treatment.

Specific antiplatelet recommendations:

• Aspirin (50-325 mg/day) should be started immediately 1
• For long-term management, options include:
  • Continuing aspirin (75-100 mg/day)
  • Switching to clopidogrel (75 mg/day)
  • Using combination therapy of aspirin plus extended-release dipyridamole 1

Why Not Other Options?

Warfarin (Options B and C):

• Oral anticoagulation with warfarin is only recommended for cardioembolic TIAs, particularly those associated with atrial fibrillation 1
• This patient has no indication of atrial fibrillation or other cardiac source of embolism
• Using warfarin for non-cardioembolic TIAs increases bleeding risk without providing additional benefit 1

No additional drug treatment (Option D):

• This approach fails to address the significant risk of recurrent stroke
• Canadian Stroke Best Practice Recommendations identify patients with transient unilateral weakness as being at highest risk for stroke recurrence 2
• Withholding treatment would miss a critical opportunity for stroke prevention 3

Additional Management Considerations

While not part of the immediate next step, comprehensive management should also include:

• Rapid diagnostic evaluation including brain imaging, vascular imaging, and ECG 1
• Blood pressure management with a target of <140/90 mmHg 1
• Statin therapy for atherothrombotic TIA 1
• Evaluation for carotid stenosis, as carotid endarterectomy may be beneficial if significant stenosis is present 1

Common Pitfalls to Avoid

1. Delaying antiplatelet therapy: The antiplatelet effect of aspirin begins within hours of administration, and early initiation is crucial for reducing recurrent stroke risk 4

2. Misclassifying TIA severity: This patient's motor symptoms place him at high risk for recurrence, requiring immediate intervention 2

3. Assuming all antiplatelet regimens are equivalent: While aspirin is the appropriate initial choice, the dose matters. For acute management, doses of 160-325 mg are recommended 5

4. Overlooking the need for comprehensive evaluation: While aspirin is the immediate next step, the patient should undergo complete evaluation to identify underlying causes and optimize secondary prevention 1