What is the most appropriate management for a 68-year-old man with a history of transient ischemic attack (TIA) and current medications including aspirin (acetylsalicylic acid) 81 mg daily and clopidogrel (antiplatelet medication) 75 mg daily?

Management of Dual Antiplatelet Therapy After TIA

The most appropriate recommendation for this 68-year-old man with a recent TIA is to discontinue clopidogrel and continue aspirin 81 mg daily for long-term secondary stroke prevention.

Rationale for Discontinuing Clopidogrel

The patient is currently on dual antiplatelet therapy (DAPT) with aspirin 81 mg and clopidogrel 75 mg daily at his 2-week follow-up visit after a TIA. According to current guidelines, DAPT with aspirin and clopidogrel is only indicated for a short duration following a minor stroke or high-risk TIA:

1. Duration of DAPT: The World Stroke Organization recommends DAPT with aspirin and clopidogrel for only 21 days after a minor stroke or high-risk TIA, followed by long-term single antiplatelet therapy 1. This recommendation is based on evidence showing that the benefit of DAPT is confined to the first 21 days after the event.

2. Risk vs. Benefit: While DAPT reduces the risk of recurrent ischemic events in the short term, the pooled analysis of the CHANCE and POINT trials demonstrated that the benefit of DAPT appears to be confined to the first 21 days after a minor stroke or TIA, with no additional benefit beyond this period 2.

3. Bleeding Risk: Continuing DAPT beyond the recommended duration increases bleeding risk without providing additional protection against stroke 3, 2.

Appropriate Long-term Management

For long-term secondary stroke prevention in patients with non-cardioembolic TIA:

1. Single Antiplatelet Therapy: The World Stroke Organization recommends long-term single antiplatelet therapy with either aspirin 81-325 mg daily or clopidogrel 75 mg daily 1.

2. Current Dose is Appropriate: The patient's current aspirin dose of 81 mg daily is within the recommended range for long-term secondary stroke prevention 4.

3. Blood Pressure Control: The patient's blood pressure is well-controlled at 122/72 mmHg, which is appropriate for a patient with history of TIA 1.

4. Lipid Management: The patient is appropriately on high-dose statin therapy (atorvastatin 80 mg) with LDL-C at 96 mg/dL, which is consistent with guideline recommendations 1.

Why Other Options Are Not Appropriate

1. Continuing current therapy: Continuing DAPT beyond 21-30 days increases bleeding risk without additional benefit in preventing recurrent stroke 3, 2.

2. Increasing aspirin to 325 mg daily: There is no evidence that higher maintenance doses of aspirin provide additional benefit over 81 mg daily for long-term stroke prevention, and higher doses may increase bleeding risk 4, 5.

3. Initiating rivaroxaban 2.5 mg daily: There is no indication for anticoagulation in this patient as he has had a non-cardioembolic TIA. Anticoagulation is only indicated for patients with atrial fibrillation or other cardioembolic sources 6.

Implementation Algorithm

1. At this 2-week follow-up visit:

   • Discontinue clopidogrel
   • Continue aspirin 81 mg daily indefinitely
   • Continue other medications (atorvastatin, chlorthalidone, lisinopril)

2. Monitor for:

   • Recurrent neurological symptoms
   • Blood pressure control (target <140/90 mmHg)
   • Lipid levels (target LDL-C <100 mg/dL)

3. Follow up in 1-3 months to reassess:

   • Neurological status
   • Medication adherence
   • Risk factor control

Potential Pitfalls and Caveats

• Ensure the TIA was truly non-cardioembolic before discontinuing DAPT
• If the patient has had recent coronary stenting (within 12 months), a different antiplatelet strategy may be needed 1
• If the patient has intracranial atherosclerotic stenosis (50-99%), blood pressure targets may need to be more aggressive 1
• Patients with very high-risk features might require individualized approaches, but the evidence still favors single antiplatelet therapy after the initial 21-30 day period