What medication should be prescribed to a 65-year-old man with diabetes mellitus (DM) and hypertension (HTN) to prevent recurrence of transient left-sided body weakness, likely a transient ischemic attack (TIA)?

Management of Transient Ischemic Attack in a 65-Year-Old Man with Diabetes and Hypertension

Aspirin should be prescribed to prevent recurrence of transient ischemic attack in this 65-year-old man with diabetes mellitus and hypertension. 1

Clinical Assessment

This patient presents with classic symptoms of a transient ischemic attack (TIA):

• Left-sided body weakness that developed gradually
• Inability to use left arm and leg for approximately 4 hours
• Spontaneous resolution of symptoms
• History of diabetes mellitus
• Hypertension (160/100 mmHg)

These findings are consistent with a TIA, which represents a medical emergency requiring prompt intervention to prevent progression to a completed stroke.

Antiplatelet Therapy Recommendation

Primary Recommendation

• Aspirin 75-325 mg daily is the recommended first-line therapy for this patient 1, 2
• The American Heart Association/American Stroke Association guidelines specifically recommend aspirin for patients who have experienced a TIA to prevent recurrent ischemic events 1

Rationale for Aspirin

1. Aspirin is effective in preventing recurrent cerebrovascular events in patients with TIA 1
2. For patients with documented transient focal neurological events who are in sinus rhythm with no atrial thrombi, daily aspirin therapy (75 to 325 mg per day) is recommended 1
3. The lowest effective dose for prevention of recurrent stroke or TIA has been shown to be 50 mg/day, but doses of 75-325 mg daily are commonly recommended 3

Alternative Antiplatelet Options

• Clopidogrel 75 mg daily could be considered as an alternative if the patient has aspirin intolerance 4
• The combination of aspirin (25 mg twice daily) and extended-release dipyridamole (200 mg twice daily) is another alternative 2

Why NOT the Other Options

Warfarin (Option A)

• Warfarin is not indicated for this patient as there is no evidence of:
  • Atrial fibrillation
  • Cardioembolic source
  • Mitral valve disease with regurgitation
  • Left atrial thrombus 1
• Warfarin is only recommended for TIA patients with specific cardiac conditions or those who experience recurrent TIAs while taking aspirin 1

Urokinase (Option B)

• Urokinase is a thrombolytic agent used for acute treatment of stroke, not for secondary prevention 2
• It is not indicated for TIA prevention and carries significant bleeding risks

Tissue Plasminogen Activator (Option D)

• tPA is only indicated for acute ischemic stroke treatment within a narrow time window (typically 3-4.5 hours from symptom onset)
• It is not appropriate for secondary prevention after TIA 2
• The patient's symptoms have already resolved, making thrombolytic therapy inappropriate and potentially dangerous

Additional Management Considerations

Blood Pressure Management

• Target blood pressure should be <140/90 mmHg 2
• Consider ACE inhibitor therapy, which has been shown to help prevent stroke in patients with hypertension 2

Lipid Management

• Initiate high-intensity statin therapy regardless of baseline LDL levels 2
• Target LDL <100 mg/dL to reduce risk of recurrent stroke

Diabetes Management

• Optimize glycemic control with target fasting blood glucose <126 mg/dL 2
• Consider metformin as first-line therapy, which may have additional cardiovascular benefits 1

Potential Pitfalls to Avoid

• Delaying antiplatelet therapy (should be started as soon as possible after TIA diagnosis)
• Using anticoagulants like warfarin without a specific indication
• Overlooking blood pressure management, which is critical in secondary stroke prevention
• Failing to address other modifiable risk factors (smoking, diet, exercise)

In conclusion, aspirin (75-325 mg daily) is the most appropriate choice for this 65-year-old man with diabetes and hypertension who experienced a transient ischemic attack, as it has been shown to effectively reduce the risk of recurrent cerebrovascular events in this patient population.