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 (TIA) symptoms in this 65-year-old man with diabetes and hypertension. 1

Clinical Assessment and Diagnosis

This patient presents with classic symptoms of a TIA:

• Left-sided body weakness developing gradually
• Inability to use left arm and leg for approximately 4 hours
• Spontaneous resolution of symptoms
• Significant medical history of diabetes mellitus and hypertension (160/100 mmHg)

These features strongly suggest a transient ischemic attack affecting the right cerebral hemisphere, which requires immediate antiplatelet therapy to prevent stroke recurrence.

First-Line Antiplatelet Therapy

Aspirin is the recommended first-line therapy for this patient based on the following evidence:

• The American Heart Association recommends aspirin (75-325 mg daily) as first-line therapy for patients who have experienced a TIA to prevent recurrent ischemic events 1
• Aspirin has been proven effective in reducing the risk for stroke in patients with TIA and minor stroke 2
• For a 65-year-old man with diabetes (which is a major cardiovascular risk factor), aspirin is indicated as his 10-year risk of coronary heart disease events is greater than 10% 2

Dosing Considerations

• A daily aspirin dose of 75-325 mg is recommended 1
• All studied aspirin doses have shown similar effectiveness, suggesting that dosing decisions should be based on patient tolerance 2
• For this patient with diabetes, a dose within this range is appropriate, as the risk reductions achieved with low dosages (75 to 162 mg per day) appear similar to those obtained with higher dosages 2

Why Not Other Options?

1. Warfarin (Option A):

   • Not indicated for this patient as there is no evidence of atrial fibrillation, cardioembolic source, or other conditions requiring anticoagulation 1
   • Warfarin is primarily indicated for cardioembolic TIAs, such as those associated with atrial fibrillation 2

2. Urokinase (Option B) or Tissue Plasminogen Activator (Option D):

   • These are thrombolytic agents used for acute treatment of stroke, not for secondary prevention
   • The patient's symptoms have already resolved, making thrombolytics inappropriate and potentially dangerous
   • These agents are not indicated for TIA prevention 1

Comprehensive Management Approach

In addition to aspirin therapy, this patient requires:

1. Blood Pressure Management:

   • Target BP <140/90 mmHg or <130/80 mmHg for diabetic patients 1
   • Consider ACE inhibitors as first-line therapy for hypertension in patients with history of TIA 1

2. Diabetes Management:

   • Target fasting blood glucose <126 mg/dL 1
   • Continue oral hypoglycemic agents with potential adjustment

3. Lipid Management:

   • Initiate high-intensity statin therapy regardless of baseline LDL levels 1

Monitoring and Follow-up

• Neuroimaging to exclude hemorrhage before initiating therapy
• Regular blood pressure and lipid monitoring
• Follow-up with neurology within 1-2 weeks and primary care within 1 week after discharge 1
• Essential investigations include brain imaging, vascular imaging (carotid Doppler ultrasound), ECG, and blood tests 1

Important Precautions

• Avoid omeprazole or esomeprazole with antiplatelet therapy as they may reduce effectiveness 1, 3
• Monitor for bleeding complications, which occur at a rate of 1-2 cases per 1000 patient-years of treatment 4
• Consider dual antiplatelet therapy (aspirin plus clopidogrel) only for the first 21 days following TIA, then transition to single antiplatelet therapy to minimize bleeding risk 1