What medication should be given to a patient with a history of hypertension (high blood pressure) presenting with a transient ischemic attack (TIA)?

Lisinopril (ACE Inhibitor) Should Be Given

For a patient with hypertension presenting with TIA, initiate an ACE inhibitor (lisinopril) immediately, ideally combined with a thiazide diuretic, as this combination has the strongest evidence for reducing recurrent stroke risk in TIA patients. 1, 2

Rationale for ACE Inhibitor Selection

• ACE inhibitors have Class I, Level A evidence for secondary stroke prevention after TIA, demonstrating significant reduction in recurrent stroke and other vascular events 3, 2

• The combination of ACE inhibitor plus thiazide diuretic reduces stroke recurrence by 43% in patients both with and without pre-existing hypertension, making this the preferred first-line regimen 1, 2

• ACE inhibitors provide additional cardiovascular and renal protective benefits beyond blood pressure reduction, particularly important in patients with multiple vascular risk factors 2, 4

Why NOT the Other Options

Furosemide (Loop Diuretic) - Incorrect Choice

• Loop diuretics are not recommended for routine hypertension management or stroke prevention 3
• Thiazide diuretics (not loop diuretics like furosemide) are the diuretic class with proven stroke prevention benefit 3

Amlodipine (Calcium Channel Blocker) - Less Preferred

• While calcium channel blockers can be used, they are not first-line for post-TIA patients 3
• Amlodipine may be added as a second or third agent if blood pressure targets are not achieved with ACE inhibitor and thiazide 3, 2
• The evidence for stroke prevention is stronger with ACE inhibitors/ARBs and thiazides 3

Timing of Initiation

• Start antihypertensive treatment immediately for TIA patients, unlike acute ischemic stroke where treatment is delayed several days 1
• Treatment should be initiated as soon as possible after the TIA or at minimum before hospital discharge 1
• This patient is neurologically stable (TIA has resolved by definition), making immediate initiation appropriate 1, 2

Blood Pressure Target

• Target BP <130/80 mmHg for patients with confirmed hypertension following TIA 3, 1
• The specific target range of 120-130 mmHg systolic is recommended by recent guidelines 1
• Most patients will require two or more antihypertensive agents to achieve target BP 2

Critical Pitfalls to Avoid

• Do NOT use short-acting nifedipine due to risk of precipitous BP drops that can precipitate ischemic events 1
• Avoid excessive or rapid BP reduction in the acute phase, as this can worsen cerebral perfusion 2, 5
• Monitor serum creatinine and potassium within 7-14 days after ACE inhibitor initiation for hyperkalemia and acute kidney injury 2
• Do NOT combine ACE inhibitor with ARB, as this increases adverse effects without additional cardiovascular benefit 2

Practical Implementation

• Start lisinopril 10 mg daily (effective dose range 10-40 mg daily for hypertension) 6
• Add hydrochlorothiazide 12.5-25 mg daily if BP target not achieved with ACE inhibitor alone 3, 2
• Check BP regularly and titrate medications to achieve target <130/80 mmHg 1, 2
• This patient is currently on no medications, making this an ideal time to initiate optimal therapy 1

Comprehensive Secondary Prevention

Beyond blood pressure management, ensure:

• Antiplatelet therapy (aspirin or clopidogrel) for stroke prevention 7
• Statin therapy for lipid management and vascular protection 2
• Lifestyle modifications including DASH diet, sodium restriction, weight reduction, and physical activity 2
• Smoking cessation if applicable 2