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) or the combination of an ACE inhibitor plus a thiazide diuretic immediately—this is a Class I recommendation with Level A evidence for secondary stroke prevention. 1

Immediate Initiation of Antihypertensive Therapy

• TIA patients should start antihypertensive treatment immediately, unlike ischemic stroke where treatment is delayed several days. 2 This is a critical distinction—TIA is a medical emergency requiring urgent intervention. 3, 4

• All TIA patients with hypertension must have antihypertensive therapy commenced before hospital discharge (Class I recommendation). 2

• The preferred initial agents are ACE inhibitors (like lisinopril), thiazide diuretics, or ARBs, with the combination of ACE inhibitor plus thiazide diuretic showing the strongest evidence. 1

Why Lisinopril Over the Other Options

Lisinopril (ACE inhibitor) is superior to both furosemide and amlodipine for this indication:

• ACE inhibitors and thiazide diuretics (not loop diuretics like furosemide) have demonstrated a 30% reduction in recurrent stroke risk in dedicated randomized controlled trials. 1

• Furosemide is a loop diuretic with no evidence base for secondary stroke prevention—the evidence specifically supports thiazide diuretics, not loop diuretics. 1

• While amlodipine (calcium channel blocker) may be added if BP targets are not achieved with first-line agents, CCBs are not first-line therapy for secondary stroke prevention after TIA. 1 The evidence hierarchy clearly places ACE inhibitors and thiazide diuretics above CCBs. 1

Blood Pressure Targets

• Target BP <140/90 mmHg for most patients, with consideration of <130/80 mmHg as a reasonable goal (Class IIb recommendation). 1, 2

• The degree of BP reduction (average 10/5 mmHg) appears more important than the specific agent used, but this does not negate the preference for evidence-based first-line agents. 1

Clinical Algorithm for This Patient

1. Immediately initiate lisinopril (typical starting dose 10 mg daily for hypertension). 5

2. Add a thiazide diuretic (such as hydrochlorothiazide 12.5-25 mg daily) if BP target not achieved with ACE inhibitor alone. 1

3. If ACE inhibitor is not tolerated (e.g., due to cough or angioedema), substitute an ARB as the alternative. 1, 2

4. Only add amlodipine or other CCBs as third-line agents if BP remains uncontrolled on ACE inhibitor/ARB plus thiazide diuretic. 1

Critical Pitfalls to Avoid

• Do not use furosemide (loop diuretic) for secondary stroke prevention—it lacks evidence and is not guideline-recommended for this indication. 1

• Do not delay antihypertensive initiation in TIA patients—unlike acute ischemic stroke where BP lowering is delayed, TIA requires immediate treatment. 2

• Do not start with amlodipine as monotherapy—while CCBs have a role, they are not first-line for secondary stroke prevention. 1

• Ensure the patient is not in the hyperacute phase where BP >220/120 mmHg would require different management, but this patient has a "history" of hypertension and is presenting with TIA, indicating they are appropriate for immediate secondary prevention therapy. 2

Comprehensive Secondary Prevention

Beyond antihypertensive therapy, this patient requires:

• Antiplatelet therapy (aspirin or clopidogrel) initiated immediately. 2, 6
• Statin therapy targeting LDL <100 mg/dL. 2
• Evaluation for atrial fibrillation and other cardioembolic sources. 6
• Lifestyle modifications including smoking cessation, weight loss, and dietary changes. 1, 6

The answer is C - Lisinopril, as it represents the evidence-based, guideline-recommended first-line agent for secondary stroke prevention in a hypertensive patient with TIA. 1, 2