Management of Transient Ischemic Attack (TIA)
All patients with TIA require immediate aggressive risk factor modification including antiplatelet therapy, high-intensity statin therapy regardless of baseline cholesterol, and blood pressure control targeting <140/90 mmHg (or <130/80 mmHg for diabetics), initiated within 7-14 days of the event. 1, 2
Immediate Risk Stratification and Triage
Calculate the ABCD2 score immediately to stratify stroke risk: Age ≥60 years (1 point), Blood pressure ≥140/90 mmHg (1 point), Clinical features of unilateral weakness (2 points) or speech impairment without weakness (1 point), Duration ≥60 minutes (2 points) or 10-59 minutes (1 point), and Diabetes (1 point). 1, 2
High-risk patients (ABCD2 ≥4) require hospitalization or specialist TIA clinic evaluation within 24-48 hours, as they face an 8% 2-day stroke risk compared to 1% for low-risk patients. 1, 2
Low-risk patients (ABCD2 <4) can be managed as outpatients with evaluation in a specialized TIA clinic within 7-10 days. 1, 3
Urgent Diagnostic Workup
Obtain brain imaging (MRI preferred over CT), carotid imaging (duplex ultrasound, CTA, or MRA), ECG, and laboratory studies (CBC, electrolytes, renal function, lipids, glucose) urgently in all TIA patients. 2, 1
High-risk patients require CT brain within 24 hours and carotid duplex ultrasound urgently if carotid territory symptoms are present. 1
Low-risk patients should have CT brain and carotid ultrasound within 48-72 hours. 1, 3
Antiplatelet Therapy for Noncardioembolic TIA
Start antiplatelet therapy immediately upon TIA diagnosis—never delay while awaiting diagnostic workup. 2
First-line therapy: Aspirin 50mg plus extended-release dipyridamole 200mg twice daily, as this combination reduces stroke risk more effectively than aspirin alone without increasing bleeding risk. 2
Alternative: Clopidogrel 75mg daily, particularly for patients with peripheral arterial disease, prior MI, or those who cannot tolerate aspirin/dipyridamole. 2, 3
Critical pitfall: Never combine aspirin and clopidogrel for long-term therapy after TIA, as bleeding risk outweighs any potential benefit. 2
Anticoagulation for Cardioembolic TIA
If atrial fibrillation (persistent or paroxysmal) is detected, initiate oral anticoagulation with target INR 2.5 (range 2.0-3.0) using warfarin, or preferably use a direct oral anticoagulant (apixaban, dabigatran, edoxaban, or rivaroxaban). 2, 3
For mechanical prosthetic heart valves, target INR 3.0 (range 2.5-3.5). 2
Blood Pressure Management
Start blood pressure-lowering medication 7-14 days after TIA (unless symptomatic hypotension is present) with a target of <140/90 mmHg, or <130/80 mmHg for diabetics. 1
Use an ACE inhibitor alone or combined with a thiazide diuretic as first-line therapy, as this combination reduces recurrent stroke risk by approximately 30% regardless of prior hypertension history. 1, 3
Alternative: Use an angiotensin receptor blocker if ACE inhibitor is not tolerated. 1
For normotensive patients, consider lowering blood pressure by approximately 9/4 mmHg provided there is no high-grade carotid stenosis. 1
Lipid Management
Initiate high-intensity statin therapy immediately for all patients with atherothrombotic TIA, targeting LDL <100 mg/dL (ideally <70 mg/dL), regardless of baseline cholesterol levels. 1, 2, 3
Prescribe atorvastatin or rosuvastatin to reduce LDL-C by ≥50%. 3, 4
Combine statin therapy with the AHA Step II diet (30% calories from fat, <7% from saturated fat, <200mg/day cholesterol) along with maintenance of ideal body weight and regular physical activity. 1
If LDL remains ≥130 mg/dL after 3 months of lifestyle modification, intensify statin therapy. 1
Important caveat: In the SPARCL trial, atorvastatin 80mg reduced ischemic stroke (9.2% vs. 11.6%) but increased hemorrhagic stroke (2.3% vs. 1.4%) compared to placebo, with patients who had prior hemorrhagic stroke at particularly increased risk (16% vs. 4%). 4
Diabetes Management
Target fasting blood glucose <126 mg/dL (7 mmol/L) and HbA1c <7% using diet, regular exercise (at least 3 times weekly), and oral hypoglycemics or insulin as needed. 1, 3
Lifestyle Modifications
Counsel all smokers on smoking cessation using counseling, nicotine replacement therapies, bupropion, and formal smoking cessation programs. 1, 2
Encourage weight reduction for patients with BMI >25 (especially BMI ≥30) through graduated lifestyle changes. 1, 2
Recommend physical activity for at least 10 minutes, 3-4 times weekly (walking, bicycling, running, or swimming). 1, 2
Do not recommend antioxidant supplements (vitamins E and C, β-carotene) for cardiovascular disease prevention. 1
Carotid Revascularization
For symptomatic carotid stenosis 70-99%, perform carotid endarterectomy within 2 weeks of TIA at centers with perioperative complication rates <6%. 2
For symptomatic stenosis 50-69%, surgery may be indicated for older men with recent hemispheric symptoms and irregular/ulcerated plaque, but only at experienced centers with complication rates <6%. 2
Maintain patients on antiplatelet therapy while awaiting endarterectomy. 3
Cardiac Risk Assessment
Evaluate for coexistent coronary artery disease, cardiac arrhythmias, congestive heart failure, and valvular heart disease, as patients with TIA have substantial frequency of heart disease that may shorten life expectancy and cause marked morbidity. 1
Special Considerations
Hormone replacement therapy should not be used for secondary stroke prevention in postmenopausal women, as it may be harmful. 1
Educate all patients to return immediately if symptoms recur, as this may represent evolving stroke requiring thrombolytic therapy. 2
The stroke risk after TIA is time-dependent, with 50% of the early risk occurring within the first 48 hours, necessitating urgent evaluation and treatment. 1, 5