What is the best next step in managing a 75-year-old man with a history of type 2 diabetes, hypertension, and lipidemia, who presented with transient symptoms of speech and writing weakness that resolved within 90 minutes?

Management of Transient Ischemic Attack (TIA) in a 75-Year-Old with Multiple Vascular Risk Factors

This patient experienced a transient ischemic attack (TIA) and requires immediate dual antiplatelet therapy with aspirin plus clopidogrel for 21 days, making option C (aspirin and clopidogrel) the correct answer.

Clinical Reasoning

This 75-year-old man presented with transient speech and writing weakness lasting 90 minutes that resolved completely—this is the classic definition of a TIA. With his constellation of type 2 diabetes, hypertension, and hyperlipidemia, he is at extremely high risk for recurrent stroke, particularly in the first 90 days after TIA when risk is highest.

Why Dual Antiplatelet Therapy is Superior

For high-risk TIA patients, dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days significantly reduces early stroke recurrence compared to aspirin alone. The evidence supporting this approach comes from multiple large trials showing that the combination reduces stroke risk by approximately 30-40% in the acute period following TIA 1.

• Patients with diabetes have increased platelet reactivity and a prothrombotic state that makes them particularly vulnerable to recurrent ischemic events 1
• The combination of aspirin and clopidogrel targets different platelet activation pathways, providing more complete platelet inhibition during the highest-risk period 1
• After 21 days, the patient should transition to single antiplatelet therapy (preferably clopidogrel over aspirin in diabetic patients based on CAPRIE trial data showing superior outcomes) 1

Why Single Agent Therapy is Insufficient

Aspirin alone (option A) or clopidogrel alone (option B) would be inadequate for this acute, high-risk scenario:

• Single antiplatelet therapy is appropriate only for chronic secondary prevention after the acute period has passed 1
• In diabetic patients with stable coronary disease, clopidogrel monotherapy may be reasonable for long-term management, but this patient is in the acute post-TIA period requiring more aggressive therapy 1
• The patient's diabetes creates additional platelet dysfunction that may impair responsiveness to single-agent therapy 1

Critical Management Considerations

Blood Pressure Control

His presenting blood pressure of 165/100 mmHg requires urgent but careful management:

• Target blood pressure should be <140/90 mmHg in most elderly diabetic patients, though <130/80 mmHg may be considered given his recent TIA 2
• Avoid excessive blood pressure lowering, particularly diastolic BP <60 mmHg, as this can compromise cerebral perfusion in elderly patients with cerebrovascular disease 2
• Monitor for orthostatic hypotension, which is common in elderly diabetic patients and can increase fall risk 2

Diabetes Management

His type 2 diabetes requires optimization while avoiding hypoglycemia:

• Target HbA1c of <7.5% is reasonable for a 75-year-old with multiple comorbidities, balancing cardiovascular risk reduction against hypoglycemia risk 1
• Screen for cognitive impairment, as older adults with diabetes are at higher risk for cognitive decline that can affect medication adherence 1

Lipid Management

Continue or intensify statin therapy for secondary stroke prevention:

• High-intensity statin therapy is indicated for secondary prevention in patients with cerebrovascular disease and diabetes 1
• Statins should be continued without interruption as they do not contribute to bleeding risk 3

Common Pitfalls to Avoid

Do not delay antiplatelet therapy while awaiting imaging. The patient's symptoms have resolved, and immediate dual antiplatelet therapy should be initiated while arranging urgent neurovascular imaging (CT/CTA or MRI/MRA) within 24-48 hours.

Do not use dual antiplatelet therapy beyond 21 days in most patients. After the acute period, transition to single antiplatelet therapy (preferably clopidogrel in diabetic patients) to minimize bleeding risk while maintaining stroke prevention 1.

Do not aggressively lower blood pressure in the immediate post-TIA period. Gradual blood pressure reduction over days to weeks is preferred to avoid compromising cerebral perfusion in the setting of potentially impaired autoregulation 2.