What are the current guidelines for evaluation and secondary‑prevention treatment of an adult who has experienced a transient ischemic attack?

Transient Ischemic Attack Treatment Guidelines

Immediate Risk Stratification and Urgent Evaluation

All patients presenting within 48 hours of suspected TIA with unilateral weakness (face, arm, or leg) or speech disturbance/aphasia must be immediately transferred to an emergency department with CT/MRI capability and treated as a medical emergency. 1

Timing-Based Triage Protocol

• Within 48 hours of symptom onset: Immediate ED transfer for urgent brain imaging (CT or MRI) and noninvasive vascular imaging (CTA or MRA from aortic arch to vertex) within 24 hours 1
• Electrocardiogram must be obtained urgently to detect atrial fibrillation 2
• Rapid-access TIA clinics have reduced 90-day stroke recurrence from historical rates of 12-20% down to 2.1-5.1% through immediate preventive interventions 1, 2

The greatest stroke risk occurs within the first 2 days after TIA, with patients having multiple risk factors facing up to 36% 7-day stroke risk without intervention 1

---

Dual Antiplatelet Therapy (DAPT) for High-Risk TIA

For minor ischemic stroke (NIHSS ≤3) or high-risk TIA presenting within 24-72 hours, initiate dual antiplatelet therapy with clopidogrel 300 mg loading dose plus aspirin 160-325 mg within 12-24 hours of symptom onset, after excluding intracranial hemorrhage on imaging. 2

DAPT Protocol Details

• Maintenance regimen: Clopidogrel 75 mg daily + aspirin 81-100 mg daily for exactly 21 days 2
• Efficacy: Reduces recurrent stroke by 25-32% (HR 0.68-0.75) with NNT of 67-91 2
• Critical duration limit: DAPT must NOT be extended beyond 21-30 days unless separate cardiac indication exists, as bleeding risk then outweighs benefit 2
• Day 21 transition: Switch to single antiplatelet therapy indefinitely 2

---

Long-Term Antiplatelet Therapy (Post-Day 21)

After completing 21 days of DAPT, continue one of the following single antiplatelet regimens indefinitely:

• Aspirin 75-100 mg daily (most cost-effective first-line option) 2
• Clopidogrel 75 mg daily (preferred if aspirin intolerance) 2, 3
• Aspirin 25 mg + extended-release dipyridamole 200 mg twice daily (alternative regimen, superior to aspirin alone) 2, 3

All three regimens are considered equally effective for long-term secondary prevention 2

---

Blood Pressure Management

Acute Phase (First 24-72 Hours)

Permit permissive hypertension during the acute phase unless BP exceeds 220/120 mmHg, as rapid reduction impairs cerebral perfusion in the ischemic penumbra. 1, 2

Subacute and Long-Term Management

Initiate or restart antihypertensive therapy within a few days after the acute window (after first 24-72 hours) with a target BP <130/80 mmHg for all TIA patients. 1, 2

• Preferred regimen: ACE inhibitor + thiazide diuretic combination as first-line therapy 1, 2
• Alternative agents: ARB or thiazide diuretic monotherapy if combination not tolerated 1
• Efficacy: Antihypertensive treatment reduces recurrent stroke risk by approximately 30% 1, 4
• Timeline: Achieve target BP control within 3 months of therapy initiation 2

For previously treated hypertensive patients, restart antihypertensive medications after the first few days 1. For previously untreated patients with established BP ≥140/90 mmHg, prescribe antihypertensive treatment a few days after the index event 1.

---

Lipid Management

All TIA patients must receive high-intensity statin therapy regardless of baseline cholesterol levels, initiated during hospitalization or immediately after discharge. 2, 4

Statin Protocol

• Preferred agents: Atorvastatin 80 mg daily OR rosuvastatin 20-40 mg daily 2
• Target goals: LDL-C <70 mg/dL AND ≥50% reduction from baseline 2, 5
• Monitoring: Recheck fasting lipids at 4-12 weeks, then every 3-12 months 2
• Evidence: High-intensity statin therapy significantly reduces recurrent vascular events even in patients with normal cholesterol 4, 5

---

Carotid Revascularization

Patients with 70-99% ipsilateral extracranial carotid stenosis should be referred for carotid endarterectomy within 6 months, ideally within 2 weeks, to maximize benefit. 2

• Patients with 50-69% stenosis may be considered for surgery based on individualized risk assessment 2
• Intensive medical therapy (antiplatelet, BP control, statin) must continue regardless of surgical decision 2
• Vascular imaging (carotid duplex, CTA, or MRA) is essential to identify large-artery atherosclerosis requiring urgent intervention 4, 5

---

Anticoagulation for Cardioembolic TIA

If atrial fibrillation is identified on ECG or cardiac monitoring, replace antiplatelet therapy with oral anticoagulation. 2, 4, 5

Anticoagulation Protocol

• Preferred agents: Direct oral anticoagulants (DOACs)—apixaban, dabigatran, edoxaban, or rivaroxaban—over warfarin 2, 5
• Warfarin indication: Target INR 2.0-3.0 for moderate-to-severe mitral stenosis or mechanical heart valves 2
• Critical caveat: Combination of antiplatelet therapy and anticoagulation is generally NOT indicated due to increased bleeding risk 5, 3

Cardiac evaluation including ECG and prolonged rhythm monitoring is essential to detect cardioembolic sources 4, 5

---

Additional Risk Factor Management

Diabetes Control

• Target HbA1c <7% while maintaining aggressive BP control 2, 4

Lifestyle Modifications

• Smoking cessation (mandatory) 1, 2
• Physical activity: Moderate-intensity aerobic exercise ≥30 minutes daily 2, 4, 5
• Diet: Mediterranean-type diet with sodium restriction 2, 4, 5
• Weight control and alcohol moderation 1, 2
• Avoid: Stimulants and intravenous opioids 2

---

Implementation Timeline

Timeframe	Critical Actions
0-24 hours	Brain/vascular imaging, ECG, DAPT loading (if eligible), admit to stroke unit [2,4]
24-72 hours	Continue DAPT, permit permissive hypertension, start high-intensity statin [1,2,4]
Days 3-7	Initiate/restart antihypertensive therapy; schedule carotid endarterectomy if indicated [1,2]
Day 21	Switch from DAPT to single antiplatelet therapy [2]
3 months	Achieve BP <130/80 mmHg and LDL-C <70 mg/dL [2]
Lifelong	Continue single antiplatelet, statin, BP control, and risk-factor modification [2,4]

---

Multidisciplinary Stroke Unit Care

All acute TIA patients must be admitted to a stroke unit with multidisciplinary team assessment documented within 2 days. 4

Essential team members include stroke specialists, nursing staff, physical therapy, occupational therapy, speech pathology, dietician, social worker, and psychology 4. Coordinated stroke unit care with rapid implementation of prevention strategies is the single most important factor in reducing recurrent stroke risk from historical 10-20% down to 2-3% 1, 4.

---

Common Pitfalls to Avoid

• Never delay evaluation beyond 48 hours for high-risk symptoms—the greatest stroke risk is within the first 2 days 1
• Never extend DAPT beyond 21-30 days without specific cardiac indication—bleeding risk outweighs benefit 2
• Never rapidly lower BP in acute phase (<24 hours)—this impairs cerebral perfusion 1, 2
• Never withhold statins based on "normal" cholesterol—benefit is independent of baseline levels 2, 4
• Never combine antiplatelet and anticoagulation for atrial fibrillation—choose anticoagulation alone 5, 3

Implementation of this comprehensive protocol can reduce the risk of recurrent stroke by up to 80% 5, 6.