In a 74-year-old man with hypertension, diabetes mellitus, hyperlipidemia, prior myocardial infarction (MI) status post coronary‑artery bypass grafting (CABG), who experienced a 15‑minute episode of transient confusion without residual deficit and imaging shows a tiny acute infarct in the left basal ganglia, with carotid ultrasound showing no significant stenosis (but increased intima‑media thickness) and normal left ventricular ejection fraction (LVEF) on echocardiogram, what is the next best step in management?

Management of Acute Ischemic Stroke with Multiple Vascular Risk Factors

This patient requires urgent initiation of dual antiplatelet therapy (aspirin plus clopidogrel or ticagrelor), aggressive vascular risk factor modification including high-intensity statin therapy, blood pressure control, and optimization of diabetes management, along with cardiac rhythm monitoring to exclude atrial fibrillation as a potential embolic source. 1, 2

Immediate Antiplatelet Therapy

Dual antiplatelet therapy should be started immediately given the acute infarct on imaging, even though symptoms were transient. 2, 3

• Aspirin 150-300 mg loading dose (if not already on maintenance aspirin), followed by 75-100 mg daily maintenance dose 1
• Add clopidogrel 300-600 mg loading dose, then 75 mg daily, OR ticagrelor 180 mg loading dose, then 90 mg twice daily 1
• The presence of a documented infarct on CT (even if small) makes this an ischemic stroke, not a TIA, despite transient symptoms 2
• Dual antiplatelet therapy is particularly important in the acute phase to prevent early recurrence 3

Cardiac Rhythm Monitoring

Extended cardiac monitoring is essential to detect paroxysmal atrial fibrillation, which would change management to anticoagulation. 1, 2

• The normal echocardiogram and absence of significant carotid stenosis increase suspicion for a cardioembolic source 1
• Prolonged cardiac monitoring (at least 24-48 hours, ideally 30 days) is reasonable when vascular etiology is not clearly identified 2
• Given his history of MI and CABG, he has substantial risk for atrial fibrillation 1
• If atrial fibrillation is detected, anticoagulation would be indicated over antiplatelet therapy 1

Aggressive Lipid Management

High-intensity statin therapy must be initiated immediately regardless of baseline LDL levels. 1

• Atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily should be started 1
• Target LDL cholesterol <100 mg/dL, though treatment is recommended regardless of baseline levels in atherothrombotic stroke 1
• His history of MI, CABG, diabetes, and now stroke makes him extremely high-risk for recurrent vascular events 1

Blood Pressure Management

Blood pressure lowering should begin within 7-14 days after the acute event (not immediately, to avoid hypoperfusion). 1

• Target blood pressure <140/90 mm Hg, or <130/80 mm Hg given his diabetes 1
• ACE inhibitor alone or combined with a diuretic is the preferred regimen, or an angiotensin receptor blocker as alternative 1
• His hypertension is a major modifiable risk factor requiring aggressive control 1

Diabetes Optimization

Fasting blood glucose should be maintained <126 mg/dL (7 mmol/L) with adjustment of his current diabetes regimen. 1

• Diet, regular exercise (at least 3 times weekly), and oral hypoglycemics or insulin should be optimized 1
• Diabetes is not an independent predictor of mortality after acute events when properly managed, but requires intensive control 4
• Target HbA1c should be individualized but generally <7% for secondary stroke prevention 1

Additional Vascular Imaging

No further carotid intervention is needed given the absence of significant stenosis on ultrasound. 1

• Carotid ultrasound showing no significant plaque but intimal thickening does not warrant endarterectomy or stenting 1
• Carotid revascularization is only indicated for 70-99% symptomatic stenosis or 50-69% stenosis in select cases 1
• Intracranial vessel imaging with CTA or MRA may be reasonable to exclude tandem lesions or intracranial stenosis that could explain the basal ganglia infarct 1

Lifestyle Modifications

Smoking cessation (if applicable), weight reduction if BMI >25, and regular physical activity are essential components. 1

• Physical activity at least 10 minutes of exercise 3-4 times weekly (walking, bicycling, swimming) 1
• Salt intake reduction 1
• Counseling and formal programs should be offered for smoking cessation 1

Common Pitfalls to Avoid

• Do not delay antiplatelet therapy waiting for cardiac monitoring results—start immediately 2, 3
• Do not withhold statin therapy based on "normal" cholesterol levels—it is indicated regardless of baseline lipids in atherothrombotic stroke 1
• Do not aggressively lower blood pressure in the acute phase (first week)—wait 7-14 days to avoid hypoperfusion 1
• Do not assume the mechanism is small vessel disease just because the infarct is in the basal ganglia—cardiac embolism can cause lacunar-appearing strokes 1, 2
• Do not forget that transient symptoms with imaging evidence of infarction constitute a stroke, not a TIA—this changes risk stratification and urgency 2

Risk Stratification Context

This patient is at extremely high risk for recurrent stroke given multiple factors: age 74, diabetes, hypertension, hyperlipidemia, prior MI/CABG, and now documented acute infarct. 1, 3 Up to 80% of early stroke risk after such events is preventable with urgent, comprehensive treatment. 3 The 15-minute duration of symptoms is irrelevant—the presence of infarction on imaging defines this as stroke requiring maximal secondary prevention. 2