Transient ischemic attack secondary prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S [2]Maryam Hadipour, M.D.[3]

Overview

The secondary prevention strategies for recurrent transient ischemic stroke and ischemic stroke may include the lifestyle modification and treatment of modifiable risk factors.

Secondary prevention

The secondary prevention strategies for recurrent transient ischemic stroke and ischemic stroke may include the following:^[1]^[2]^[3]

Life style modification for secondary prevention

Life style modification measures which may help reduce the risk of recurrent stroke and prevent complications may include:

Increased physical activity->10 min of exercise such as walking, running, bicycling or swimming >3 times/wk
Eating healthy balanced diet. Mediterranean diets are recommended for stroke risk reduction.
Smoking cessation
Decreased alcohol intake
Controlling diseases that are risk factors, including diabetes, hyperlipidemia, and hypertension.

Treatment of modifiable risk factors

Blood pressure

BP control to less than 130/80mm Hg with an angiotensin inhibitor alone or in combination with a diuretic or angiotensin receptor blocker^[4]

Diabetes mellitus

Diabetes control with fasting blood glucose level <126mg/dl or HbA1C < 7% or < 7%-8%^[4]

Hyperlipidemia

Initiation of statin for hyperlipidemia with goal LDL level<70mg/dL (Please note that the previous guideline suggested LDL level < 110mg/dL or < 90mg/dL but it is now suggested to use highest tolerable dose of statins and PCSK-9 inhibitors to reach the LDL < 70mg/dL level, if tolerable).^[4]

Antithrombotic stroke

Long term antiplatelet therapy with aspirin, dipyrimadole plus aspirin, clopidogrel or aspirin alone^[1]^[3]^[5]^[6]^[4]
Anticoagulation not required

Cardioembolic stroke

Anticoagualtion for atrial fibrillation with Vit K antagonist or NOACs.
If intolerant to anticoagulation, aspirin 325 mg or clopidogrel 75 mg (if aspirin intolerant)^[3]

TIA with ongoing non Q wave MI or unstable angina

Use of aspirin(75 mg-100mg) in combination with clopidogrel (75 mg) may be beneficial.^[3]
An ECG is suggested to perform on any patient, presenting with MI or recurrent TIA or stroke, in order to rule out AF.^[4]

Other situations

Patients having history of TIA undergoing endartectomy may benefit from aspirin (25 to 325mg) before surgery.^[3]
Because patients with symptomatic high-grade cervical carotid stenosis are candidates for revascularization, it is appropriate to screen for stenosis in any patient who may have such stenosis. Initial testing for carotid stenosis should be done with a noninvasive test such as CTA, MRA, or ultrasonography rather than digital subtraction angiography.^[4]

Secondary prevention for specific causes of transient ischemic stroke^[7]

Cause of ischemic stroke		Revascularization			Multifactorial risk reduction
Cause of ischemic stroke		Carotid endartectomy	Carotid stenting	Other Surgical options	Antiplatelet therapy	Statins	Antihypertensives	Anticoagulants
Large artery disease	Carotid Artery Stenosis	✔	✔
	Carotid occlusion		✔					✔
	Vertebral artery stenosis			Angioplasty	✔	✔	✔
	Large vessel atherosclerosis		✔	Percutaneous transluminal angioplasty	✔✔	✔✔	✔✔	✔✔
	Arterial dissection			Endovascular surgical repair	✔			✔
Cardiac embolism	Atrial fibrillation				✔			✔
	Valvular heart disease							✔
	Mitral valve disease				✔
	Recent MI/ left ventricular thrombus							✔
	Heart failure				✔			✔
	Dilated cardiomyopathy				✔			✔
Hematological disorders	Protein C/S deficiency							✔
	Sickle cell disease			Repeated blood transfusions and Hydroxurea				✔
	Antithrombin III deficiency							✔
	Antiphospholipid antibody syndrome			✔			✔

For AHA/ASA guidelines for the secondary prevention of transient ischemic stroke, please click here

References

↑ ^1.0 ^1.1 Yakhkind A, McTaggart RA, Jayaraman MV, Siket MS, Silver B, Yaghi S (2016). “Minor Stroke and Transient Ischemic Attack: Research and Practice”. Front Neurol. 7: 86. doi:10.3389/fneur.2016.00086. PMC 4901037. PMID 27375548.
↑ Yaghi S, Elkind MS (2016). “Lipid Control and Beyond: Current and Future Indications for Statin Therapy in Stroke”. Curr Treat Options Cardiovasc Med. 18 (4): 27. doi:10.1007/s11936-016-0448-8. PMID 26920158.
↑ ^3.0 ^3.1 ^3.2 ^3.3 ^3.4 Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA; et al. (2006). “National Stroke Association guidelines for the management of transient ischemic attacks”. Ann Neurol. 60 (3): 301–13. doi:10.1002/ana.20942. PMID 16912978.
↑ ^4.0 ^4.1 ^4.2 ^4.3 ^4.4 ^4.5 Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS (July 2021). “2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association”. Stroke. 52 (7): e364–e467. doi:10.1161/STR.0000000000000375. PMID 34024117 Check |pmid= value (help).
↑ SPS3 Investigators. Benavente OR, Hart RG, McClure LA, Szychowski JM, Coffey CS; et al. (2012). “Effects of clopidogrel added to aspirin in patients with recent lacunar stroke”. N Engl J Med. 367 (9): 817–25. doi:10.1056/NEJMoa1204133. PMC 4067036. PMID 22931315. Review in: Ann Intern Med. 2012 Dec 18;157(12):JC6-2
↑ Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C; et al. (2013). “Clopidogrel with aspirin in acute minor stroke or transient ischemic attack”. N Engl J Med. 369 (1): 11–9. doi:10.1056/NEJMoa1215340. PMID 23803136. Review in: Ann Intern Med. 2013 Oct 15;159(8):JC5 Review in: Evid Based Med. 2014 Apr;19(2):58
↑ Donnan GA, Fisher M, Macleod M, Davis SM (2008). “Stroke”. Lancet. 371 (9624): 1612–23. doi:10.1016/S0140-6736(08)60694-7. PMID 18468545.

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[pmid27375548-1] 1.0 ^1.1 Yakhkind A, McTaggart RA, Jayaraman MV, Siket MS, Silver B, Yaghi S (2016). “Minor Stroke and Transient Ischemic Attack: Research and Practice”. Front Neurol. 7: 86. doi:10.3389/fneur.2016.00086. PMC 4901037. PMID 27375548.

[pmid26920158-2] Yaghi S, Elkind MS (2016). “Lipid Control and Beyond: Current and Future Indications for Statin Therapy in Stroke”. Curr Treat Options Cardiovasc Med. 18 (4): 27. doi:10.1007/s11936-016-0448-8. PMID 26920158.

[pmid16912978-3] 3.0 ^3.1 ^3.2 ^3.3 ^3.4 Johnston SC, Nguyen-Huynh MN, Schwarz ME, Fuller K, Williams CE, Josephson SA; et al. (2006). “National Stroke Association guidelines for the management of transient ischemic attacks”. Ann Neurol. 60 (3): 301–13. doi:10.1002/ana.20942. PMID 16912978.

[pmid34024117-4] 4.0 ^4.1 ^4.2 ^4.3 ^4.4 ^4.5 Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS (July 2021). “2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association”. Stroke. 52 (7): e364–e467. doi:10.1161/STR.0000000000000375. PMID 34024117 Check |pmid= value (help).

[pmid22931315-5] SPS3 Investigators. Benavente OR, Hart RG, McClure LA, Szychowski JM, Coffey CS; et al. (2012). “Effects of clopidogrel added to aspirin in patients with recent lacunar stroke”. N Engl J Med. 367 (9): 817–25. doi:10.1056/NEJMoa1204133. PMC 4067036. PMID 22931315. Review in: Ann Intern Med. 2012 Dec 18;157(12):JC6-2

[pmid23803136-6] Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C; et al. (2013). “Clopidogrel with aspirin in acute minor stroke or transient ischemic attack”. N Engl J Med. 369 (1): 11–9. doi:10.1056/NEJMoa1215340. PMID 23803136. Review in: Ann Intern Med. 2013 Oct 15;159(8):JC5 Review in: Evid Based Med. 2014 Apr;19(2):58

[pmid18468545-7] Donnan GA, Fisher M, Macleod M, Davis SM (2008). “Stroke”. Lancet. 371 (9624): 1612–23. doi:10.1016/S0140-6736(08)60694-7. PMID 18468545.

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