Managing TIA: Early action and essential risk-reduction steps
Your patient with a focal neurologic deficit is rushed to the ED for diagnostic imaging. Which initial and long-term interventions can best reduce their risk of recurrent TIA and stroke?
PRACTICE RECOMMENDATIONS
In the hospital, the treating physician should:
› Immediately initiate brain imaging with diffusion-weighted magnetic resonance imaging when TIA is suspected, upon the patient’s arrival at the hospital. A
› Control blood pressure when a TIA is confirmed, to decrease the risk of recurrent stroke. A
› Initiate antiplatelet therapy, to decrease the risk of recurrent stroke. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
For a patient who has an ABCD2 score ≥ 4, has had a prior TIA, or has large-vessel disease, dual antiplatelet therapy is recommended for the first 21 days, with a subsequent return to monotherapy. Dual antiplatelet therapy of clopidogrel + aspirin increases the risk of adverse reactions and has not been shown to have greater long-term benefit23-25 (TABLE 22,20,21).
Step 2: BP management. This is the next immediate step. As many as 80% of patients who present with a TIA have elevated BP upon admission. BP needs to be treated and carefully monitored during this early treatment phase. The recommendation is for a systolic BP < 185 mm Hg and a diastolic BP < 110 mm Hg.24
Step 3: Anticoagulation. Treatment with warfarin or a direct oral anticoagulant (DOAC) is recommended for patients who have the potential for forming emboli—eg, in the setting of atrial fibrillation, ventricular thrombus, mechanical heart valve, or venous thromboembolism.
Step 4. High-intensity statin. A statin agent is recommended as part of immediate and long-term medical management, regardless of the low-density lipoprotein cholesterol (LDL-C) level, to reduce the risk of stroke.2,24
Carotid artery management. Surgical intervention is not always considered a component of immediate medical management. However, guidelines recommend that carotid endarterectomy or stenting be considered in patients who have stenosis > 70%.2
CASE
Mr. L is admitted to the hospital and undergoes neurosurgical intervention. Medical management is instituted.
Long-term management and secondary prevention
The main risk factors for stroke can be divided into modifiable, vascular, and unmodifiable. Addressing both modifiable and vascular risks is important for secondary prevention.
Continue to: Modifiable and vascular risk factors
