Acute treatment and secondary prevention of transient ischaemic attacks (TIA) and ischaemic stroke

What's New

Combines the two guidelines: acute treatment & secondary prevention. Now includes info on which patients should be prescribed dual antiplatelets & the duration following a major TIA or minor stroke

Antiplatelets
All patients with a TIA with full recovery:
  • Prescribe aspirin 300mg once daily for 14 days
  • Followed by clopidogrel 75mg once daily, long term
High risk TIA (ABCD2 score 4 to 7) with full recovery:
  • The high risk TIA regimen should occur following a CT scan, and be instituted by a stroke physician
  • Consider clopidogrel 300mg loading dose after initial aspirin loading
  • Followed by dual antiplatelet therapy (DAPT): clopidogrel 75mg and aspirin 75mg once daily, for 21 days
  • After 21 days, stop aspirin and continue clopidogrel 75mg monotherapy long term
Stroke:
  • All patients with a confirmed stroke should be referred to the stroke service
  • A stroke consultant will review the patient to decide if they are classed as a minor or moderate/severe ischaemic stroke. These patients require brain imaging prior to commencing secondary prevention.
  • Once haemorrhage is excluded:
    • Minor ischaemic stroke patients receive the same DAPT regimen as high risk TIA’s, including clopidogrel loading dose
    • Moderate/severe ischaemic stroke patients receive aspirin 300mg once daily for 14 days, and thereafter they will usually be converted to clopidogrel 75mg daily
  • If already on clopidogrel, eg for coronary artery stent, seek stroke specialist advice before switching to aspirin
  • If already on aspirin 75mg daily, then increase dose to 300mg daily for 14 days, depending on presentation and diagnosis
  • If already on warfarin or other oral anticoagulant, see anticoagulant advice below
  • If thrombolysed, initiate aspirin 300mg 24 hours after thrombolysis and repeat CT scan.

 Prescribing information

  • Only for use in confirmed non-haemorrhagic stroke after a CT scan.
  • For patients with dysphagia, aspirin 300mg once daily should be administered rectally as a suppository, or both the 75mg and 300mg doses as the dispersible tablet via an enteral tube, if this route is available.
    Clopidogrel tablets can be crushed and dispersed in water for administration via enteral tubes or for those patients with swallowing difficulties.
  • In documented aspirin intolerance or allergy prescribe clopidogrel 75mg daily.
  • For patients at risk of gastro-intestinal complications with aspirin (known peptic ulcer or dyspepsia) co-prescribe gastroprotection (see Formulary). The preferred PPI of choice is lansoprazole, as other PPI’s, including omeprazole, are known to reduce the efficacy of clopidogrel.
  • Discontinue NSAIDs as they antagonise the antiplatelet effect of aspirin.
Anticoagulants

For patients presenting with a stroke already prescribed an anticoagulant, withhold this until the patient has had a review by a stroke consultant. Anticoagulants should be started when indicated as per the 1 to 3 to 6 to 12 day rule, and guided by an experienced stroke physician

Prescribing information

  • For patients presenting with stroke in atrial fibrillation (AF) while on oral anticoagulants, in most circumstances consider withholding the oral anticoagulant until Stroke Team review. 
    If on warfarin and INR below 2, consider aspirin 300mg.
    If on a DOAC, consider aspirin 300mg 48 hours after last dose of DOAC.
  • Consider patients with ischaemic stroke or TIA in atrial fibrillation (AF) for anticoagulant treatment. Refer to Embolism prophylaxis in atrial fibrillation (AF).
  • In patients with atrial fibrillation, assess stroke risk using CHA2DS2VASc and bleeding risk using HAS-BLED: Stroke prevention in atrial fibrillation risk tool: http://sparctool.com/ 
  • In days following a TIA, assess risk for stroke using ABCD2
Antihypertensives

NEW antihypertensives should not be prescribed in the acute phase following an ischaemic stroke.

 Prescribing information 

 
  • Consider patients with more than one event in seven days as high-risk and initiate antihypertensives immediately. Unless contraindicated an ACE-inhibitor such as ramipril is appropriate, titrate up until adequate blood pressure control is achieved.
  • Regular antihypertensive medication should be continued as before in the post-stroke period if the blood pressure is permissible (refer to the table below). 
 Blood Pressure Action
 Consistently less than 130/80mmHg Withhold any regular antihypertensive medication.

Consistently 130/80mmHg or greater but less than 220 systolic BP
OR less than 130 mean arterial pressure

Continue regular antihypertensive medication if no other acute contra-indications.

Consistently 220 or greater systolic BP
OR greater than 130 mean arterial pressure

Continue regular antihypertensive medication if no other acute contra-indications. Seek specialist advice from a physician experienced in stroke.

Prescribing information

  • Check U&Es prior to initiation, within 14 days of initiation and at each dose titration. Once stabilised on treatment, recheck U&Es annually.
  • If intolerant of ACE inhibitors, eg ACE-induced cough, discontinue and consider alternative treatment as per British and Irish Hypertension Society Guidelines
Blood pressure target post stroke: 130/80mmHg 
Statins

Initiate atorvastatin 80mg daily

Prescribing information

  • Prior to prescribing a statin, check non-fasting total cholesterol (TC), high-density lipoprotein (HDL) and triglyceride (TG) levels, as well as liver function tests (LFTs) and thyroid function tests (TFTs)
  • For further information refer to Statins for the prevention of atherosclerosis
  • Consider drug interactions; refer to table in above lipid-lowering guidance or to BNF
  • If a person is not able to tolerate atorvastatin 80mg consider a lower dose or alternative statin. Refer to BNF for common side-effects

Note: patients post-haemorrhagic stroke should not normally be prescribed a statin unless the risks of further vascular events outweigh the risk of further haemorrhage.

Further information

Patient information can be accessed here

The Community Rehabilitation Teams Referral Form for North West Sutherland and East Highland can be accessed here

Editorial Information

Last reviewed: 23 April 2020

Next review: 30 April 2023

Author(s): Stroke Clinical Network

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Consultant in acute medicine and stroke

Document Id: TAM393