Transient ischemic attack medical therapy

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

Overview

Medical therapy for the management of transient ischemic attack includes emergency or early assessment and long term management to prevent future risk of stroke.

Medical Therapy

The approach to medical management of patients with transient ischemic attack may involve the following:
a) Early assessment and emergency management
b) Long term management and follow up

Early assessment and emergency management

• Rapid transport to the hospital
• History and examination
• IV access
• Fingerstick glucose to rule out hypoglycemia
• EKG testing to rule out ongoing ischemia
• Neuroimaging to rule out infarction

Risk assessment and management plan

After initial evaluation of patient, the decision to further manage the patient in the emergency department observation unit, hospital admission or outpatient follow up depends on no of factors which may include

• ABCD2 scoring(AHA guidelines)
• Assessment by emergency physician
• Opinion of neurologist
• Risk of future stroke or TIA
• Patient preference
• Local resources

Guidelines for the hospitalization of patients with TIA

AHA guidelines

• ABCD2 score of 3
• ABCD2 score of 0-2 and uncertainity of completion of work up in 2 days in outpatient
• ABCD2 score of 0-2 and other evidence suggesting patient's transient ischemic attack may be caused by focal ischemia

NSA guidelines

24-48 hours

• Hospitalization recommended for early t-PA availability in case of recuurent attack or infarction
• Early risk assessment and management plan

<1 week
Hospitalization in less than a week of TIA may be recommended in following situations:

• Symptoms >1 hour
• Known hypercoaguable disorder
• Symptomatic internal carotid artery stenosis>50
• Two or more TIAs per week (crescendo TIA)
• Cardiac source of embolism (atrial fibrillation)
• California and ABCD2 suggesting admission

Pharmacological therapy

Hypertension

• Blood pressure control may be considered in patients with evidence of end organ damage or levels above 220/120mmHg
• Blood pressure autoregulation without medication may be considered in patients with increased levels in patients with TIA to enhance cerebral perfusion

Non cardioembolic TIA

• Antiplatelet therapy is recommended as first line.
• Aspirin 50-325mg/day, combination of aspirin and extended release dipyridamole and clopidogrel may be considered first line treatment.
• Aspirin and clopidogrel may be started within 24 hours of minor stroke or TIA and may be continued for 21 days.

Cardioembolic TIA

• Anticoagulation may be recommended in patients with known cardiac source of emboli such as atrial fibrillation and acute MI with ventricular thrombus
• Anticoagulation therapy with warfarin may be recommended with target INR 2-3
• Aspirin 325mg may be recommended in patients unable to take anticoagulants

Long Term management

Long term management mainly depends on the modification of underlying risk factors:

• Control of Blood pressure to <140/90mmHg with ACE inhibitors or Angiotensin receptor blockers or both
• Blood sugar control <126 mg/dl with antidiabetics
• Treatment of hyperlipidemia with statins
• Anticoagulant and antiplatelets for underlying cardiac disease.