Red Flags
- Recurrent stroke or TIA on guideline-directed medical therapy — review for atrial fibrillation (extended cardiac monitoring), large-vessel atherosclerosis, hypercoagulability, paradoxical embolism[1]
- Symptomatic carotid stenosis 50–99% — revascularisation (CEA or CAS) within 2 weeks of index event for greatest benefit[1]
- Atrial fibrillation diagnosis after stroke without anticoagulation — start DOAC unless contraindicated; do not delay solely for routine follow-up[1]
- Severe blood pressure (SBP ≥180 mm Hg or DBP ≥110 mm Hg) post-stroke — gradual lowering over weeks; aim <130/80 long-term[1]
First-line treatment
Interventions
- Aetiology-driven choice of antithrombotic[1]Non-cardioembolic: single antiplatelet (aspirin or clopidogrel). Cardioembolic (AF, mechanical valve, intracardiac thrombus): anticoagulation. PFO with cryptogenic stroke age <60 with high-risk features: device closure + antiplatelet
- Comprehensive risk-factor management[1]BP <130/80; LDL-C <70 mg/dL (1.8 mmol/L) with high-intensity statin ± ezetimibe ± PCSK9 inhibitor; HbA1c <7% with cardiovascular-protective agents (SGLT2 inhibitor, GLP-1 RA); smoking cessation; weight management; aerobic exercise ≥150 min/week
- Carotid revascularisation for symptomatic stenosis[1]CEA preferred over CAS for stenosis 70–99%; consider CAS for 50–69% or anatomically unfavourable; perform within 2 weeks of index event when stable
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Aspirin (single-antiplatelet)[1] | Antiplatelet (COX-1 irreversible inhibitor) | 75–325 mg PO daily; lifelong unless intolerant | — | First-line for non-cardioembolic stroke/TIA; combine with PPI if GI bleeding risk |
| Clopidogrel (single-antiplatelet)[1] | P2Y12 receptor antagonist | 75 mg PO daily | — | Alternative when aspirin not tolerated; equivalent efficacy in CAPRIE; rare risk of TTP |
| Aspirin + clopidogrel (short-term DAPT)[1] | Dual antiplatelet therapy | Aspirin 75 mg + clopidogrel 75 mg PO daily for 21 days, then aspirin alone | — | Minor non-cardioembolic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4) — start within 24 h. POINT and CHANCE trials. Long-term DAPT increases bleeding without benefit |
| Aspirin + ticagrelor (alternative DAPT)[1] | Dual antiplatelet therapy | Aspirin 75 mg + ticagrelor 90 mg BD × 30 days | — | Minor stroke or high-risk TIA per THALES; alternative to clopidogrel-aspirin where clopidogrel non-response or contraindicated |
| Apixaban or rivaroxaban (cardioembolic AF)[1] | DOAC (factor Xa inhibitor) | Apixaban 5 mg BD (2.5 mg if any 2 of: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL); rivaroxaban 20 mg PO daily with food (15 mg if CrCl 15–50) | — | First-line for non-valvular AF; superior or equivalent to warfarin with less ICH; contraindicated in mechanical valve and moderate-severe rheumatic mitral stenosis |
| Atorvastatin or rosuvastatin (high-intensity)[1] | HMG-CoA reductase inhibitor | Atorvastatin 80 mg PO daily; rosuvastatin 20–40 mg PO daily | — | All atherosclerotic stroke; LDL-C target <70 mg/dL; add ezetimibe 10 mg or PCSK9 inhibitor if not at target |
| Antihypertensive (ACEi/ARB ± thiazide ± CCB)[1] | Antihypertensive — combination | Per BP and comorbidities; lower target gradually over weeks; combination over uptitration of single agent | — | Target BP <130/80 for most; <140/90 in selected lacunar stroke without diabetes; ACEi/ARB + thiazide is common backbone |
Aspirin (single-antiplatelet)[1]
Antiplatelet (COX-1 irreversible inhibitor)
- Adult
- 75–325 mg PO daily; lifelong unless intolerant
- Paediatric
- —
First-line for non-cardioembolic stroke/TIA; combine with PPI if GI bleeding risk
Clopidogrel (single-antiplatelet)[1]
P2Y12 receptor antagonist
- Adult
- 75 mg PO daily
- Paediatric
- —
Alternative when aspirin not tolerated; equivalent efficacy in CAPRIE; rare risk of TTP
Aspirin + clopidogrel (short-term DAPT)[1]
Dual antiplatelet therapy
- Adult
- Aspirin 75 mg + clopidogrel 75 mg PO daily for 21 days, then aspirin alone
- Paediatric
- —
Minor non-cardioembolic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4) — start within 24 h. POINT and CHANCE trials. Long-term DAPT increases bleeding without benefit
Aspirin + ticagrelor (alternative DAPT)[1]
Dual antiplatelet therapy
- Adult
- Aspirin 75 mg + ticagrelor 90 mg BD × 30 days
- Paediatric
- —
Minor stroke or high-risk TIA per THALES; alternative to clopidogrel-aspirin where clopidogrel non-response or contraindicated
Apixaban or rivaroxaban (cardioembolic AF)[1]
DOAC (factor Xa inhibitor)
- Adult
- Apixaban 5 mg BD (2.5 mg if any 2 of: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL); rivaroxaban 20 mg PO daily with food (15 mg if CrCl 15–50)
- Paediatric
- —
First-line for non-valvular AF; superior or equivalent to warfarin with less ICH; contraindicated in mechanical valve and moderate-severe rheumatic mitral stenosis
Atorvastatin or rosuvastatin (high-intensity)[1]
HMG-CoA reductase inhibitor
- Adult
- Atorvastatin 80 mg PO daily; rosuvastatin 20–40 mg PO daily
- Paediatric
- —
All atherosclerotic stroke; LDL-C target <70 mg/dL; add ezetimibe 10 mg or PCSK9 inhibitor if not at target
Antihypertensive (ACEi/ARB ± thiazide ± CCB)[1]
Antihypertensive — combination
- Adult
- Per BP and comorbidities; lower target gradually over weeks; combination over uptitration of single agent
- Paediatric
- —
Target BP <130/80 for most; <140/90 in selected lacunar stroke without diabetes; ACEi/ARB + thiazide is common backbone
Safety-net
- Take antiplatelet or anticoagulant every day without missing doses — most recurrences happen in patients who pause therapy[1]
- Symptoms recurring (face droop, arm weakness, slurred speech, sudden vision change) — call emergency services and chew aspirin if not already on anticoagulation[1]
- If you have AF and miss doses, do not double up — restart at next scheduled dose and tell your prescriber[1]
Referral criteria
- Symptomatic carotid stenosis 50–99%Vascular surgery within 2 weeks[1]
- Cryptogenic stroke age <60 with PFO and high-risk featuresCardiology / neurology multidisciplinary for PFO closure consideration[1]
- Atrial fibrillation newly diagnosed post-strokeCardiology and anticoagulation initiation[1]
- Recurrent ischaemic event on guideline-directed medical therapyStroke clinic for re-evaluation including hypercoagulability and rare aetiologies[1]
Clinical summary
Aetiology-driven secondary prevention after ischaemic stroke or TIA, including antiplatelet, anticoagulation, lipid, BP, and structural interventions.