Stroke and TIA — secondary prevention

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.

References

1.AHA/ASA 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack (2021)