For the management of acute stroke or TIA, see Acute stroke/TIA.

For the management of someone presenting with a suspected completed TIA , see TIA, completed.

Secondary prevention of TIA

• For people who have had a TIA, long-term antiplatelet treatment should usually be started in primary care as soon as the diagnosis is confirmed.
• A combination of modified-release dipyridamole (200 mg twice daily) and aspirin (50 mg to 300 mg daily) is recommended indefinitely.
• Consider also prescribing a proton pump inhibitor to reduce the risk of gastrointestinal bleeding in people at high risk of gastrointestinal bleeding or to relieve aspirin-induced dyspepsia.
• If aspirin is contraindicated or not tolerated, give modified-release dipyridamole alone.
• If modified-release dipyridamole is contraindicated or not tolerated, give aspirin alone.
• If both aspirin and modified-release dipyridamole are contraindicated or not tolerated, give clopidogrel (75 mg daily) alone (off-label use).
• For further information on antiplatelet therapy (including managing gastrointestinal issues), see the CKS topic on Antiplatelet treatment.

Secondary prevention of ischaemic stroke

• For people who have had an ischaemic stroke, high-dose aspirin is usually continued for about 2 weeks after the event, and then low–dose long–term antiplatelet treatment is started.
• Clopidogrel (75 mg daily) is the preferred antiplatelet for secondary prevention of ischaemic stroke.
• If clopidogrel is contraindicated or not tolerated, give a combination of modified-release dipyridamole (200 mg twice daily) and aspirin (50 mg to 300 mg daily).
• Consider also prescribing a proton pump inhibitor to reduce the risk of gastrointestinal bleeding in people at high risk of gastrointestinal bleeding or to relieve aspirin-induced dyspepsia.
• If both clopidogrel and modified-release dipyridamole are contraindicated or not tolerated, give aspirin alone.
• If both clopidogrel and aspirin are contraindicated or not tolerated, give modified-release dipyridamole alone.
• For further information on antiplatelet therapy (including managing gastrointestinal issues), see the CKS topic on Antiplatelet treatment.

Recurrent stroke or TIA

• People who have recurrent strokes or TIAs should not be given more intensive antiplatelet treatment or anticoagulation unless there are exceptional circumstances or as part of a clinical trial. Seek specialist advice regarding management of these people.

People with persistent or paroxysmal atrial fibrillation or with cerebral venous sinus thrombosis

• Anticoagulation is recommended for people with persistent or paroxysmal atrial fibrillation, and is usually recommended for people with cerebral venous sinus thrombosis.
• Anticoagulation is normally initiated in secondary care, and should not be started until intracerebral haemorrhage has been excluded by brain imaging.
• For more information on managing anticoagulation in people with atrial fibrillation, see the CKS topic on Atrial fibrillation and the CKS topic on Anticoagulation - oral.

These recommendations are in line with guidelines issued by the National Institute for Health and Clinical Excellence (NICE) and the Royal College of Physicians Intercollegiate Stroke Working Party (RCP ICSWP) [Intercollegiate Stroke Working Party, 2008; National Collaborating Centre for Chronic Conditions, 2008; NICE, 2010b].

Basis for antiplatelet therapy

• Long-term antiplatelet therapy is recommended because evidence from a large meta-analysis indicates that prolonged antiplatelet therapy reduces the risk of all-cause mortality, vascular mortality, and non-fatal vascular events (stroke and myocardial infarction) in people with a history of stroke or transient ischaemic attack [Antithrombotic Trialists' Collaboration, 2002].
• Treatment is no longer limited to 2 years from the most recent event [NICE, 2010b].
• In their previous guidance [NICE et al, 2004], NICE found the combination of aspirin and modified-release dipyridamole to be most cost effective when given for 2 years from the most recent event. This recommendation was based on the European Stroke Prevention Study 2 (ESPS-2), which had a 2-year follow up [Diener et al, 1996].
• However, the subsequent ESPRIT study had a duration of follow-up of 3.5 years [The ESPRIT Study Group, 2006]. The Kaplan-Meier survival curves for each treatment group in this study continued to diverge over time, and NICE concluded that a time limit on the duration of treatment was no longer needed [NICE, 2010b].
• Secondary prevention of occlusive vascular events following an ischaemic stroke
• There is good evidence from two large randomized controlled trials that the combination of aspirin and modified-release dipyridamole is more effective than aspirin alone in reducing stroke recurrence in people with stroke or TIA in the preceding 3–6 months [Diener et al, 1996; ESPRIT Study Group et al, 2006].
• Evidence from the Clopidogrel versus Aspirin in Patients at Risk for Ischemic Events (CAPRIE) trial found clopidogrel to be only marginally more effective than aspirin at reducing serious vascular events [CAPRIE Steering Committee, 1996].
• Compared with aspirin (325 mg daily), 196 people would need to be treated with clopidogrel (75 mg daily) for one extra person to benefit from treatment (number needed to treat = 196) [MeReC, 2005].
• Evidence from ESPS-2 [Diener et al, 1996] and the PRoFESS trial [Sacco et al, 2008] showed no statistical difference between the modified-release dipyridamole-only and aspirin-only groups in reducing the risk of any of the primary outcomes reported (e.g. stroke, death)
• Following the availability of generic clopidogrel [NICE, 2010b], NICE found that generic clopidogrel was now a cost-effective use of NHS resources. Modified-release dipyridamole plus aspirin was now cost-effective only when used in people who had a contraindication or intolerance to clopidogrel. Modified-release dipyridamole alone was now cost effective only when used in people where both aspirin and clopidogrel were contraindicated or not tolerated.
• Secondary prevention of occlusive vascular events following a TIA
• NICE recommends modified-release dipyridamole with aspirin first line because it is licensed for this indication, and is more cost-effective than use of aspirin alone [NICE, 2010b].
• NICE was unable to make a recommendation regarding the place of clopidogrel for the prevention of occlusive vascular events following a TIA because it is not licensed for this indication [NICE, 2010b]. However, feedback from CKS expert reviewers is that off-label use of clopidogrel is considered to be a reasonable option if both aspirin and dipyridamole are contraindicated or not tolerated.
• People who have further occlusive vascular events whilst on antiplatelet treatment
• CKS recommends seeking specialist advice for people who have a further ischaemic cerebrovascular event while taking aspirin and modified-release dipyridamole. The evidence to support treatments using other combinations of antiplatelet drugs is poor:
• Although the Joint British Societies guidance recommends changing aspirin to clopidogrel (75 mg daily) in people with recurrent stroke while taking aspirin and modified-release dipyridamole [British Cardiac Society et al, 2005], CKS found no trials involving the combined use of clopidogrel and dipyridamole. The evidence from the CAPRIE trial found the difference between aspirin and clopidogrel to be marginal.
• CKS does not recommend a combination of aspirin and clopidogrel as evidence from two large trials did not find the combination to be more effective than aspirin monotherapy (the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance [CHARISMA] trial) or clopidogrel monotherapy (Management of Atherosclerosis with Clopidogrel in High-risk patients [MATCH] trial) in reducing stroke [Diener et al, 2004; Bhatt et al, 2006]. The combination is associated with a higher risk of major bleeding.