Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Stroke and transient ischaemic attack - Management
What antithrombotic treatment is recommended for someone who has had a stroke or TIA?

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.
    • 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.
      • Clopidogrel (75 mg daily) alone is an alternative (off-label use).
    • If modified-release dipyridamole is not tolerated, give aspirin alone.
  • 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.

In depth

© NHS Institute for Innovation and Improvement