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Elevated homocysteine and lipoprotein a levels are associated with an increased risk of cerebrovascular disease. However, there is no evidence that lowering either of these levels has any effect on either primary or secondary prevention of TIA or stroke, and therefore they should not be routinely ordered during the evaluation of TIA.

In the absence of a history or clinical evidence of active lupus, tests such as ESR, ANA, and other auto-antibodies are unlikely to be useful in the initial evaluation of TIA. Antiphospholipid antibody testing or tests for other inherited thrombophilias may be indicated in specific patients e.

Immediate management. A bedside swallow study should be performed, and once hemorrhagic stroke has been ruled out, aspirin oral or rectal should be given to all patients who do not have a contraindication. Admission to the hospital is usually advised to expedite the work-up. Permissive hypertension is generally recommended, although specific parameters for this are not well defined. The benefit of permissive hypertension is likely greater in patients with acute ischemic stroke as compared to patients with TIA.

If a patient is taking a beta-blocker it may be reasonable to continue it even if other antihypertensives are held, in order to reduce the risk of myocardial infarction while in the hospital. TIA patients often have rapidly resolving deficits, but they are also at elevated risk of stroke in the time period immediately following the TIA. Progression or evolution of deficits in a patient after an initial negative neuroimaging study would be an indication for urgent reimaging to look for evolving stroke. Physical therapy, occupational therapy, and speech therapy services can be consulted as needed, although typically TIA symptoms will completely resolve prior to hospital discharge and rehab services will not be indicated.

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Blood glucose should be monitored while the patient is hospitalized and, if elevated, insulin therapy should be instituted to maintain glycemic control. A fasting lipid panel should be drawn so that response to lipid-lowering therapy can be monitored in the outpatient setting. Changes in neurologic status should prompt urgent reimaging to look for evidence of evolving stroke.

Antiplatelet agents effective in secondary prevention of TIA include aspirin, clopidogrel Plavix , and aspirin-dipyridamole Aggrenox. Clopidogrel and aspirin-dipyridamole are each considered to be superior to aspirin alone, though the additional benefit of each agent is modest and is offset by significantly higher drug costs.

Transient ischemic attack

Aspirin may actually be the best agent when efficacy, tolerance, and cost are taken into account. Short-term combination therapy with aspirin and clopidogrel may be effective in certain populations Asians, patients with high grade intracranial stenosis but long-term dual antiplatelet therapy for TIA does not confer any additional benefit while significantly increasing the risk of bleeding complications.

This may be accomplished with a single agent or some combination of a diuretic, ACE inhibitor, angiotensin receptor blocker, calcium channel blocker, or beta-blocker. Statins are the only class of lipid-lowering agents shown to reduce the risk of TIA or stroke, even in patients with normal or average LDL. Strict glycemic control has not been shown to decrease macrovascular complications of diabetes, including TIA. However, it is reasonable to use existing guidelines for glycemic control in TIA patients with diabetes. Smoking is associated with an increased risk of TIA and stroke, and all patients with TIA who are smokers should undergo smoking cessation counseling.

Adverse effects of medications started for secondary prevention of TIA are the most common side-effects of management. These can include bleeding complications from antiplatelet therapy, hypotension from antihypertensives, and LFT abnormalities or muscle pain or weakness from statins. Dose adjustment or changing or discontinuing medications may be required. Aspirin — start at mg daily in the acute setting, then mg daily thereafter no clear evidence to recommend a specific dose. Chlorthalidone thiazide — Renal Insufficiency.

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Choice of antihypertensive therapy could change in patients with CKD e. Some statins should be dose-adjusted for CKD. The FDA recommends that transaminases should be checked prior to initiation of statin therapy, and 12 weeks following initiation. Patients with chronic liver disease should be monitored closely for progressive LFT abnormalities while on statin therapy.

Statins should not be used in patients with progressive or decompensated liver disease or hepatic failure. Antiplatelet agents may increase the risk of bleeding in patients with impaired synthetic hepatic function and coagulopathy.

Drugs Used to Treat Transient Ischemic Attack

Patients with heart failure may be at higher risk of a cardiac source of embolism CSE or cardiac arrhythmia such as atrial fibrillation that can increase the risk of TIA. Management is not significantly changed by the presence of either systolic or diastolic heart failure. Antihypertensive therapy for heart failure ACE inhibitors, beta-blockers, diuretics aligns well with recommendations for treating hypertension in TIA.

Long-term dual antiplatelet therapy is not recommended for secondary prevention of TIA given the lack of benefit and increased risk of bleeding, but patients with coronary artery stents or a recent myocardial infarction may have indications for dual antiplatelet therapy. Monitoring of blood glucose or measurement of hemoglobin A1c during a hospitalization for TIA may lead to a new diagnosis of diabetes.


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Glycemic control according to established guidelines is recommended. Antihypertensive therapy for patients with TIA and diabetes should generally include an ACE inhibitor or angiotensin receptor blocker unless there is a contraindication to both of these agents. Malignancy is a hypercoagulable state and may increase the risk of TIA. Paradoxical embolism from DVT e. CNS malignancy or infection should be considered and ruled out in immunosuppressed patients who present with TIA symptoms.

Hypercoagulable states increase the risk of TIA, and paradoxical embolism should be considered in these patients. Caution should be exercised in patients with a bleeding diathesis when prescribing antiplatelet therapy. The extent of diagnostic testing may be changed by the presence of advanced dementia. For example, a patient with advanced dementia who is not a candidate for carotid endarterectomy or anticoagulation should probably not undergo evaluation of the extracranial vasculature or echocardiography during an evaluation for TIA.

Patients with advanced dementia or active psychiatric conditions may not be able to tolerate MRI. Some psychiatric conditions, such as conversion disorder or tardive dyskinesia from neuroleptic therapy, can mimic TIA. Sign-out Considerations While Hospitalized. An acute change in neurologic status in patients admitted with TIA should prompt urgent reimaging to look for stroke. Most patients with TIA can undergo a complete evaluation within hours and will not require an extended hospital stay.

Patients with TIA are generally ready for discharge once their symptoms have resolved, when they have completed their diagnostic work-up, and when their relevant medical conditions and secondary prevention issues blood pressure, glycemic control, smoking cessation, etc. Follow-up with a primary care provider after hospital discharge is important for long-term management of risk factors blood pressure, lipids, diabetes, smoking cessation. When possible, a primary care clinic appointment within 7 days of discharge is recommended. For patients with recurrent TIA, or in whom the diagnosis is uncertain e.

A baseline lipid panel is useful in patients who are starting statin therapy. Hemoglobin A1c should be ordered in patients in whom diabetes is diagnosed or suspected. Creatinine and potassium should be ordered in patients started on diuretics or ACE inhibitors.

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Ticagrelor Not Better After TIA or Mild Stroke

Patients with TIA can generally return to their prior living situation, since their symptoms will have generally resolved by the time of discharge. Patients with TIA are at increased risk of stroke in the days and weeks following their initial event. All patients and their families should be counseled on signs and symptoms of stroke and should be urged to seek medical attention immediately if they develop these symptoms.

Smoking cessation counseling should be performed in patients who have smoked in the past year.


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Patients should be advised to limit their dietary sodium intake in order to help with blood pressure control. Patients with diabetes should be instructed on glycemic control and a diabetic diet. Core Indicator Standards and Documentation. The Joint Commission requires facilities certified as Primary Stroke Centers to report on eight core quality measures each quarter.

These measures generally apply to patients with TIA as well, and should be addressed in physician documentation, especially if a measure is not met.

Transient Ischemic Attacks: Part II. Treatment - American Family Physician

The eight quality measures are:. In-hospital prophylactic measures for TIA include VTE prophylaxis, fall and aspiration precautions in patients whose deficits have not yet resolved, and frequent neurologic checks to detect progression of TIA to stroke. As with other non-ICU medical patients, GI prophylaxis is not indicated in most cases, and may even be harmful by increasing the risk of pneumonia and clostridium difficile infections.

Secondary prevention of TIA consists of prescribing an appropriate medical regimen and addressing modifiable risk factors in patients, as discussed above.