How should I determine the appropriate secondary prevention strategies for a patient with a history of TIA?

To determine the appropriate secondary prevention strategies for a patient with a history of transient ischemic attack (TIA), follow these key steps:

• Immediate antiplatelet therapy: Start aspirin 300 mg daily immediately unless contraindicated, as initial treatment to reduce early risk of stroke recurrence ².
• Specialist assessment and urgent referral: Refer the patient for specialist assessment and investigation to be seen within 24 hours of symptom onset to confirm diagnosis and guide further management ².
• Secondary prevention initiation: After confirmation of TIA, initiate secondary prevention measures promptly, including antiplatelet therapy beyond aspirin, blood pressure control, lipid lowering with high-intensity statins (e.g., atorvastatin 80 mg daily), and lifestyle modification ¹,².
• Antithrombotic therapy choice: Use anticoagulation only if there is atrial fibrillation or other specific indications (e.g., cardiac embolism, arterial dissection). Do not use anticoagulation routinely in sinus rhythm ¹,³. Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel or ticagrelor may be considered short-term (21–30 days) in high-risk non-cardioembolic TIA or minor stroke, usually initiated in secondary care ¹.
• Carotid imaging and intervention: Perform urgent carotid imaging if the patient is a candidate for carotid endarterectomy. Refer urgently for surgery if symptomatic carotid stenosis is ≥50% (NASCET criteria) or ≥70% (ECST criteria) ².
• Manage vascular risk factors: Optimize control of hypertension, diabetes, obesity, and screen for obstructive sleep apnea. Avoid combined oral contraceptives in premenopausal women with TIA ¹.
• Other considerations: Do not use vitamin or mineral supplements (folate, B6, B12, vitamin E, calcium, vitamin D) for stroke prevention as evidence shows no benefit ¹. Advise against hormone replacement therapy for secondary prevention ¹. Arrange annual influenza vaccination ¹.