Table 6 Reduction strategies for the prevention of TIA and ischaemic strokes

Risk factor management

Hypertension

Class I, Level of Evidence A, Benefit has been associated with an average reduction of &10/5 mm Hg (Normal defined by JNC 7 criteria as 120/80 mmHg). Drugs should be optimised to the target patient (consider the cardiac history, DM etc)

Diabetes mellitus

Class I, Level of Evidence A, Rigorous control of hypertension and intensive lipid lowering treatment, any drugs appropriate and most often > 1 drug needed.

Hypercholesterolemia

Class I, Level of Evidence A, Lifestyle modification, dietary guidelines and statins

Cigarette Smoking

Class I, Level of Evidence C, Strongly advise every patient with stroke or TIA to quit

Alcohol Intake

Class I, Level of Evidence A. Heavy drinkers should eliminate or reduce their consumption of alcohol.(it is actually a J-shaped association between alcohol and ischemic stroke, with a protective effect in light or moderate drinkers and an elevated stroke risk with heavy alcohol consumption)

Obesity

Class IIb, Level of Evidence C. BMI of between 18.5 and 24.9 kg/m² and a waist circumference of < 35 in for women and < 40 in for men

Physical inactivity

Class IIb, Level of Evidence C. At least 30 minutes of moderate-intensity physical exercise

Interventional Approaches

Carotid endartrectomy(CEA)

Class I, Level of Evidence A. TIA or ischemic stroke within the last6 months and severe (70% to 99%) carotid artery stenosis, CEA by a surgeon with a peri-operative morbidity and mortality of < 6%. Consider CEA for certain high risk candidates with moderate stenosis (50-99%). If the TIA preferably within 2 weeks of after TIA.

Carotid angioplasty and stenting may be suitable for some patients with symptomatic high-grade stenosis and factors that make CEA unfavourable.

Extracranial Vertebrobasilar Disease/Intracranial Atherosclerosis

Class IIb, Level of Evidence C Endovascular treatment - when patients are having symptoms despite medical therapies

Medical Treatments

Cardiogenic Embolism and PAF

Class I, Level of Evidence A, paroxysmal (intermittent) AF, anticoagulation with adjusted-Dose Warfarin (target INR, 2.5; range, 2.0 to 3.0). Aspirin to be given in those patients with a clear contra-indication to Warfarin.

Cardiogenic Embolism - LV thrombus

Oral anticoagulation is reasonable, aiming for an INR of 2.0 to 3.0 for at least 3 months and up to 1 year (Class IIa, Level of Evidence B)

Noncardioembolic ischemic stroke or TIA

(Class IIa, Level of Evidence A) Aspirin (50 to 325 mg/d), the combination of aspirin and extended-release dipyridamole, and clopidogrel are all acceptable options for initial therapy. Aspirin to clopidogrel increases the risk of haemorrhage and is not routinely recommended for ischemic stroke or TIA patients (Class III, Level of Evidence A).

Patent Foramen Ovale

PFO closure may be considered for patients with recurrent cryptogenic stroke despite optimal medical therapy (Class IIb, Level of Evidence C)