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(Stroke. 1999;30:2502-2511.)                                                                                             Back to  TIA

Supplement to the Guidelines for the Management of Transient Ischemic Attacks

A Statement From the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association

Gregory W. Albers, MD, Chair; Robert G. Hart, MD; Helmi L. Lutsep, MD; David W. Newell, MD; Ralph L. Sacco, MD
   Recommendations

Risk Factor Management
Risk factor guidelines are grade C because randomized trials have not been completed in TIA patients.

  1. After thorough evaluation to determine the cause of the TIA, hypertension should be treated to maintain systolic blood pressure below 140 mm Hg and diastolic blood pressure below 90 mm Hg. For persons with diabetes, blood pressure levels <130/85 mm Hg are recommended.
  2. Cigarette smoking should be discontinued. Counseling, nicotine replacement therapies, bupropion, and formal smoking cessation programs may all be helpful.
  3. Coronary artery disease, cardiac arrhythmias, congestive heart failure, and valvular heart disease should be treated appropriately.
  4. Excessive use of alcohol should be eliminated. Formal alcohol cessation programs are recommended. Mild to moderate use of alcohol (1 to 2 drinks per day) has been associated with a reduction in stroke rates.
  5. Treatment of hyperlipidemia is recommended. The AHA Step II diet (<30% of calories derived from fat, <7% from saturated fat, and <200 mg/d cholesterol consumed) is recommended along with maintenance of ideal body weight and engagement in regular physical activity. If lipid levels remain elevated (LDL >130 mg/dL), use of a lipid-lowering agent, preferably a statin, is recommended. The goal of therapy should be an LDL level <100 mg/dL.
  6. Fasting blood glucose levels <126 mg/dL are recommended. Diet and oral hypoglycemics or insulin should be prescribed as needed to control diabetes.
  7. Physical activity (30 to 60 minutes of exercise >3 to 4 times per week) is recommended.
  8. Discontinuation of postmenopausal estrogen replacement therapy is not recommended.

Medical Therapy (Table)
Atherothrombotic TIAs
Patients who have had an atherothrombotic TIA should receive daily therapy with an antiplatelet agent to reduce the risk of recurrent stroke (grade A-1). Aspirin, clopidogrel, ticlopidine, and the combination of aspirin and extended-release dipyridamole are all acceptable options for initial therapy (grade A-2).

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 		 Table 1. Use of Antithrombotic Agents in Patients With TIAs

In general, aspirin at a dosage range of 50 to 325 mg/d is recommended as initial therapy for patients who are not allergic or intolerant to aspirin. For patients who have an atherothrombotic TIA while taking aspirin, there is no compelling evidence that increasing the dose of aspirin provides additional benefit. Alternative antiplatelet agents are typically considered for these patients, although they have not been specifically evaluated in patients who have "failed aspirin." Although ticlopidine may be more effective for preventing stroke (on the basis of indirect comparisons), clopidogrel (75 mg/d) is generally recommended in favor of ticlopidine (250 mg BID) (grade C-2) because of its superior safety profile. The combination of extended-release dipyridamole and aspirin may also be more effective than clopidogrel (on the basis of indirect comparisons; grade C-2), and both have a favorable safety profile.

Anticoagulant therapy is not routinely recommended for patients with atherothrombotic TIAs, as either short- or long-term therapy (grade B-2). Anticoagulant therapy is an option for patients with a TIA who continue to have symptoms despite antiplatelet therapy (grade C-2). At anticoagulation intensities of INR 3.0 to 4.5, the risk of brain hemorrhage outweighs the potential benefits (grade A-1). Therefore, if oral anticoagulants are used for atherothrombotic TIA patients, a target INR <3.0 should be chosen.

Cardioembolic TIAs
Long-term oral anticoagulation is recommended for patients with atrial fibrillation who have a TIA (grade A-1). For these patients, a target INR of 2.5 (range 2.0 to 3.0) is recommended. Oral anticoagulation is also beneficial for prevention of stroke in patients with other high-risk cardiac sources of embolism (see section on Anticoagulants, Cardioembolic Stroke). Aspirin is recommended for patients with contraindications to oral anticoagulation.

Surgical Management
Extracranial Carotid Artery Disease
Stenosis of 70% to 99%*
Carotid endarterectomy is indicated for patients who are good surgical candidates and who have experienced = or >1 TIA or minor stroke within the last 2 years, regardless of the response to antiplatelet drugs (grade A-1).

Stenosis of 50% to 69%*
Patients with a recent TIA or minor stroke have a reduced stroke rate with endarterectomy versus medical treatment and should be considered for endarterectomy (grade A-1). The absolute benefit of surgery is less than that for patients with higher degrees of stenosis and among women and patients with retinal TIAs. Consideration should be given to clinical features that influence stroke risk and surgical morbidity.

Stenosis <50%*
Patients with <50% stenosis with recent symptoms of cerebral ischemia do not benefit from carotid endarterectomy (grade A-1). Antiplatelet therapy is recommended for these patients (see section on Medical Therapy).

Endovascular Treatment
Prospective trials evaluating the results of angioplasty and stent placement in comparison with carotid endarterectomy are now in progress. The use of endovascular treatment is not routinely recommended for treatment of carotid bifurcation stenosis.

Bypass Surgery
Extracranial-intracranial bypass is not recommended for patients with TIAs (grade A-1). A subgroup of patients with anterior circulation ischemia unresponsive to medical therapy with hemodynamic disturbances may benefit from bypass surgery. Additional studies are required to determine the role of surgery in these patients. Patients with moyamoya disease may benefit from extracranial-intracranial bypass (grade C-2).

Therapy for Vertebrobasilar Ischemia
Surgical or endovascular therapy may be appropriate for patients with significant vertebrobasilar stenosis who have continued symptoms referable to the posterior circulation despite medical therapy. For significant stenosis at the origin of the vertebral artery, vertebral artery transposition to the common carotid artery or angioplasty and stenting are treatment options (grade C-2). For significant stenosis at the distal vertebral artery, endarterectomy, bypass, or endovascular procedures are treatment options. For midvertebral lesions with fixed stenosis or positional obstruction with ischemic symptoms, surgical reconstruction or decompression can be effective in relieving symptoms (grade C-2).

   Footnotes

 
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee in July 1999. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0179. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1466, fax 214-691-6342

         

12281999
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