Management of Recurrent TIAs in a Patient on Aspirin with History of Stroke

Initial Management

For patients with recent minor noncardioembolic ischemic stroke or high-risk TIA, dual antiplatelet therapy with aspirin plus clopidogrel should be initiated early, ideally within 12-24 hours of symptom onset, and continued for 21-90 days, after which the patient should return to single antiplatelet therapy, as recommended by the American Heart Association 1

After the initial 21-90 day period of dual antiplatelet therapy, patients should return to single antiplatelet therapy, with options including aspirin (50-325 mg/day) for long-term secondary prevention 1
The American College of Cardiology recommends a combination of aspirin and extended-release dipyridamole for long-term secondary prevention 3

For patients with cardioembolic stroke, oral anticoagulation is preferred over antiplatelet therapy, according to the American Heart Association 2
For patients with ischemic stroke related to 50%-99% intracranial stenosis, aspirin 325 mg/day is recommended, as stated by the American Stroke Association 1
The American Heart Association notes that there is no evidence that increasing the dose of aspirin provides additional benefit for patients who have an ischemic event while taking aspirin 4, 3

Dual antiplatelet therapy should be avoided in patients with severe uncontrolled hypertension, known allergies to either aspirin or clopidogrel, or hemophilia or other bleeding disorders, as recommended by the American College of Cardiology 2