Trip Answers

Question answered:10/01/09

CKS have a guideline on TIA (not in AF) [1].  It has a section ‘What immediate treatment should I give?’ which reports:

 

"Ongoing ischaemic event
In general, no immediate treatment in primary care is indicated in people who are having ongoing ischaemic symptoms:
 - Antiplatelet drugs should not be given until a diagnosis of primary haemorrhage has been excluded.
 - Blood pressure should not be lowered in the acute phase of stroke unless there are likely to be complications from hypertension, such as hypertensive encephalopathy.

 

transient ischaemic attack
People who have had a suspected TIA should be given antiplatelet therapy immediately (unless they are already taking an anticoagulant, which requires urgent referral, within 48 hours):
 - For most people, this means taking a loading dose of aspirin (300 mg). If the person is already taking aspirin, there is no consensus on whether an additional dose is required or not, although it is unlikely to do harm.
 - If the person is genuinely intolerant of aspirin (defined as proven hypersensitivity to aspirin-containing medicines, or a history of severe dyspepsia induced by low-dose aspirin), there is no consensus or evidence on what is the best course of action. Reasonable choices are:
 - Aspirin combined with a proton pump inhibitor in people with gastrointestinal intolerance.
 - Clopidogrel in people with genuine aspirin hypersensitivity. Note: clopidogrel is not licensed for the prevention of cardiovascular events after TIA, or for 7 days following an ischaemic stroke [ABPI Medicines Compendium, 2005].
 - After the initial dose of antiplatelet drug, standard antiplatelet treatment should be continued, starting the following day, until the person has been fully assessed."
 

The CKS guideline links the phrase “standard antiplatelet treatment” to the section “Which antiplatelet drugs are available”, which states:

 

"All people who have had an occlusive stroke or transient ischaemic attack (TIA) should receive antiplatelet drugs (unless in atrial fibrillation, where anticoagulation may be the preferred treatment) [NICE, 2005]. There is convincing evidence from randomized controlled trials (RCTs) that antiplatelet drugs have a protective effect against atherosclerotic disease, including stroke and coronary heart disease, both in people who have already had an event (secondary prevention), and those who have not had an event but are at high risk of having one (primary prevention) [Lip et al, 2005].

Three antiplatelet drugs are available in the UK to prevent ischaemic events: aspirin, dipyridamole, and clopidogrel. Each has a different mechanism of action, and is suitable for use in different patient groups. In some instances, antiplatelet drugs can be combined."
 

References

1) http://cks.library.nhs.uk/tia_not_in_af
 

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