Synopsis
Identify the mechanism of an ischaemic stroke or TIA and deliver an individualised antithrombotic, vascular risk and procedural prevention plan that reduces recurrence without avoidable bleeding.
- Secondary prevention begins immediately but must follow mechanism: non-cardioembolic disease usually needs antiplatelet therapy, whereas atrial fibrillation generally needs oral anticoagulation once safe.
- Clopidogrel 75 mg once daily is a common long-term first-line antiplatelet after non-cardioembolic ischaemic stroke; short dual antiplatelet courses are reserved for selected minor stroke or high-risk TIA protocols.
- Do not combine long-term anticoagulation with an antiplatelet solely because a patient has had a stroke; use overlap only for a separate, time-limited cardiovascular indication after specialist review.
- Offer high-intensity statin treatment, usually atorvastatin 80 mg daily, for established cerebrovascular disease unless interactions, adverse-effect risk or preference support a lower dose.
- Treat blood pressure after the acute phase with an individualised regimen, checking postural symptoms, renal function and adherence rather than reacting to one ward measurement.
- Urgently image the carotids after a compatible retinal or non-disabling hemispheric event and refer recent symptomatic 50–99% NASCET stenosis for time-critical endarterectomy assessment.
- Investigate occult atrial fibrillation with monitoring proportionate to an embolic phenotype; a normal admission ECG or pulse does not exclude paroxysmal AF.
- Smoking cessation, diabetes care, physical activity, diet, weight, sleep and medicine adherence contribute materially, while rehabilitation and prevention should be planned together rather than sequentially.
Key red flags
Any recurrent focal neurological symptom is a new emergency assessment, not an issue to save for the next prevention clinic.
Recent symptomatic severe carotid stenosis has a narrow time window for maximum surgical benefit and needs immediate vascular-stroke coordination.
Melena, haematemesis, symptomatic anaemia, sudden severe headache or new neurological decline while on antithrombotics requires urgent bleeding assessment.
Uncontrolled severe hypertension, rapidly changing renal function or marked thrombocytopenia should trigger prompt treatment and antithrombotic safety review.
Pregnancy, mechanical heart valve, antiphospholipid syndrome or active cancer changes standard antithrombotic choices and warrants specialist input.
Investigation priorities
Define infarct distribution and detect carotid, vertebral or intracranial disease that explains the event and may require intervention.
Management branches
Stroke assessment identifies atherosclerotic or small-vessel disease without a cardioembolic indication for anticoagulation.
- Confirm haemorrhage has been excluded and review whether a specialist-defined brief dual antiplatelet course is indicated for an early minor event.
- Transition to the recommended long-term single antiplatelet, commonly clopidogrel, and document the reason and intended duration.
- Assess bleeding, full blood count, gastroprotection needs, interactions, adherence and any planned invasive procedure.
- Treat lipids, blood pressure, diabetes and smoking concurrently and reconsider mechanism if another event occurs despite confirmed adherence.
Routine evaluation has not established a convincing stroke mechanism.
- Recheck that brain and complete arterial imaging, medication history and sufficient rhythm monitoring have actually been completed and interpreted together.
- Tailor longer rhythm monitoring, echocardiography, malignancy or thrombophilia investigation to the infarct pattern, age and clinical clues rather than ordering broad panels.
- Use antiplatelet treatment for an embolic stroke of undetermined source unless a proven anticoagulation indication emerges; empirical DOAC therapy is not routine.