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.
Key red flags
Any recurrent focal neurological symptom is a new emergency assessment, not an issue to save for the next prevention clinic.
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.
Routine evaluation has not established a convincing stroke mechanism.
Key medicines
ClopidogrelUse 75 mg orally once daily for long-term non-cardioembolic secondary prevention when selected; any loading dose or short dual regimen follows the acute stroke protocol.
ApixabanFor eligible non-valvular atrial fibrillation, use 5 mg orally twice daily, reducing to 2.5 mg twice daily only when the authorised dose-reduction criteria are met.