Acute treatment and secondary prevention of transient ischaemic attacks (TIA) and ischaemic stroke (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • North NHS Highland only
  • Primary and Secondary Care
  • Adults only

Antiplatelets

All patients with a TIA WITH FULL RECOVERY:

For patients within 24 hours of onset of TIA or minor ischaemic stroke and with a low risk of bleeding:

The following dual antiplatelet therapy (DAPT) should be given:

  • Clopidogrel (initial dose 300 mg, followed by 75 mg per day)
  • PLUS aspirin (initial dose 300 mg followed by 75 mg per day for 21 days)
  • FOLLOWED BY clopidogrel 75 mg, once daily monotherapy, as long-term, maintenance dose

If patients are documented as poor metabolisers of CYP2C19 then prescribe:

  • Aspirin: (initial dose 300mg, followed by 75mg per day for 21 days)
  • PLUS ticagrelor (initial dose of 180mg, followed by 90mg twice daily for 21 days)
  • THEN, after 21 days, CHANGE to dipyridamole MR 200mg twice daily AND aspirin 75mg once daily, continued long term

Lansoprazole should be considered for concurrent use with dual antiplatelet therapy to reduce the risk of gastrointestinal haemorrhage.

Clopidogrel 300mg x 1 STAT, followed by 75mg daily long-term maintenance dose, is typically used in TIA patients with HIGH BLEEDING RISK.

From February 2026 all patients presenting with a TIA or ischaemic stroke will undergo pharmacogenetic testing to identify clinically relevant CPY2C19 variants. Results may come back whilst the patient is still undergoing treatment with aspirin and clopidogrel. If results state that the patient is known to be a poor metaboliser of CYP2C19 then clopidogrel should be discontinued. The following should be prescribed:
  • Ticagrelor 90mg twice daily for 21 days, continuing the aspirin 75mg.
  • Then after 21 days prescribe dipyridamole MR 200mg twice daily (long term), continuing the aspirin 75mg once daily long term
Please contact the Stroke Team as soon as possible if intolerant of other antiplatelets.

Stroke:

All patients with a confirmed stroke should be referred to the Stroke Service

A Stroke Consultant will review the patient to decide if they are classed as a minor or moderate / severe ischaemic stroke. These patients require brain imaging prior to commencing secondary prevention.

Once haemorrhage is excluded:

  • Minor ischaemic stroke patients (NHISS score 3 or less):
    • Receive the same DAPT regimen as above, INCLUDING clopidogrel loading dose.
    • If patient is a known poor metabolisers of CYP2C19: Follow ALTERNATIVE DAPT regimen 
  • Moderate / severe ischaemic stroke patients (i.e. a disabling stroke):
    • Receive aspirin 300mg once daily for 14 days, AND THEREAFTER they will usually be converted to clopidogrel 75mg daily.
    • If patient is a known poor metaboliser of CYP2C19 then: AVOID clopidogrel and instead, on day 15, prescribe dipyridamole MR 200mg twice daily AND aspirin 75mg once daily, both long term. 
  • If already on clopidogrel, eg for coronary artery stent: seek Stroke Specialist advice before switching to aspirin
  • If already on warfarin or other oral anticoagulant: see anticoagulant advice below
  • If thrombolysed: initiate aspirin 300mg 24 hours after thrombolysis and repeat CT scan.

Prescribing information

ONLY for use in confirmed non-haemorrhagic stroke after a CT scan.

  • For patients with dysphagia:
    • Aspirin 300mg once daily should be administered rectally as a suppository, or both the 75mg and 300mg doses as the dispersible tablet via an enteral tube, if this route is available.
    • Clopidogrel tablets can be crushed and dispersed in water for administration via enteral tubes or for those patients with swallowing difficulties.
  • In documented aspirin intolerance or allergy:
    • prescribe clopidogrel 75mg daily.
  • For patients at risk of gastro-intestinal complications with aspirin (known peptic ulcer or dyspepsia):
    • Co-prescribe gastroprotection (see Formulary). The preferred PPI of choice is lansoprazole, as other PPI’s, including omeprazole, are known to reduce the efficacy of clopidogrel.
  • DISCONTINUE NSAIDs as they antagonise the antiplatelet effect of aspirin.

Anticoagulants

For patients presenting with a stroke already prescribed an anticoagulant: WITHHOLD this until the patient has had a review by a Stroke Consultant.

Anticoagulants should be started within 48 hours after a minor or moderate stroke, or 6 to 7 days after a major stroke. This will be advised by a Stroke Physician.  

Prescribing information

  • For patients presenting with stroke in atrial fibrillation (AF) while on oral anticoagulants: in most circumstances consider withholding the oral anticoagulant until Stroke Team review. 
    • If on warfarin and INR below 2: consider aspirin 300mg.
    • If on a DOAC: consider aspirin 300mg 24 hours after last dose of DOAC.
  • Consider patients with ischaemic stroke or TIA in atrial fibrillation (AF) for anticoagulant treatment.
  • In patients with atrial fibrillation, assess stroke risk using CHA2DS2VASc and bleeding risk using ORBIT Bleeding Risk Score for Atrial Fibrillation

Antihypertensives

NEW antihypertensives should NOT be prescribed in the acute phase following an ischaemic stroke.

Prescribing information

  • When patients are stable (2 weeks after stroke and immediately after TIA), initiate antihypertensive treatment as per: British and Irish Hypertension Society Guidelines
  • For patients in the acute phase with a BP consistently over 220 / 110mmHg see thrombolysis 
  • Regular antihypertensive medication should be continued as before in the post-stroke period, if the blood pressure is permissible. 
  • Check U&Es prior to initiation, within 14 days of initiation and at each dose titration. Once stabilised on treatment, recheck U&Es annually.
  • If intolerant of ACE inhibitors, eg ACE-induced cough, discontinue and consider alternative treatment as per British and Irish Hypertension Society Guidelines

Blood pressure target post stroke: 130 / 80mmHg 

Statins

Initiate atorvastatin 40 to 80mg daily

Prescribing information

  • Prior to prescribing a statin, check non-fasting total cholesterol (TC), high-density lipoprotein (HDL) and triglyceride (TG) levels, as well as liver function tests (LFTs) and thyroid function tests (TFTs)
  • For further information refer to Lipid lowering therapy for the prevention of atherosclerosis (Guidelines)
  • Consider drug interactions; refer to table in above lipid-lowering guidance or to BNF
  • If a person is not able to tolerate atorvastatin 40 to 80mg consider a lower dose or alternative statin. Refer to BNF for common side-effects

Note: patients post-haemorrhagic stroke should not normally be prescribed a statin unless the risks of further vascular events outweigh the risk of further haemorrhage.

Further information

  • Community rehabilitation referrals should be made through the local Single Point of Access (SPOA)

Abbreviations

  • AF: atrial fibrillation 
  • CT: computed tomography scan 
  • DAPT: dual antiplatelet therapy
  • DOAC: direct oral anticoagulants
  • HDL: high-density lipoprotein
  • NHISS: national institutes of health stroke scale
  • LFTs: liver function tests
  • NSAIDs: non steroidal anti-inflammatory drugs
  • STAT: single dose
  • SPOA: SPOA
  • TC: total cholesterol
  • TFTs: thyroid function tests
  • TG: triglyceride 
  • TIA: transient ischemic attack
  • U&Es: urea and electrolytes

Editorial Information

Last reviewed: 03/11/2025

Next review date: 05/11/2028

Author(s): Stroke and Rehab.

Version: V2.1

Approved By: TAM subgroup of the ADTC

Reviewer name(s): C Christie, Stroke Coordinator, G Williams, Stroke Consultant, W Rutherford, Consultant Physician.

Document Id: TAM393