Primary prevention

Use the QRISK3 assessment tool to assess cardiovascular disease risk for the primary prevention of cardiovascular disease (CVD) within the next 10 years in people aged between 25 and 84 years.[38]​​

Do not use a risk assessment tool for people who are at high risk of CVD, including people with:[38]

  • Type 1 diabetes

  • An estimated glomerular filtration rate less than 60 mL/minute/1.73 m2 and/or albuminuria

  • Familial hypercholesterolaemia or other inherited disorders of lipid metabolism.

Advise those at high risk of developing cardiovascular disease on lifestyle measures that reduce the risk of a stroke, including recommendations to:​[38]

  • Exercise regularly

  • Maintain a cardioprotective diet

  • Manage weight

  • Reduce alcohol consumption

  • Stop smoking.

Manage underlying conditions that predispose a patient to stroke such as:[39]

  • Atrial fibrillation

  • Hypertension

  • Hypercholesterolaemia

  • Type 1 and type 2 diabetes.

Do not routinely offer aspirin for primary prevention of cardiovascular disease.[38]

Secondary prevention

Give secondary prevention as soon as possible to all patients after the diagnosis of transient ischaemic attack is confirmed.[40]​​

  • Discuss individual lifestyle factors with the patient. Advise patients on lifestyle measures including recommendations to:[40]​​

    • Exercise regularly[81]​

    • Maintain a healthy diet

    • Manage weight

    • Reduce alcohol consumption

    • Stop smoking

    • Reduce caffeine intake in people with hypertension.[82]

  • Review medications used in secondary prevention. Some patients may have been started on these drugs at diagnosis.

    • Antiplatelet therapy

      • For long-term secondary prevention, the National Clinical Guideline for Stroke for the UK and Ireland recommends single antiplatelet treatment with clopidogrel in people without paroxysmal or permanent atrial fibrillation; aspirin can be given to people who are allergic or cannot tolerate clopidogrel.​[40]

      • For patients with recurrent TIA or stroke while taking clopidogrel, consideration should be given to clopidogrel resistance.[40]

    • High-intensity statin therapy

      • Should be started or continued (if started at diagnosis) in all patients if not contraindicated or investigation confirms no evidence of atherosclerosis.[40]

        • A lower dose should be used if there is the potential for medication interactions or a high risk of adverse effects.

        • If the patient reports adverse effects, suggest stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the statin.[38]

        • Use an alternative statin at the maximum tolerated dose if a high-intensity statin is unsuitable or not tolerated.

        • The National Institute for Health and Care Excellence (NICE) in the UK recommends to offer ezetimibe instead of a statin to people for whom statins are contraindicated or, if the patient cannot tolerate statins of any intensity or dose.[38]

      • Lipid targets for secondary prevention vary according to guidelines:

        • ​The National Clinical Guideline for Stroke for the UK and Ireland recommends to aim to reduce fasting LDL-cholesterol to below 1.8 mmol/L (equivalent to a non-HDL-cholesterol below 2.5 mmol/L in a non-fasting sample) in patients with TIA and evidence of atherosclerosis.[40]

        • NICE in the UK recommends to aim to reduce fasting LDL-cholesterol to 2.0 mmol/L (equivalent to a non-HDL cholesterol of 2.6 mmol/L or less) for secondary prevention in patients with cardiovascular disease.[38]

      • If target fasting LDL-cholesterol is not achieved at first review at 4-6 weeks, the National Clinical Guideline for Stroke for the UK and Ireland recommends to:[40]

      • When there is no evidence of atherosclerosis on investigation you should base your decision for lipid-lowering therapy on the patient's overall cardiovascular risk.[40]

      • Consider a diagnosis of familial hypercholesterolaemia in people with TIA below 60 years of age with very high cholesterol (below 30 years with total cholesterol above 7.5 mmol/L or 30 years or older with total cholesterol concentration above 9.0 mmol/L).[40] 

      • Consider the measurement of lipoprotein(a), and if raised above 200 nmol/L specialist referral, in people with TIA of presumed atherosclerotic cause below 60 years of age.[40]

      • Note that although the National Clinical Guideline for Stroke for the UK and Ireland recommends to consider ezetimibe only if target fasting LDL-cholesterol is not achieved at first review at 4-6 weeks, NICE in the UK recommends to consider ezetimibe in addition to the maximum tolerated intensity and dose of statin to reduce CVD risk further, even if the lipid target for secondary prevention of cardiovascular disease is met.[38]

    • Antihypertensives

      • Give a thiazide-like diuretic, long-acting calcium-channel blocker, or ACE inhibitor to treat hypertension.[40]

        • For people with TIA aged 55 or over, or of African or Caribbean origin at any age, start a long-acting dihydropyridine calcium-channel blocker or a thiazide-like diuretic. If target blood pressure is not achieved, an ACE inhibitor or angiotensin-II receptor antagonist should be added.

        • For people with TIA not of African or Caribbean origin and younger than age 55 years, start an ACE inhibitor or an angiotensin-II receptor antagonist.

      • Monitor blood pressure-lowering treatment frequently and adjust treatment as tolerated to achieve a target systolic blood pressure below 130 mmHg (equivalent to a home systolic blood pressure below 125 mmHg).

        • In people with severe bilateral carotid stenosis a target blood pressure of 140-150 mmHg is appropriate.[40]

      • Consider home or ambulatory blood pressure monitoring to guide management to improve treatment compliance and blood pressure control.[40]

  • Optimise management of other comorbidities and risk factors for stroke. These include diabetes mellitus, obstructive sleep apnoea, heart failure, and contraception.

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