Secondary prevention of ischemic events after TIA or minor ischemic stroke

In patients who have suffered a transient ischemic attack (TIA) or minor ischemic stroke, two basic approaches are available for preventing subsequent serious ischemic events (vascular death, nonfatal stroke, or nonfatal myocardial infarction [MI]) - pharmacologic therapy or surgery. Of the pharmacologic agents used in this setting, aspirin has been the most widely studied, and has been shown to reduce vascular events by 20% at most. Aspirin doses of 30 to 75 mg/d appear to be as effective in preventing ischemic events as doses between 300 and 1,300 mg/d and to produce fewer side effects. Some experts advocate the use of either ticlopidine or sulfin-pyrazone as an alternative prophylactic agent in patients who cannot tolerate aspirin. Blood pressure-lowering may be an effective method of preventing stroke in high-risk patients, both hypertensives and normotensive patients who have had a TIA or minor stroke. Carotid endarterectomy can be used in patients with severe carotid stenosis, but is contraindicated in those with mild stenosis, and its efficacy in those with moderate stenosis is unknown. Current evidence does not support the use of extracranial-intracranial bypass surgery for secondary prevention.