Transient ischaemic attack

Once you have excluded hypoglycaemia as the cause of sudden-onset neurological symptoms, give a loading dose of aspirin (if not contraindicated) immediately to patients with suspected TIA.[9]National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Apr 2022 [internet publication]. https://www.nice.org.uk/guidance/ng128 [40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf

• Give a proton-pump inhibitor to anyone with dyspepsia associated with aspirin use.[9]National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Apr 2022 [internet publication]. https://www.nice.org.uk/guidance/ng128

Give clopidogrel as an alternative to aspirin in patients who are allergic or intolerant to aspirin. This is standard practice.

Treatment recommended for ALL patients in selected patient group

Refer immediately any person with suspected TIA for specialist assessment and investigation to a TIA clinic (or suitable alternative) to be seen within 24 hours of onset of symptoms following your initial assessment.[9]National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Apr 2022 [internet publication]. https://www.nice.org.uk/guidance/ng128 [40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf ​ Assessment should be conducted by a stroke specialist clinician in a neurovascular clinic or an acute stroke unit.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf ​​ 

• Do not use scoring systems, such as ABCD2, to inform the urgency of referral or subsequent treatment options.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf ​ Consider all people with suspected TIA to be at high risk of having a stroke.[9]National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Apr 2022 [internet publication]. https://www.nice.org.uk/guidance/ng128 [41]Fonseca AC, Merwick Á, Dennis M, et al. European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack. Eur Stroke J. 2021 Jun;6(2):CLXIII-XXVI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370080 http://www.ncbi.nlm.nih.gov/pubmed/34414299?tool=bestpractice.com

It is important to urgently confirm or refute the diagnosis of suspected TIA with specialist opinion because there are no reliable diagnostic tools.[9]National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Apr 2022 [internet publication]. https://www.nice.org.uk/guidance/ng128

Give secondary prevention as soon as possible to all patients after the diagnosis of TIA is confirmed.[9]National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Apr 2022 [internet publication]. https://www.nice.org.uk/guidance/ng128 [40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf

Start dual antiplatelet therapy with either aspirin and clopidogrel for 21 days, or aspirin and ticagrelor for 30 days, in patients presenting within 24 hours of TIA and with a low risk of bleeding. For patients who are not appropriate for dual antiplatelet therapy give a clopidogrel loading dose followed by a daily maintenance dose. After completion of dual antiplatelet therapy, for long-term prevention of vascular events in people with TIA without paroxysmal or permanent atrial fibrillation, single antiplatelet treatment should be used.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf ​​ 

• A proton-pump inhibitor should be considered for concurrent use with dual antiplatelet therapy to reduce the risk of gastrointestinal haemorrhage.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf

• Give a proton-pump inhibitor to anyone with dyspepsia associated with aspirin use.[9]National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Apr 2022 [internet publication]. https://www.nice.org.uk/guidance/ng128

For long-term secondary prevention in patients without paroxysmal or permanent atrial fibrillation, the National Clinical Guideline for Stroke for the UK and Ireland recommends single antiplatelet treatment with clopidogrel as standard treatment.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf ​ Aspirin should be used for those who are unable to tolerate clopidogrel.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf  

The European Stroke Organisation (ESO) recommends that clopidogrel and aspirin should be combined in adults with a high-risk TIA (ABCD2 score ≥4) within 24 hours of the TIA. The ESO recommends that dual therapy should be continued for 21 days followed by single antiplatelet therapy.[61]Dawson J, Merwick Á, Webb A, et al. European Stroke Organisation expedited recommendation for the use of short-term dual antiplatelet therapy early after minor stroke and high-risk TIA. Eur Stroke J. 2021 Jun;6(2):CLXXXVII-CXCI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370083 http://www.ncbi.nlm.nih.gov/pubmed/34414300?tool=bestpractice.com  In March 2021, the ESO guidelines made a weak recommendation based on moderate-quality evidence for 30 days of dual antiplatelet therapy with ticagrelor and aspirin in people with high-risk TIA (ABCD2 score of 6 or more or other high-risk features, defined as either intracranial atherosclerotic disease or at least 50% stenosis in an internal carotid artery that could account for the presentation) in the past 24 hours.[61]Dawson J, Merwick Á, Webb A, et al. European Stroke Organisation expedited recommendation for the use of short-term dual antiplatelet therapy early after minor stroke and high-risk TIA. Eur Stroke J. 2021 Jun;6(2):CLXXXVII-CXCI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370083 http://www.ncbi.nlm.nih.gov/pubmed/34414300?tool=bestpractice.com  The ESO stated that this regimen should be considered as an alternative to clopidogrel plus aspirin, particularly in people known to be intolerant of clopidogrel.[61]Dawson J, Merwick Á, Webb A, et al. European Stroke Organisation expedited recommendation for the use of short-term dual antiplatelet therapy early after minor stroke and high-risk TIA. Eur Stroke J. 2021 Jun;6(2):CLXXXVII-CXCI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370083 http://www.ncbi.nlm.nih.gov/pubmed/34414300?tool=bestpractice.com  The use of dual antiplatelet therapy with aspirin and ticagrelor is also supported by the European Society of Cardiology.[62]Aboyans V, Bauersachs R, Mazzolai L, et al. Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy. Eur Heart J. 2021 Oct 14;42(39):4013-24. https://academic.oup.com/eurheartj/article/42/39/4013/6323985 http://www.ncbi.nlm.nih.gov/pubmed/34279602?tool=bestpractice.com However, an application to the European Medicines Agency (EMA) to change the marketing authorisation of ticagrelor to include the prevention of stroke in adults who have had a mild to moderate ischaemic stroke or high-risk TIA was withdrawn in December 2021. Based on trial data and the company's response to its questions, the EMA expressed concern that the benefits of short-term treatment with ticagrelor plus aspirin in preventing stroke in these patients did not clearly outweigh the risks of fatal and non-fatal bleeding.

Treatment recommended for ALL patients in selected patient group

Start high-intensity statin therapy (e.g., atorvastatin) immediately, unless contraindicated, in all patients independent of baseline low-density lipoprotein for long-term secondary prevention.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf ​ 

• Consider increasing the statin intensity or dose if the patient is not currently taking a high-intensity statin at the maximum tolerated dose.[38]National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification. Dec 2023 [internet publication]. https://www.nice.org.uk/guidance/ng238 ​

• Use an alternative statin at the maximum tolerated dose if high-intensity statin therapy is unsuitable or not tolerated.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf ​ Check local protocols for recommended alternatives in your region.

Additional treatment recommended for SOME patients in selected patient group

Give an anticoagulant with a rapid onset of action, if not contraindicated, to patients with paroxysmal, persistent, or permanent atrial fibrillation as soon as intracranial bleeding and other contraindications (such as severe hypertension - clinic blood pressure of 180/120 or higher, which should be treated first) are excluded.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf ​ Cerebral microbleeds (regardless of number or distribution) need not preclude the use of such treatment.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf

Anticoagulation should include measures to reduce bleeding risk, using a validated tool to identify modifiable risk factors.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf

• Give a direct oral anticoagulant (DOAC) as first-line treatment for people with TIA due to non-valvular atrial fibrillation.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf

• Give adjusted-dose warfarin to people with TIA due to valvular/rheumatic atrial fibrillation or with mechanical heart valve replacement, and those with contraindications or intolerance to DOAC treatment (target INR 2.5, range 2.0 to 3.0) with a target time in the therapeutic range of greater than 72%.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf

• For people with cardioembolic TIA for whom treatment with anticoagulation is considered inappropriate because of a high risk of bleeding:[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf

  • Do not use antiplatelet treatment as an alternative when there are absolute contraindications to anticoagulation (e.g., undiagnosed bleeding)

  • A left atrial appendage occlusion device may be considered as an alternative, provided the short-term peri-procedural use of antiplatelet therapy is an acceptable risk.

• For people with cardioembolic TIA for whom treatment with anticoagulation is considered inappropriate for reasons other than the risk of bleeding:[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf

  • Antiplatelet treatment may be considered to reduce the risk of recurrent vaso-occlusive disease.

People who initially present with recurrent TIA or stroke should receive the same antithrombotic treatment as those who have had a single event. More intensive antiplatelet therapy or anticoagulation treatment should only be given as part of a clinical trial or in exceptional clinical circumstances.[40]Royal College of Physicians; Scottish Intercollegiate Guidelines Network; Royal College of Physicians of Ireland. National clinical guidelines for stroke for the United Kingdom and Ireland. April 2023 [internet publication]. https://www.strokeguideline.org/app/uploads/2023/04/National-Clinical-Guideline-for-Stroke-2023.pdf

Seek specialist advice for alternatives in patients with contraindications to anticoagulants with a rapid onset.

See New-onset atrial fibrillation.