TIA — Transient Ischaemic Attack
Urgent assessment & secondary prevention | NICE NG128 | UK primary care & acute interface
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The full reasoning pathway — confirm symptoms have fully resolved (else it's a stroke), give aspirin 300 mg at once, get specialist assessment within 24 h, then drive secondary prevention (antiplatelet, statin, BP, AF anticoagulation, carotids) and DVLA advice.StartDecisionInvestigateActionReferStop / Admit
PresentationSuspected TIA
Transient focal neurology — unilateral weakness, speech disturbance, amaurosis fugax — now fully resolved. Confirm time course and that symptoms are focal (not syncope/migraine aura). Examine BP, pulse (AF), carotids, heart.
Step 1 · Safety — is this still a stroke?Ongoing deficit or very high risk?
ANY persisting / fluctuating deficit (FAST positive) → it's a stroke, not a TIA
On anticoagulation or a bleeding disorder (exclude haemorrhage)
YES — still deficit / high-risk
Stop · admit999 / emergency
Ongoing/fluctuating deficit → acute stroke pathway (thrombolysis/thrombectomy window). Crescendo TIA or on anticoagulant → same-day specialist assessment.
NO — fully resolved
Step 7 · Act nowAspirin 300 mg + TIA clinic <24 h
Aspirin 300 mg immediately (unless contraindicated/already on it — then specialist advises); refer to be seen within 24 hours; advise not to drive.
Step 2 · specialist-led investigation
Step 2 · Investigate (TIA clinic)Confirm, image, find the source
Diffusion-weighted MRI (preferred) to confirm territory; carotid Doppler (urgent if anterior-circulation candidate for endarterectomy); ECG / prolonged monitoring for paroxysmal AF; bloods — FBC, glucose/HbA1c, lipids, U&E, clotting; echo if cardioembolic source suspected. ABCD2 no longer used to defer assessment — everyone is seen within 24 h.
Step 7 · secondary prevention
Step 7 · Action — secondary preventionAntiplatelet · statin · BP · AF · carotid
Antiplatelet: aspirin 300 mg for ~2 weeks → then clopidogrel 75 mg OD long-term (clopidogrel monotherapy is the usual maintenance). Specialist may use short-term DAPT for high-risk TIA.
Statin: high-intensity atorvastatin 80 mg ON.
AF: anticoagulate (DOAC) once haemorrhage excluded — usually after a short delay per specialist.
BP & diabetes optimisation; carotid endarterectomy if symptomatic stenosis 50–99% (NASCET) — refer within 1 week.
Step 6 · escalation thresholds
Step 6 · ReferEscalation thresholds
999 any persisting/fluctuating deficit → acute stroke.
TIA clinic within 24 hours for ALL suspected TIA (same-day if crescendo or anticoagulated).
Vascular surgery (≤1 week) symptomatic carotid stenosis 50–99% for endarterectomy.
Step 8 · modify risk
Step 8 · Lifestyle — vascular risk reductionTreat the whole vascular tree
Smoking cessation · BP and diabetes control · Mediterranean diet, reduce salt · weight loss · alcohol ≤14 u/wk · regular physical activity once cleared. These compound the drug-based secondary prevention.
Step 9 · safety-net & DVLA
Step 9 · Safety-net, follow-up & drivingWhen to come back
Call 999 if any symptom returns and persists (FAST). DVLA: must not drive for 1 month after a single TIA (no need to notify DVLA if fully recovered); ≥1 month off and DVLA notification if multiple TIAs/recurrent. Ensure prevention meds started, carotid result actioned, and risk factors reviewed at follow-up.
⚠️ A TIA is a warning shot: stroke risk is highest in the first 48 hours — give aspirin 300 mg straightaway and ensure specialist assessment within 24 hours. If any deficit persists it is a stroke → 999. Advise the patient not to drive.
1
Safety
Red flags — is this still an evolving stroke? Act FAST
Critical decision first: Is the deficit still present? → If YES = STROKE, not TIA → 999 immediately. TIA = complete resolution of all symptoms.
Ongoing neurological deficit ANY persisting facial droop, arm/leg weakness, speech disturbance → 999 immediately (stroke, not TIA — thrombolysis/thrombectomy window)
Fluctuating/worsening deficit Symptoms improving but not fully resolved, or worsening → 999 (progressing stroke — needs urgent imaging)
Posterior circulation symptoms Diplopia, ataxia, dysarthria, dysphagia, vertigo with neurological signs → 999 (basilar territory — higher early stroke risk than carotid TIA)
ABCD2 score ≥4 or crescendo TIA ≥2 TIAs in 7 days → same-day specialist TIA assessment (very high early stroke risk — do not wait)
On anticoagulation + neurological symptoms Subtherapeutic INR/NOAC lapse → same-day assessment; INR, consider intracranial bleed if on anticoagulant
Suspected carotid dissection Neck pain + Horner's + TIA in young patient → same-day MRI/MRA neck (carotid artery dissection)
The 48-hour stroke risk after TIA is 3–10% without treatment — rising to 15–20% in the first 7 days. The ABCD2 score (Age, BP, Clinical features, Duration, Diabetes) stratifies early stroke risk. Crescendo TIA (≥2 in 7 days) carries 10–20% 48h stroke risk — equivalent to STEMI urgency. Basilar TIA carries higher stroke risk than anterior circulation TIA. Thrombolysis window for ischaemic stroke is 4.5 hours — every minute matters.
2
Diagnose
Confirm TIA — is this truly vascular? Exclude mimics
TIA = focal neurological deficit due to focal brain or retinal ischaemia, lasting <24 hours (usually <1 hour) with complete resolution. Up to 50% of suspected TIAs are mimics.
"Curtain coming down" monocular visual loss — carotid TIA until proven otherwise. Same urgency as hemispheric TIA
Mimic 1: Migraine aura
Gradual spread (march), visual aura typically positive (scintillations), followed by headache, young patient, prior history. Negative symptoms (loss of function) favour TIA
Mimic 2: Hypoglycaemia
BM stat. Neurological deficit + low BM → treat glucose first. Resolved with glucose = hypoglycaemia, not TIA
Mimic 3: Todd's paresis
Post-ictal weakness after witnessed seizure. Ask witnesses about rhythmic jerking, LOC, tongue-biting, incontinence
Mimic 4: Peripheral causes
Carpal tunnel (wrist/hand) | Peripheral neuropathy | Vestibular neuritis (isolated vertigo without diplopia/ataxia) — not TIA
Studies show 30–50% of GP-referred "TIA" are mimics. The ABCD2 score alone performs poorly at distinguishing TIA from mimic — specialist assessment is required. Treating a mimic as TIA (unnecessary antiplatelet, lipid-lowering, urgent imaging) causes harm and wastes resources. The key clinical question: "Were the symptoms maximal at onset (vascular) or did they gradually build (migraine/seizure)?"
3
Diagnose
ABCD2 score — risk stratification for urgent referral timing
Calculate ABCD2 score to determine urgency of specialist TIA clinic referral (NICE NG128). All scores require same-day or next-day specialist assessment.
A — Age ≥60
Yes = 1 point
B — Blood pressure ≥140/90
At presentation = 1 point
C — Clinical features
Unilateral weakness = 2 points | Speech disturbance without weakness = 1 point | Other = 0
D — Duration
10–59 minutes = 1 point | ≥60 minutes = 2 points
D — Diabetes
Known diabetes = 1 point
Score interpretation
0–3 = Low risk (2-day stroke risk 1%) — TIA clinic within 24h | 4–5 = Moderate (4%) — TIA clinic same day | 6–7 = High risk (8.1%) — immediate specialist review. Note: NICE NG128 recommends ALL TIA get same-day or next-day specialist assessment regardless of score
ABCD2 score alone should not be used to delay referral — NICE NG128 (2019) moved away from score-based thresholds because even low-scoring TIAs can be high risk (e.g., cardioembolic source, carotid stenosis). The score is useful for triage within a same-day service, not for deciding whether to refer. All suspected TIAs should be seen by a specialist within 24 hours.
4
Diagnose
Targeted examination in primary care
Neurological
NIHSS or focused: facial symmetry, arm/leg power, speech (FAST screen). Is there ANY residual deficit? If yes → 999
BP both arms
Both arms — >15 mmHg difference suggests subclavian steal/aortic disease. BP at presentation for ABCD2 scoring
AF is present in 15–20% of TIA/stroke patients — identifying it in primary care allows anticoagulation which reduces stroke risk by 64% vs antiplatelet alone. A sustained irregular pulse mandates ECG — paroxysmal AF may require 24–48h Holter monitor. Carotid bruit has 75% sensitivity for >70% stenosis — directing urgent carotid imaging for endarterectomy consideration (which reduces stroke risk by 48% within 2 weeks of TIA).
5
Diagnose
Investigations — primary care immediately + specialist investigations
Immediate in GP Do now
BM (exclude hypoglycaemia), ECG (AF, ischaemia), BP, BNP/NT-proBNP if cardiac failure suspected. These should NOT delay referral
Blood tests Same-day
FBC, U&E, glucose, HbA1c, lipid profile, coagulation (if on anticoagulant), TFTs. Thrombophilia screen if <50 years old
Specialist imaging
MRI DWI brain (preferred — detects acute ischaemia in 80% of TIAs vs 20% for CT). Carotid Doppler USS (stenosis >50% → urgent CEA). Cardiac echo if embolic source suspected
24–48h cardiac monitoring
If AF not detected on ECG and embolic TIA likely (cortical infarct on MRI, no other cause found)
NOT required in PC
CT head alone is inadequate for TIA assessment (misses ischaemia). Do not request and reassure based on normal CT. Specialist assessment is required
MRI DWI is positive in 50–67% of clinical TIAs — these patients have 10x higher stroke risk than MRI-negative TIAs (NEJM 2016). CT is normal in acute ischaemia. Carotid stenosis >50% is found in 15–20% of anterior TIAs — carotid endarterectomy (CEA) within 2 weeks reduces 2-year stroke risk from 20% to 9% (NASCET). Every day of delay in CEA reduces benefit by approximately 10%.
6
Refer
Referral — NICE NG128 mandates specialist assessment within 24h
999 → HASU
ANY ongoing neurological deficit → stroke, not TIA. HASU (Hyperacute Stroke Unit) within 4.5h for thrombolysis consideration. Do not wait
Same-day TIA clinic
All suspected TIA: NICE NG128 mandates specialist assessment within 24h. Crescendo TIA or ABCD2 ≥4 → same-day emergency assessment
Start immediately In GP
Aspirin 300 mg loading dose NOW (unless anticoagulated or contraindicated). Do not wait for specialist. Reduces 48h stroke risk by 80% in high-risk TIA (EXPRESS trial)
Follow-up post-TIA clinic
GP follow-up at 1 week: medications initiated? Lifestyle advice given? Driving advice documented? BP at target?
Driving advice Mandatory
Must not drive for 1 month after TIA (DVLA). Advise patient and document in notes. For Group 2 (HGV/bus): 1 year. Inform DVLA if any ongoing impairment
EXPRESS trial (Oxford, 2007): same-day specialist TIA clinic with immediate antiplatelet, statin, and BP treatment reduced 90-day stroke risk from 10.3% to 2.1% — an 80% reduction. This single trial showed specialist TIA services save more lives than almost any other intervention in stroke prevention. Aspirin 300 mg given immediately in primary care (before hospital review) is safe and dramatically reduces early stroke risk. Failure to give aspirin at first contact is an avoidable clinical error.
After 300 mg aspirin loading. Clopidogrel superior to aspirin alone long-term. Dual antiplatelet (aspirin + clopidogrel) for 21 days post-TIA if high-risk, then clopidogrel monotherapy
Cardioembolic TIA (AF confirmed)
DOAC (apixaban or rivaroxaban) Long-term
Apixaban 5 mg BD or rivaroxaban 20 mg OD. Start within 2 weeks of TIA (earlier if low bleed risk). 64% stroke risk reduction vs antiplatelet
StatinAtorvastatin 80 mg OD — started immediately. Reduces recurrent stroke by 16% (SPARCL trial). Target LDL <1.8 mmol/L
BPTarget <130/80 mmHg (post-TIA). Start antihypertensive within days: ACE inhibitor/ARB (perindopril 4 mg OD or ramipril 5 mg OD) ± indapamide 1.5 mg. BP control reduces recurrent stroke by 30–40%
CarotidCEA if stenosis 50–99% — refer urgently (benefit greatest within 2 weeks). Carotid stenting if CEA not suitable. Primary care: do NOT delay referral for vascular surgery
CHANCE trial (2013): dual antiplatelet (aspirin + clopidogrel) for 21 days post-TIA reduces recurrent stroke by 32% vs aspirin alone (NNT=29). POINT trial confirmed this. SPARCL trial: atorvastatin 80mg reduces recurrent stroke by 16% independently of cholesterol level in TIA patients. Do not wait for lipid result before starting — the benefit is pleiotropic (anti-inflammatory, plaque stabilisation), not purely LDL-dependent.
Smoking cessation Most important modifiable risk. Smoking doubles stroke risk. 5-year post-cessation risk equals never-smoker risk. Refer NHS Stop Smoking Service. Varenicline most effective
Blood pressure control Home BP monitoring. Target <130/80 mmHg. Each 10 mmHg reduction = 30% stroke risk reduction. Reduce salt <6g/day, DASH diet, regular aerobic exercise
Dietary change Mediterranean diet: high vegetables, fruits, olive oil, fish. Reduces recurrent stroke by 30% (PREDIMED). Salt restriction essential for BP control
Physical activity 150 min moderate aerobic exercise/week. Reduces stroke risk by 25%. Start gradually post-TIA — full return to activity if no deficits
Diabetes management HbA1c <53 mmol/mol (7%). SGLT2 inhibitors (empagliflozin) reduce cardiovascular events including stroke. GLP1-RA also benefit
Weight management BMI <25 kg/m². Obesity increases AF risk (and thus cardioembolic stroke). 10% weight loss reduces BP by 5–10 mmHg
Smoking cessation alone reduces stroke recurrence by 50% within 1–2 years. Mediterranean diet reduces fatal cardiovascular events including stroke by 30% (PREDIMED, 7,447 participants). Comprehensive risk factor management (statin + antiplatelet + BP + lifestyle) can reduce 10-year recurrent stroke risk from 25–30% to <8% — a transformation in outcomes achievable in primary care.
9
Safety
Follow-up & safety-netting post-TIA
1 week post-TIA
Review: medications started (antiplatelet/anticoagulant + statin + antihypertensive)? Driving advice confirmed? BP at target? Investigations result reviewed?
1 month
BP review. Lipid result — LDL at target (<1.8 mmol/L)? Renal function if started ACEi/ARB. Dual antiplatelet stopping at 21 days → clopidogrel monotherapy
3–6 months
Cardiac monitoring results (Holter, implantable loop recorder if embolic). Carotid endarterectomy outcome if performed. Lifestyle adherence
Annual
BP, lipids, HbA1c, eGFR. Medication review. Recurrent neurological symptoms — re-assess. Update DVLA notification if driving status changes
999 safety-net
"If FAST symptoms return — ANY facial droop, arm/leg weakness, speech change, vision loss — call 999 IMMEDIATELY. Do not wait to see if it gets better." Document advice given
Driving DVLA
Must not drive for 1 month (Group 1). 1 year (Group 2 — HGV/bus). Patient's responsibility to notify DVLA. GP duty to advise — document in notes. Can resume if no residual neurological impairment after 1 month review
5–10% of TIA patients have a stroke within 90 days without treatment. With optimal treatment (antiplatelet + statin + BP), this reduces to 1–2%. Paroxysmal AF detected by prolonged cardiac monitoring (implantable loop recorder) is found in 12–15% of otherwise unexplained stroke/TIA patients — anticoagulation in these patients reduces recurrent stroke by 64%. Driving cessation advice must be documented — a legal and medicolegal requirement. Failure to advise has resulted in successful litigation.
Educational use only. Based on NICE NG128 (Stroke & TIA 2019), EXPRESS Trial (Rothwell 2007), CHANCE Trial (Wang 2013), SPARCL Trial (Amarenco 2006), NASCET, POINT Trial. DVLA At a Glance Guide. Adapt to individual patient context.