Updated Recommendations about TIA from AHA

The American Heart Association (AHA) issued a scientific statement in a recent issue of Stroke, updating the optimal protocol for the diagnosis, risk assessment, and treatment/management of individuals with suspected transient ischemic attacks (TIA) presenting in the Emergency Department (ED).  A goal for this comprehensive statement is to provide guidance to facilities and clinicians about optimal clinical pathways based on available evidence that can assist in the appropriate triage of individuals with suspected TIA and help prevent future cerebrovascular events. The 90-day stroke risk after a TIA ranges between 10% and 20%, with 50% of strokes occurring 2 days after an index event.

If a patient experiences a suspected TIA, a full neurovascular workup is warranted to minimize the chance of a recurrent event. Regarding brain imaging, prompt multimodal brain MRI scanning with diffusion weighted imaging (DWI) is preferred over a noncontrast head computed tomography (NCCT) alone. Computed tomography angiography (CTA) alongside NCCT can detect stenosis and hemorrhage in patients with chronic kidney disease. 

Telemetry, troponin assay, electrocardiography, a complete blood panel, blood glucose testing, a lipid profile, hemoglobin A1c, and a chemistry panel all should be performed to assess risk factors and to rule out TIA mimics. Monitor cardiac rhythm for 30 days to determine the source of a cardiac embolism. 

Risk stratification scales, the most popular being Age, Blood Pressure, Clinical Features, Duration, and Diabetes (ABCD²), are useful in determining high-risk patients when included as part of a comprehensive assessment. Blood vessel imaging is recommended regardless of ABCD² score.

Rapid ED TIA protocols with prompt referral to cerebrovascular units or admittance to the ED or hospital are crucial for presumed symptomatic intracranial or extracranial stenosis. An early neurologic consultation, preferably within 48 hours after TIA, is associated with lower mortality rates. 

Behavioral and lifestyle counseling regarding stroke literacy and medication adherence can reduce the risk of recurrent stroke. Antithrombotics used alongside antihypertensives are paramount in reducing the risk of future events. Social determinants of health should be addressed to ensure health equality. 

The full scientific statement is available here.