What are the guideline sources, guidelines and references for Transient ischemic attack ?
Guideline sources The following summarized guidelines for the evaluation and management of transient ischemic attack are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2023), the European Stroke Organisation (ESO 2022; 2021; 2019), the Society for Cardiovascular Angiography and Interventions (SCAI 2022), the American Heart Association (AHA/ASA 2021), the European Society of Cardiology (ESC/EACTS/EHRA 2021), the American Society of Hematology (ASH 2020), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the American College of Physicians (ACP/AAFP 2017), the American College of Emergency Physicians (ACEP 2016), the Canadian Cardiovascular Society (CCS 2014), and the Society for Cardiovascular Angiography and Interventions (SCAI/SNIS/SVM/AANS/ASNR/CNS/AANN/SVS/AHA/ACR/SAIP/ACC/ASA/SIR 2011). 1 2 3 4 5 6 7 8 9 10 11 12 13 CalculatorABCD score for stroke CalculatorAlberta stroke program early CT CalculatorATRIA stro https://web.pathway.md/diseases/recEZztKL9u6QvVHg 1/13 6/24/23, 4:09 PM Transient ischemic attack Pathway Guidelines 1. Classification and risk stratification Risk prediction tools: As per ESO 2021 guidelines, avoid using prediction tools alone to identify high risk patients/make triage and treatment decisions in patients with a suspected TIA. D As per ACEP 2016 guidelines: Do not rely on current existing risk stratification instruments, such as the ABCD score (age, BP, clinical features, duration of TIA, and presence of diabetes), in adult patients with a suspected TIA to identify patients eligible for safe discharge from the emergency department. D Consider using a rapid emergency department-based diagnostic protocol in adult patients with a suspected TIA without high-risk conditions to evaluate patients at short-term risk for stroke. C 2. Diagnostic investigations Timing for initial assessment: As per AHA 2021 guidelines, obtain diagnostic evaluation for gaining insights into the etiology and planning optimal strategies for preventing recurrent stroke, completed or underway within 48 hours of the onset of stroke symptoms, in patients with a TIA. B As per ESO 2021 guidelines, obtain a specialist review within 24 hours after the onset of symptoms in patients with a TIA. B Show 2 more Brain imaging: As per AHA 2021 guidelines, obtain brain CT or MRI to confirm the diagnosis of symptomatic ischemic cerebral vascular disease in patients with a suspected TIA. B Show 3 more As per ESO 2021 guidelines, consider obtaining MRI (multimodal) or CT perfusion, if feasible, rather than non-contrast CT, to confirm the ischemic pathophysiology of transient neurological symptoms in patients with a suspected TIA, if it will influence treatment and/or in case diagnostic uncertainty. E As per ACEP 2016 guidelines: Obtain MRI with DWI, when feasible, to identify patients at high short-term risk for stroke in adult patients with a suspected TIA. B https://web.pathway.md/diseases/recEZztKL9u6QvVHg 2/13 6/24/23, 4:09 PM Transient ischemic attack Pathway Consider obtaining non-contrast head CT to identify TIA mimics (such as intracranial hemorrhage and mass lesion) if non-contrast brain MRI is not readily available. C Cervical imaging: As per AHA 2021 guidelines, obtain CT angiography or MRA (or carotid ultrasound) to screen for carotid stenosis in patients with a TIA eligible for revascularization. B As per ESO 2021 guidelines, consider obtaining MRA or CT angiography for additional confirmation after an ultrasound of large artery stenosis of 50% to guide further management in patients with a suspected TIA. C As per ACEP 2016 guidelines: Obtain cervical vascular imaging (such as carotid ultrasound, CT angiography, or MRA), when feasible, to identify patients at high short-term risk for stroke in adult patients with a suspected TIA. B Consider obtaining carotid ultrasound to exclude severe carotid stenosis in adult patients with a suspected TIA. C Electrocardiogram: As per ESO 2021 guidelines, obtain an ECG to screen for AF and atrial flutter and to assess for other concomitant cardiac conditions in patients with a suspected TIA. B As per ESC 2021 guidelines, obtain short-term ECG recording for at least the first 24 hours, followed by continuous ECG monitoring for at least 72 hours whenever possible, to monitor for AF in patients with a TIA without previously known AF. B As per CCS 2014 guidelines, obtain continuous ECG monitoring for at least 24 hours to screen for paroxysmal AF in patients with a TIA potentially eligible for OAC therapy. B 3. Medical management Antithrombotic therapy, intracranial atherosclerotic disease: As per ESO 2022 guidelines: Consider initiating dual antiplatelet therapy over monotherapy in patients with a TIA related to intracranial stenosis due to intracranial atherosclerotic disease. C Do not initiate oral anticoagulation over aspirin, unless there is another formal indication for it, in patients with a TIA due to high-grade stenosis related to intracranial atherosclerotic disease. D As per ASA/AHA 2021 guidelines, initiate aspirin 325 mg/day over warfarin to reduce the risk of recurrent ischemic stroke and vascular death in patients with a TIA caused by 50-99% stenosis of a major intracranial artery. B Show 4 more Antithrombotic therapy (before imaging): consider initiating de novo antiplatelet monotherapy in patients with a suspected TIA if a wait of > 24 hours to planned imaging is foreseen and a delay https://web.pathway.md/diseases/recEZztKL9u6QvVHg 3/13 6/24/23, 4:09 PM Transient ischemic attack Pathway is judged to increase the risk of further ischemic events, above the risk of starting antiplatelet medication. C Management of hypertension, antihypertensive therapy: As per ASA/AHA 2021 guidelines, consider initiating antihypertensive therapy to reduce the risk of recurrent stroke, intracerebral hemorrhage, and other vascular events in patients with no history of hypertension experiencing a TIA and having an average office BP of 130/80 mmHg. C Show 2 more As per PCNA/NMA/ASPC/ASH/APhA/AGS/ACPM/ABC/AAPA/AHA/ACC 2018 guidelines, restart antihypertensive therapy after the first few days of the index event to reduce the risk of recurrent stroke and other vascular events in adult patients with previously treated hypertension experiencing a TIA. A Show 4 more Management of hypertension, BP targets: As per ASA/AHA 2021 guidelines: Target an office BP < 130/80 mmHg to reduce the risk of recurrent stroke and vascular events in most patients with hypertension experiencing a TIA. B Target a systolic BP < 140 mmHg to prevent recurrent stroke and vascular events in patients with a TIA attributable to 50-99% stenosis of a major intracranial artery. B As per PCNA/NMA/ASPC/ASH/APhA/AGS/ACPM/ABC/AAPA/AHA/ACC 2018 guidelines, consider targeting a BP < 130/80 mmHg in adult patients with a TIA. C As per ACP/AAFP 2017 guidelines, consider initiating or intensifying pharmacologic treatment to achieve a target systolic BP of < 140 mmHg with the goal of reducing the risk for stroke or cardiac events in 60 years old patients with a history of TIA. C Set treatment goals based on a periodic discussion of the benefits and harms of specific BP targets with the patient. Management of hypertension (permissive hypertension): insufficient evidence to recommend permissive or induced hypertension over conventional BP management (target normotension) during the acute phase in patients with a TIA related to high-grade intracranial atherosclerosis causing severe hemodynamic compromise. I Management of dyslipidemia: As per ESO 2022 guidelines, consider initiating lipid management to improve outcomes in patients with a TIA related to an intracranial atherosclerotic disease. C As per AHA 2021 guidelines, initiate lipid-lowering therapy with a statin, and ezetimibe if needed, with a goal of low-density lipoprotein cholesterol < 70 mg/dL to reduce the risk of major cardiovascular events in patients with a TIA and atherosclerotic disease (intracranial, carotid, aortic, or coronary). A Show 3 more Management of diabetes: consider advising lifestyle optimization (healthy diet, regular physical activity, and smoking cessation) to prevent the progression of prediabetes to diabetes in patients with a TIA and prediabetes. C https://web.pathway.md/diseases/recEZztKL9u6QvVHg 4/13 6/24/23, 4:09 PM Transient ischemic attack Pathway Show 6 more Management of obesity: calculate BMI at the time of the event and annually thereafter to screen for and to classify obesity in patients with ASCVD. B Show 2 more Management of obstructive sleep apnea: Consider obtaining evaluation for obstructive sleep apnea in patients with a TIA. C Consider offering positive airway pressure (such as CPAP) to relieve sleep apnea and improve BP, sleepiness, and other apnea-related outcomes in patients with a TIA and obstructive sleep apnea. C Antithrombotic therapy, non-cardioembolic TIA: As per ASA/AHA 2021 guidelines, initiate antiplatelet therapy over oral anticoagulation to reduce the risk of recurrent ischemic stroke and other cardiovascular events while minimizing the risk of bleeding in patients with a non-cardioembolic TIA. A Show 5 more As per ESO 2021 guidelines: Initiate short-term dual antiplatelet therapy with aspirin and clopidogrel over monotherapy, subsequently followed by monotherapy, in patients with an acute non-cardioembolic high-risk TIA (ABCD score of 4). A Do not initiate dual antiplatelet therapy over monotherapy in patients with an acute non- cardioembolic low-risk TIA or uncertain TIA diagnosis. D 4. Nonpharmacologic interventions Dietary modifications: Consider advising to follow a Mediterranean-type diet, typically with an emphasis on monounsaturated fat, plant-based foods, and fish consumption, with either high extra virgin olive oil or nut supplementation, in preference to a low-fat diet, to reduce the risk of recurrent stroke in patients with a TIA. C Consider advising to reduce the sodium intake by at least 1 g/day sodium (2.5 g/day salt) to reduce the risk of CVD events, including stroke, in patients with a TIA and hypertension. C Physical activity: As per ESO 2022 guidelines, consider offering lifestyle changes, including increased physical activity, to improve outcomes in patients with a TIA related to intracranial atherosclerotic disease. C As per AHA 2021 guidelines, advise practicing at least moderate-intensity aerobic activity for a minimum of 10 minutes 4 times weekly or vigorous-intensity aerobic activity for a minimum of 20 minutes twice weekly to lower the risk of recurrent stroke and the composite cardiovascular endpoint of recurrent stroke, myocardial infarction, or vascular death in patients with a TIA capable of physical activity. B Show 2 more https://web.pathway.md/diseases/recEZztKL9u6QvVHg 5/13 6/24/23, 4:09 PM Transient ischemic attack Pathway Smoking cessation: offer counseling with or without pharmacotherapy (nicotine replacement, bupropion, or varenicline) to assist in quitting smoking in smoker patients with a TIA. A Show 2 more Alcohol restriction: advise eliminating or reducing consumption of alcohol to reduce stroke risk in patients with a TIA consuming excess alcohol (> 2 alcoholic drinks a day for males or > 1 alcoholic drink a day for females). B Substance use cessation: Provide counseling and advise stopping using stimulants in patients with a TIA using stimulants (such as amphetamines, amphetamine derivatives, cocaine, or khat) and patients with infective endocarditis in the context of IV drug use. B Offer specialized services to help manage dependency in patients with a TIA having a substance use disorder (drugs or alcohol). B 5. Therapeutic procedures Ischemic preconditioning: considering performing ischemic preconditioning as an adjuvant to best medical treatment in patients with a TIA related to high-grade stenosis due to intracranial atherosclerotic disease. Consider enrolling patients in a dedicated RCT whenever possible. C Intracranial angioplasty/stenting: As per ESO 2022 guidelines, do not perform angioplasty and/or stenting, in addition to best medical treatment, as first-line treatment in patients with a TIA related to high-grade stenosis due to intracranial atherosclerotic disease. D As per AHA 2021 guidelines, do not perform angioplasty and stenting as an initial treatment in patients with a TIA attributable to severe stenosis (70-99%) of a major intracranial artery, even in patients taking an antithrombotic agent at the time of the TIA. D Show 2 more 6. Surgical interventions Indications for surgery: As per ESO 2022 guidelines, do not perform neurosurgical procedures in patients with a TIA related to high-grade stenosis due to intracranial atherosclerotic disease. D As per AHA 2021 guidelines: Do not perform extracranial-intracranial bypass surgery in patients with a TIA attributable to 50-99% stenosis or occlusion of a major intracranial artery. D Do not perform extracranial-intracranial bypass surgery in patients with a recent (within 120 days) TIA ipsilateral to atherosclerotic stenosis or occlusion of the middle cerebral artery. D 7. Specific circumstances https://web.pathway.md/diseases/recEZztKL9u6QvVHg 6/13 6/24/23, 4:09 PM Transient ischemic attack Pathway Patients with carotid artery stenosis (medical therapy): initiate intensive medical therapy with antiplatelet therapy, lipid-lowering therapy, and antihypertensive therapy to reduce the risk of stroke in patients with a TIA and carotid artery stenosis. A Patients with carotid artery stenosis (timing of revascularization): Consider performing revascularization, when indicated, within 2 weeks of the index event to increase the likelihood of stroke-free outcomes in patients with a TIA. C Perform carotid artery stenting or carotid endarterectomy by operators with established periprocedural stroke and mortality rates of < 6% to reduce the risk of surgical adverse events in patients with a TIA and symptomatic extracranial carotid stenosis. A Patients with carotid artery stenosis (carotid endarterectomy): perform carotid endarterectomy to reduce the risk of future stroke in patients with a TIA within the past 6 months and ipsilateral severe (70-99%) carotid artery stenosis, provided the perioperative morbidity and mortality risk is < 6%. A Show 4 more Patients with carotid artery stenosis (carotid artery stenting): consider performing carotid artery stenting to reduce the periprocedural complication rate in patients with symptomatic severe stenosis ( 70%) with anatomic or medical conditions increasing the risk for surgery (such as radiation-induced stenosis or restenosis after carotid endarterectomy). C Show 2 more Patients with carotid artery stenosis (transcarotid artery revascularization): insufficient evidence to recommend transcarotid artery revascularization for the prevention of recurrent TIAs in patients with a recent TIA (past 6 months). I Patients with carotid artery stenosis (bypass surgery): do not perform extracranial-intracranial bypass surgery in patients with a recent (within 120 days) TIA ipsilateral to atherosclerotic stenosis or occlusion of the carotid artery. D Patients with vertebral artery stenosis: As per ESVS 2023 guidelines, do not perform routine stenting in patients presenting with a vertebrobasilar territory TIA and a 50-99% vertebral artery stenosis. D Show 2 more As per AHA 2021 guidelines: Initiate intensive medical therapy (antiplatelet therapy, lipid-lowering, BP control) to reduce stroke risk in patients with recently symptomatic extracranial vertebral artery stenosis. A Insufficient evidence to recommend stenting I or open surgical procedures, including vertebral endarterectomy and vertebral artery transposition, in patients with a TIA and extracranial vertebral artery stenosis having symptoms despite optimal medical treatment. I As per ASA 2011 guidelines, initiate antiplatelet therapy with aspirin alone (75-325 mg/day), clopidogrel alone (75 mg/day), or the combination of aspirin plus ER dipyridamole (25 and 200 mg BID, respectively), preferred over the combination of aspirin with clopidogrel, in patients with obstructive or nonobstructive extracranial vertebral artery atherosclerosis sustained a TIA. B Show 2 more https://web.pathway.md/diseases/recEZztKL9u6QvVHg 7/13 6/24/23, 4:09 PM Transient ischemic attack Pathway Patients with carotid or vertebral artery dissection: As per AHA 2021 guidelines, initiate antithrombotic therapy for at least 3 months to prevent recurrent TIAs in patients with a TIA after an extracranial carotid or vertebral arterial dissection. B Show 2 more As per ASA 2011 guidelines, consider initiating anticoagulant (heparin, LMWH, or warfarin) or antiplatelet therapy (aspirin, clopidogrel, or the combination of ER dipyridamole plus aspirin) for at least 3-6 months for patients with extracranial carotid or vertebral arterial dissection associated with a TIA. C Patients with vertebrobasilar dolichoectasia: consider initiating antiplatelet or anticoagulant therapy for the prevention of recurrent ischemic events in patients with a history of TIA and vertebrobasilar dolichoectasia without other attributable causes. C Patients with fibromuscular dysplasia: Initiate antiplatelet therapy, control BP control, and offer lifestyle modifications for the prevention of future ischemic events in patients with a history of TIA and FMD without other attributable causes. B Consider initiating antiplatelet therapy for the prevention of future ischemic events in patients with a history of TIA attributable to dissection with FMD and no evidence of intraluminal thrombus. C Patients with carotid web: initiate antiplatelet therapy to prevent recurrent TIAs in patients with carotid web in the distribution of TIA without other attributable causes of stroke. B Patients with aortic arch atherosclerosis: Initiate intensive lipid management with an LDL cholesterol target of < 70 mg/dL to prevent recurrent stroke in patients with a TIA and evidence of an aortic arch atheroma. B Initiate antiplatelet therapy to prevent recurrent stroke in patients with a TIA and evidence of an aortic arch atheroma. B Patients with Moyamoya disease: As per AHA 2021 guidelines: Consider initiating antiplatelet therapy, typically aspirin monotherapy, for the prevention of ischemic stroke or TIA in patients with Moyamoya disease and a history of TIA. C Consider performing surgical revascularization with direct or indirect extracranial-intracranial bypass for the prevention of ischemic stroke or TIA in patients with Moyamoya disease and a history of TIA. C As per ASH 2020 guidelines, consider performing revascularization surgery, in addition to continuing regular blood transfusions, in pediatric and adult patients with Moyamoya syndrome and a history of TIA. C Patients with atrial fibrillation, anticoagulant therapy: As per ASA/AHA 2021 guidelines, initiate oral anticoagulation, such as apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin, to reduce the risk of recurrent stroke in patients with a TIA https://web.pathway.md/diseases/recEZztKL9u6QvVHg 8/13 6/24/23, 4:09 PM Transient ischemic attack Pathway and nonvalvular AF. A Initiate oral anticoagulation to reduce the risk of recurrent stroke regardless of the pattern of AF, i.e. paroxysmal, persistent, or permanent. B Show 5 more As per EACTS/EHRA/ESC 2021 guidelines, initiate long-term oral anticoagulation (with a preference for direct oral coagulants over vitamin K antagonists in direct oral coagulant-eligible patients) for secondary prevention of stroke in patients with AF and a TIA, in the absence of strict contraindications to OACs. A Patients with atrial fibrillation (antiplatelet therapy): Do not use antiplatelet agents, either as single or dual therapy, for secondary prevention of all events in patients with nonvalvular AF and a previous TIA. D Insufficient evidence to recommend antiplatelet therapy for secondary prevention of all events in patients with nonvalvular AF, previous TIA, and small vessel disease. I Patients with atrial fibrillation, LAA closure: As per ASA/AHA 2021 guidelines, consider performing percutaneous closure of the LA appendage with the Watchman device to reduce the risk of recurrent stroke and bleeding in patients with a TIA in the setting of nonvalvular AF having contraindications for lifelong anticoagulation but able to tolerate at least 45 days. C As per ESO 2019 guidelines, consider performing LA appendage closure as an alternative to life-long oral anticoagulation after carefully weighing the risks and benefits in individual patients with a TIA and nonvalvular AF. E As per ESO 2019 guidelines, insufficient evidence to recommend LA appendage occlusion over long-term vitamin K antagonists for secondary prevention of all events in patients with nonvalvular AF and a previous TIA. I Patients with intracardiac thrombi: consider obtaining advanced cardiac imaging (such as contrast-enhanced echocardiography or cardiac MRI) to assess for the presence of LV thrombus in patients with a TIA in the setting of acute myocardial infarction. C Show 3 more Patients with valvular heart disease (antithrombotic therapy): initiate warfarin to reduce the risk of recurrent TIAs in patients with a TIA and valvular AF (moderate-to-severe MS or any mechanical heart valve). B Show 4 more Patients with valvular heart disease (valvular surgery): consider performing early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) to reduce the risk of recurrent embolisms, if there is no evidence of intracranial hemorrhage or extensive neurological damage, in patients with a TIA and infective endocarditis presenting with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy. C Show 3 more Patients with congenital heart disease: Initiate anticoagulation with warfarin to reduce the risk of recurrent TIAs in patients with a TIA and Fontan palliation. B https://web.pathway.md/diseases/recEZztKL9u6QvVHg 9/13 6/24/23, 4:09 PM Transient ischemic attack Pathway Consider initiating anticoagulation with warfarin to reduce the risk of recurrent TIAs in patients with cyanotic congenital heart disease and other complex lesions and a TIA of presumed cardioembolic origin. C Patients with patent foramen ovale: avoid performing patent foramen ovale closure in patients with a history of TIA and without a prior patent foramen ovale-associated stroke. D Patients with cardiomyopathy: initiate anticoagulation with warfarin for at least 3 months to reduce the risk of recurrent TIAs in patients with a TIA and LA or LA appendage thrombus in the setting of ischemic, non-ischemic, or restrictive cardiomyopathy and LV dysfunction. B Show 4 more Patients with cardiac tumors: consider performing tumor resection to reduce the risk of recurrent stroke in patients with a TIA with a left-sided cardiac tumor. C Patients with inherited thrombophilias: Consider initiating antiplatelet therapy to reduce the risk of recurrent TIAs in patients with a TIA of an unknown source despite thorough diagnostic evaluation, no other thrombotic history, and having any of the following: prothrombin 20210A mutation activated protein C resistance elevated factor VIII levels protein C deficiency protein S deficiency antithrombin III deficiency. C Patients with antiphospholipid syndrome: initiate antiplatelet therapy alone to reduce the risk of recurrent stroke in patients with a TIA having an isolated antiphospholipid antibody but not fulfilling the criteria for antiphospholipid syndrome. B Show 3 more Patients with hyperhomocysteinemia: Do not initiate folate, vitamin B6, or vitamin B12 supplementation for the prevention of subsequent stroke in patients with a TIA and hyperhomocysteinemia. D Offer a low-methionine, cysteine-enhanced diet and initiate vitamin B6, vitamin B12, and folate supplementation to reduce plasma homocysteine to population normal levels and thereby reduce the risk of recurrent ischemic stroke in patients with a TIA and cystathionine -synthase deficiency. B Patients with sickle cell disease: Administer chronic blood transfusions to reduce Hgb S to < 30% of total Hgb for the prevention of recurrent ischemic stroke in patients with sickle cell disease and a history of TIA. B Consider initiating hydroxyurea for the prevention of recurrent ischemic stroke in patients with sickle cell disease with a history of TIA, if transfusion therapy is not available or practical. C Patients with autoimmune vasculitis: initiate immediate oral high-dose corticosteroids to reduce recurrent stroke risk in patients with a TIA and symptoms attributed to giant cell arteritis. B Show 3 more https://web.pathway.md/diseases/recEZztKL9u6QvVHg 10/13 6/24/23, 4:09 PM Transient ischemic attack Pathway Patients with infectious vasculitis: Treat the underlying infectious etiology (such as VZV, cerebral vasculitis, neurosyphilis, or bacterial meningitis) to reduce the risk of stroke in patients with a TIA and infectious vasculitis. B Consider initiating daily aspirin plus combined antiretroviral therapy to reduce the risk of recurrent stroke in patients with a TIA in the context of human immunodeficiency virus vasculopathy. C Patients with Fabry disease: insufficient evidence regarding the role of agalsidase alfa or agalsidase beta in preventing recurrent TIAs in patients with a TIA and Anderson-Fabry disease. I 8. Preventative measures Secondary prevention (health system-based interventions): implement voluntary hospital- based or outpatient-focused quality monitoring and improvement programs to improve short-term and long-term adherence to nationally accepted, evidence-based guidelines for secondary stroke prevention in patients with ischemic stroke or TIA. B Show 2 more Secondary prevention (behavioral changes): offer behavior change interventions targeting stroke literacy, lifestyle factors, and medication adherence to reduce cardiovascular events in patients with a TIA. B Show 4 more 9. Quality improvement Health equity: assess and address social determinants of health (literacy level, language proficiency, medication affordability, food insecurity, housing, and transportation barriers) when managing stroke risk factors to reduce healthcare disparities. B Show 3 more References 1. 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Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke. 2011 Jan;42 1 227 76. Open https://web.pathway.md/diseases/recEZztKL9u6QvVHg 13/13