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Transient ischemic attack

What's new

Added 2023 ESVS, 2022 ESO, 2021 AHA/ASA, and 2021 ESC/EHRA/EACTS guidelines for the evaluation and management of transient ischemic attack.

Guidelines

Key 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 2021), the ...
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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.
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Diagnostic investigations

Timing for initial assessment: as per AHA/ASA 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.
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  • Brain imaging

  • Cervical imaging

  • ECG

Medical management

Antithrombotic therapy, before imaging: as per ESO 2021 guidelines, 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 is judged to increase the risk of further ischemic events, above the risk of starting antiplatelet medication.
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  • Antithrombotic therapy (intracranial atherosclerotic disease)

  • Antithrombotic therapy (non-cardioembolic TIA)

  • Management of hypertension (antihypertensive therapy)

  • Management of hypertension (BP targets)

  • Management of hypertension (induced hypertension)

  • Management of dyslipidemia

  • Management of diabetes

  • Management of obesity

  • Management of obstructive sleep apnea

Nonpharmacologic interventions

Dietary modifications
As per AHA/ASA 2021 guidelines:
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.
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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.
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  • Physical activity

  • Smoking cessation

  • Alcohol restriction

  • Substance use cessation

Therapeutic procedures

Ischemic preconditioning: as per ESO 2022 guidelines, 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.
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  • Intracranial angioplasty/stenting

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.
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Specific circumstances

Patients with carotid artery stenosis, medical therapy: as per AHA/ASA 2021 guidelines, 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.
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  • Patients with carotid artery stenosis (timing of revascularization)

  • Patients with carotid artery stenosis (carotid endarterectomy)

  • Patients with carotid artery stenosis (carotid artery stenting)

  • Patients with carotid artery stenosis (transcarotid artery revascularization)

  • Patients with carotid artery stenosis (bypass surgery)

  • Patients with vertebral artery stenosis

  • Patients with carotid or vertebral artery dissection

  • Patients with vertebrobasilar dolichoectasia

  • Patients with FMD

  • Patients with carotid web

  • Patients with aortic arch atherosclerosis

  • Patients with Moyamoya disease

  • Patients with AF (anticoagulant therapy)

  • Patients with AF (antiplatelet therapy)

  • Patients with AF (LAA closure)

  • Patients with intracardiac thrombi

  • Patients with valvular heart disease (antithrombotic therapy)

  • Patients with valvular heart disease (valvular surgery)

  • Patients with congenital heart disease

  • Patients with patent foramen ovale

  • Patients with cardiomyopathy

  • Patients with cardiac tumors

  • Patients with inherited thrombophilias

  • Patients with antiphospholipid syndrome

  • Patients with hyperhomocysteinemia

  • Patients with sickle cell disease

  • Patients with autoimmune vasculitis

  • Patients with infectious vasculitis

  • Patients with Fabry disease

Preventative measures

Secondary prevention, health system-based interventions: as per AHA/ASA 2021 guidelines, 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.
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  • Secondary prevention (behavioral changes)

Quality improvement

Health equity: as per AHA/ASA 2021 guidelines, 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.
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