NICE Guidelines

NICE Guideline (2019) [15] recommends that:

Offer aspirin (300 mg daily), unless contraindicated, to people who have had a suspected TIA, to be started immediately.

Give a proton-pump inhibitor to anyone with dyspepsia associated with aspirin use.

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

Refer immediately people who have had a suspected TIA for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms.

Do not use scoring systems, such as ABCD2, to assess risk of subsequent stroke or to inform urgency of referral for people who have had a suspected or confirmed TIA. (Evidence showed that risk prediction scores (ABCD2 and ABCD3) used in isolation are poor at discriminating low and high risk of stroke after TIA. Adding imaging of the brain and carotid arteries to the risk scores (as is done in the ABCD2‑I and ABCD3‑I tools) modestly improves discrimination. However, appropriate imaging (including MRI) is not available in general practice or for paramedics, 2 of the key situations when these tools would be used. Arranging specialist assessment less urgently for some people based on a tool with poor discriminative ability for stroke risk has the potential for harm. Therefore, the committee agreed that risk scores should not be used.

The committee agreed, based on their clinical experience and the limited predictive performance of risk scores, that all cases of suspected TIA should be considered as potentially high risk for stroke. Also, because there is no reliable diagnostic test for TIA (the risk stratification tools are not diagnostic tests), it is important to urgently confirm or refute the diagnosis of a suspected TIA with specialist opinion. This is particularly so because in practice, a significant proportion of suspected TIA (30% to 50%) will have an alternative diagnosis (that is, TIA-mimic). Therefore, it was agreed that everyone who has had a suspected TIA should have specialist assessment and investigation within 24 hours of the onset of symptoms. The committee noted the results of an original cost–utility analysis, which was undertaken for this review question in the 2008 version of the stroke guideline (CG68). The analysis concluded that ‘immediate assessment’ had both better health outcomes and lower costs than ‘assessment within a week’ for the entire population of suspected TIA, without the use of a risk stratification tool.

The committee acknowledged that having a TIA (or suspected TIA) is a worrying time and most people would prefer to be assessed as soon as possible. Urgent specialist assessment should ensure that people at high risk of stroke are identified early. This would allow preventative treatment to begin, which should be introduced as soon as the diagnosis of TIA is confirmed.)

Offer secondary prevention, in addition to aspirin, as soon as possible after the diagnosis of TIA is confirmed.[15]