Clinical Commander

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cardio.tia.v1

Transient ischemic attack (TIA)

cardiologyacutechronicadultacuteinpatientoutpatienttransition
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TIA dossier — ED triage as time-critical (highest stroke recurrence in first 48 h); DAPT × 21 d via aspirin + clopidogrel (CHANCE/POINT); ticagrelor (THALES) alternative. Mandatory workup: non-contrast CT (rule out hemorrhage), MRI brain with DWI (30% TIA actually have DWI lesions), carotid imaging, ECG, echo, telemetry ≥24 h, extended cardiac monitoring if cryptogenic (CRYSTAL-AF). Symptomatic carotid ≥50% → CEA/CAS within 14 d. AF detected → DOAC. PFO closure if cryptogenic + RCT criteria. Settings cover ED + inpatient + outpatient + transition. Next steps: (1) author manifest at prisma/seed/manifests/cardio.tia.v1.ts; (2) atoms; (3) design brief; (4) RxCUI verification via npm run research:rxnav:validate; (5) engine-specific test file; (6) wire to neurology stroke pathway dossier. Calculator gaps: ABCD3-I, ESRS, CRYSTAL-AF cumulative-incidence, NIHSS-recurrence not yet in clinical-tools-registry.ts — add before promoting to AUTHORED. ABCD2 + NIHSS are present.

Entry points (6)

  • symptom
    Transient focal neurologic deficit (resolved or resolving) per AHA/ASA 2021
    transient_focal_neuro_deficit
  • symptom
    Transient monocular blindness (amaurosis fugax) per AHA/ASA 2021
    amaurosis_fugax
  • symptom
    Transient aphasia / expressive or receptive (AHA/ASA 2021)
    transient_aphasia
  • symptom
    Transient hemiparesis or hemisensory loss (AHA/ASA 2021)
    transient_hemiparesis_or_hemisensory
  • symptom
    Posterior-circulation transient symptoms (diplopia, dysarthria, vertigo, ataxia) per AHA/ASA 2021
    transient_diplopia_dysarthria_vertigo
  • history
    TIA within the last 30 days — high recurrence risk (EXPRESS, Rothwell Lancet 2007)
    recent_tia_within_30d

Required inputs (23)

  • agerequired
    demographic • used at CONTEXT
    ABCD2 age ≥60 = 1 point (Johnston Lancet 2007); risk increases with age
  • sbprequired
    vital • used at CONTEXT
    BP ≥140/90 at presentation = ABCD2 1 point (Johnston Lancet 2007); chronic target <130/80 per AHA/ASA 2021
  • dbprequired
    vital • used at CONTEXT
    Diastolic component of ABCD2 BP criterion (Johnston Lancet 2007)
  • glucose_fingerstickrequired
    vital • used at CONTEXT
    Hypoglycemia = stroke mimic; hyperglycemia worsens prognosis (AHA/ASA 2021)
  • symptom_duration_minrequired
    symptom • used at RISK_STRATIFICATION
    ABCD2 ≥60 min = 2 points; 10–59 min = 1 point (Johnston Lancet 2007)
  • unilateral_weaknessrequired
    symptom • used at RISK_STRATIFICATION
    ABCD2 unilateral weakness = 2 points (Johnston Lancet 2007)
  • speech_disturbance_no_weaknessrequired
    symptom • used at RISK_STRATIFICATION
    ABCD2 speech-only deficit = 1 point (Johnston Lancet 2007)
  • diabetes_mellitusrequired
    history • used at RISK_STRATIFICATION
    ABCD2 DM = 1 point (Johnston Lancet 2007)
  • prior_stroke_or_tiarequired
    history • used at CONTEXT
    Recurrent event escalates urgency + DAPT vs DOAC per AHA/ASA 2021
  • atrial_fibrillationrequired
    history • used at CONTEXT
    AF mandates DOAC over antiplatelet (AHA/ASA 2021)
  • carotid_disease
    history • used at CONTEXT
    Symptomatic carotid stenosis ≥50% → CEA/CAS within 14 d (AHA/ASA 2021)
  • creatininerequired
    lab • used at CONTEXT
    eGFR for DOAC dosing + contrast risk (AHA/ASA 2021)
  • a1crequired
    lab • used at INITIAL_WORKUP
    DM diagnosis + glucose control plan (AHA/ASA 2021)
  • lipidsrequired
    lab • used at INITIAL_WORKUP
    High-intensity statin indication per AHA/ASA 2021; LDL target
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Bleeding risk baseline; thrombocytopenia (AHA/ASA 2021)
  • coag
    lab • used at INITIAL_WORKUP
    PT/PTT/INR baseline before antithrombotic (AHA/ASA 2021)
  • ct_head_noncontrastrequired
    imaging • used at RED_FLAGS
    Rule out hemorrhage and acute infarction; mandatory before antithrombotic per AHA/ASA 2021
  • mri_brain_dwirequired
    imaging • used at INITIAL_WORKUP
    DWI lesion → 30% of TIAs are radiographic infarct per AHA/ASA 2021 (would be reclassified as minor stroke)
  • carotid_imagingrequired
    imaging • used at INITIAL_WORKUP
    Carotid duplex, CTA, or MRA for symptomatic stenosis screen (AHA/ASA 2021)
  • echo_tte_or_tee
    imaging • used at INITIAL_WORKUP
    Cardioembolic source — LV thrombus, valve, PFO, LAA thrombus (AHA/ASA 2021)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    AF / ischemic changes / LVH (AHA/ASA 2021)
  • extended_cardiac_monitoring
    imaging • used at BRANCHING_WORKUP
    30-day Holter / mobile cardiac telemetry / ILR if cryptogenic — increases AF detection (CRYSTAL-AF; AHA/ASA 2021)
  • current_medsrequired
    medication • used at CONTEXT
    Existing antithrombotic / statin / BP regimen reconciliation; bleeding-risk meds per AHA/ASA 2021

12-phase flow (12)

  1. 1FRAME
    TIA = transient focal CNS ischemia without acute infarction on imaging per AHA 2009 tissue-based definition; symptoms typically <24 h. Rule out stroke (persistent deficit) and mimics (seizure, migraine, hypoglycemia, conversion, syncope, peripheral neuropathy) per AHA/ASA 2021
    inputs: symptom_duration_min
    advance: symptoms resolved + non-mimic features confirmed
  2. 2ENTRY
    Recognise transient focal deficit as TIA — ED triage as time-critical; highest stroke recurrence in first 48 h (EXPRESS, Rothwell Lancet 2007; SOS-TIA, Lavallee Lancet Neurol 2007)
    inputs: age
    advance: TIA suspected + ED-level workup initiated
  3. 3CONTEXT
    Vascular risk factors (HTN, DM, dyslipidemia, AF, smoking, OSA, prior stroke), medications, allergies, baseline neuro status, hand dominance per AHA/ASA 2021
    inputs: sbp, dbp, glucose_fingerstick, creatinine, diabetes_mellitus, prior_stroke_or_tia, atrial_fibrillation, carotid_disease, current_meds
    advance: context complete
  4. 4RED_FLAGS
    Persistent deficit (= acute stroke per AHA/ASA 2021, route to stroke pathway), hemorrhage on CT, AMS, hypoglycemia, status migrainosus mimic, seizure with Todd paralysis
    inputs: ct_head_noncontrast, glucose_fingerstick
    actions: acute_stroke, sah, ich
    advance: no red flags or routed to acute stroke pathway
  5. 5INITIAL_WORKUP
    Non-contrast CT head (rule out hemorrhage per AHA/ASA 2021), MRI brain with DWI (preferred — 30% TIA actually have DWI lesions per AHA/ASA 2021), carotid imaging (duplex/CTA/MRA), ECG, echo, BMP, A1c, lipids, CBC; troponin for cardioembolic suspicion
    inputs: ct_head_noncontrast, mri_brain_dwi, carotid_imaging, echo_tte_or_tee, ecg, a1c, lipids, cbc
    actions: panel.cardiac, panel.lipid, panel.glucose_a1c, panel.cbc
    advance: imaging + labs returned
  6. 6BRANCHING_WORKUP
    Cryptogenic TIA → extended cardiac monitoring (≥30 d Holter / MCT / ILR per CRYSTAL-AF; AHA/ASA 2021); thrombophilia + autoimmune in young / atypical; PFO with bubble study; cervical artery dissection workup if neck pain / trauma
    inputs: extended_cardiac_monitoring
    actions: afib_new_onset, aps
    advance: etiology established or extended monitoring initiated
  7. 7DIFFERENTIAL
    TOAST classification per AHA/ASA 2021: large-artery atherosclerosis (carotid/vertebral/intracranial) / cardioembolic (AF, LV thrombus, valve, PFO) / small-vessel (lacunar) / other (dissection, vasculitis, hypercoagulable) / cryptogenic
    advance: TOAST subtype assigned
  8. 8RISK_STRATIFICATION
    ABCD2 score (Johnston Lancet 2007): Age ≥60, BP ≥140/90, Clinical features, Duration, Diabetes; ABCD3-I incorporates DWI lesion + ipsilateral carotid stenosis ≥50% — superior; ESRS for chronic recurrence
    inputs: age, sbp, dbp, symptom_duration_min, unilateral_weakness, speech_disturbance_no_weakness, diabetes_mellitus
    advance: risk score documented
  9. 9TREATMENT
    Hyperacute: aspirin 325 mg load + clopidogrel 600 mg load → DAPT × 21 d then aspirin 81 mg alone (CHANCE, Wang NEJM 2013; POINT, Johnston NEJM 2018) for minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4); OR ticagrelor 180 mg load → 90 mg BID × 30 d (THALES, Johnston NEJM 2020); high-intensity statin (atorvastatin 80 OR rosuvastatin 40 per SPARCL); BP <130/80 chronic — gradual per AHA/ASA 2021; A1c <7%; AF → DOAC (apixaban/rivaroxaban/dabigatran/edoxaban); symptomatic carotid ≥50% → CEA/CAS within 14 d; PFO closure if cryptogenic + RCT-proven indication (CLOSE / RESPECT); smoking cessation; lifestyle
    inputs: sbp, creatinine, a1c, lipids
    advance: antithrombotic, statin, BP, glucose, surgical, lifestyle plan all documented
  10. 10DISPOSITION
    TIA observation unit ≤24 h or admit if ABCD2 ≥4 (Johnston Lancet 2007), recurrent symptoms, suspected cardioembolic, or carotid candidate; rapid-access TIA clinic if discharged (EXPRESS, Rothwell Lancet 2007)
    advance: disposition + neurology / vascular surgery follow-up scheduled
  11. 11MONITORING
    Neuro check q1h × 24 h if admitted per AHA/ASA 2021; daily BP; lipid + A1c at 6–12 wks; carotid imaging follow-up; AF screen with extended monitoring
    inputs: sbp, creatinine
    actions: panel.cardiac, panel.lipid, panel.glucose_a1c
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Neurology / vascular clinic at 1–2 wks per AHA/ASA 2021; PCP at 1–4 wks; cardiac rehab if appropriate; vaccinations; depression screen
    advance: follow-up scheduled