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cardio.tia.v1PRODUCTION
cardio.tia.v1

Transient ischemic attack (TIA)

cardiologyacutechronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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

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symptoms resolved + non-mimic features confirmed

Patient inputs (23)

ABCD2 age ≥60 = 1 point (Johnston Lancet 2007); risk increases with age

BP ≥140/90 at presentation = ABCD2 1 point (Johnston Lancet 2007); chronic target <130/80 per AHA/ASA 2021

Diastolic component of ABCD2 BP criterion (Johnston Lancet 2007)

Hypoglycemia = stroke mimic; hyperglycemia worsens prognosis (AHA/ASA 2021)

Recurrent event escalates urgency + DAPT vs DOAC per AHA/ASA 2021

AF mandates DOAC over antiplatelet (AHA/ASA 2021)

eGFR for DOAC dosing + contrast risk (AHA/ASA 2021)

Existing antithrombotic / statin / BP regimen reconciliation; bleeding-risk meds per AHA/ASA 2021

DM diagnosis + glucose control plan (AHA/ASA 2021)

High-intensity statin indication per AHA/ASA 2021; LDL target

Bleeding risk baseline; thrombocytopenia (AHA/ASA 2021)

DWI lesion → 30% of TIAs are radiographic infarct per AHA/ASA 2021 (would be reclassified as minor stroke)

Carotid duplex, CTA, or MRA for symptomatic stenosis screen (AHA/ASA 2021)

AF / ischemic changes / LVH (AHA/ASA 2021)

Rule out hemorrhage and acute infarction; mandatory before antithrombotic per AHA/ASA 2021

ABCD2 ≥60 min = 2 points; 10–59 min = 1 point (Johnston Lancet 2007)

ABCD2 unilateral weakness = 2 points (Johnston Lancet 2007)

ABCD2 speech-only deficit = 1 point (Johnston Lancet 2007)

ABCD2 DM = 1 point (Johnston Lancet 2007)

30-day Holter / mobile cardiac telemetry / ILR if cryptogenic — increases AF detection (CRYSTAL-AF; AHA/ASA 2021)

Symptomatic carotid stenosis ≥50% → CEA/CAS within 14 d (AHA/ASA 2021)

PT/PTT/INR baseline before antithrombotic (AHA/ASA 2021)

Cardioembolic source — LV thrombus, valve, PFO, LAA thrombus (AHA/ASA 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningpersistent_deficit_at_presentation
    Persistent focal neurologic deficit at presentation (NIHSS >0) per AHA/ASA 2021
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrecurrent_tia_or_progression_to_stroke
    Recurrent TIA or progression to stroke after starting therapy (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemorrhage_on_initial_ct
    Hemorrhage on non-contrast CT (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereabcd2_ge_4
    ABCD2 score ≥4 (Johnston Lancet 2007)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_carotid_stenosis_ge_50
    Symptomatic carotid stenosis ≥50% on duplex / CTA / MRA (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenew_atrial_fibrillation_detected
    New AF on telemetry / Holter / MCT / ILR (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecyp2c19_lof_in_clopidogrel
    Known CYP2C19 loss-of-function variant or clopidogrel-resistance suspected (East Asian, recurrent event on clopidogrel) per AHA/ASA 2021
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Acute antithrombotic for TIA (within 24 h of symptom onset)
axis: tia_acute_antithrombotic
Selected axis "Acute antithrombotic for TIA (within 24 h of symptom onset)" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet
    325 mg load → 81 mg • PO • load once → 81 mg daily maintenance
    triggers: suspected_TIA_no_hemorrhage
    Foundational antiplatelet per AHA/ASA 2021; load 325 mg if not already on aspirin; 81 mg lifelong
    rxcui 1191
  • clopidogrel
    first line
    P2Y12_inhibitor
    600 mg load → 75 mg • PO • load once → 75 mg daily × 21 d
    triggers: ABCD2>=4, minor_stroke_NIHSS_le_3, high_risk_TIA
    CHANCE / POINT — DAPT × 21 d (POINT: 21 d optimal, after which bleeding risk exceeds benefit) then aspirin alone
    rxcui 32968
  • ticagrelor
    second line
    P2Y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 30 d
    triggers: CYP2C19_loss_of_function_known_or_suspected, clopidogrel_intolerant
    THALES Johnston NEJM 2020 — ticagrelor + aspirin × 30 d non-inferior; useful if CYP2C19 LOF (e.g., East Asian)
    rxcui 1116632

outpatient playbook — drug actions (5)

  1. 1. aspirin 81 mg daily lifelong (or clopidogrel 75 mg or aspirin/dipyridamole ER)
    81 mg • PO • daily
    trigger: Non-cardioembolic TIA — chronic phase
    Foundational per AHA/ASA 2021
  2. 2. apixaban / rivaroxaban / dabigatran / edoxaban / warfarin
    per agent + renal dose adjustment • PO • BID/daily
    trigger: AF detected acutely or on extended monitoring
    ARISTOTLE / ROCKET-AF / RE-LY / ENGAGE per AHA/ASA 2021; warfarin only for mechanical valve / severe MS
  3. 3. high-intensity statin lifelong
    atorvastatin 80 OR rosuvastatin 40 • PO • daily
    trigger: Post-TIA secondary prevention
    SPARCL (NEJM 2006)
  4. 4. BP regimen — combination per 2025 AHA
    ACEi/ARB + thiazide-like + CCB • PO • daily
    trigger: Target <130/80 chronic
    PROGRESS + 2025 AHA
  5. 5. metformin / SGLT2i / GLP-1 if DM2
    per ADA 2026 • PO/SC • per agent
    trigger: DM2 with ASCVD
    ADA 2026 — favours SGLT2i / GLP-1 in DM + ASCVD

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Transient focal neurologic deficit (resolved or resolving) per AHA/ASA 2021; Transient monocular blindness (amaurosis fugax) per AHA/ASA 2021; Transient aphasia / expressive or receptive (AHA/ASA 2021).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Transient ischemic attack (TIA)** (cardio.tia.v1).
Phenotype framing: 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
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute antithrombotic for TIA (within 24 h of symptom onset)**.
1. aspirin 325 mg load → 81 mg PO load once → 81 mg daily maintenance (antiplatelet, first line) — Foundational antiplatelet per AHA/ASA 2021; load 325 mg if not already on aspirin; 81 mg lifelong
2. clopidogrel 600 mg load → 75 mg PO load once → 75 mg daily × 21 d (P2Y12_inhibitor, first line) — CHANCE / POINT — DAPT × 21 d (POINT: 21 d optimal, after which bleeding risk exceeds benefit) then aspirin alone
3. ticagrelor 180 mg load → 90 mg BID PO BID × 30 d (P2Y12_inhibitor, second line) — THALES Johnston NEJM 2020 — ticagrelor + aspirin × 30 d non-inferior; useful if CYP2C19 LOF (e.g., East Asian)

Setting playbook (outpatient) — Long-term secondary prevention per AHA/ASA 2021 — antithrombotic, statin, BP control, glucose control, lifestyle, AF screening
4. aspirin 81 mg daily lifelong (or clopidogrel 75 mg or aspirin/dipyridamole ER) 81 mg PO daily — Non-cardioembolic TIA — chronic phase (Foundational per AHA/ASA 2021)
5. apixaban / rivaroxaban / dabigatran / edoxaban / warfarin per agent + renal dose adjustment PO BID/daily — AF detected acutely or on extended monitoring (ARISTOTLE / ROCKET-AF / RE-LY / ENGAGE per AHA/ASA 2021; warfarin only for mechanical valve / severe MS)
6. high-intensity statin lifelong atorvastatin 80 OR rosuvastatin 40 PO daily — Post-TIA secondary prevention (SPARCL (NEJM 2006))
7. BP regimen — combination per 2025 AHA ACEi/ARB + thiazide-like + CCB PO daily — Target <130/80 chronic (PROGRESS + 2025 AHA)
8. metformin / SGLT2i / GLP-1 if DM2 per ADA 2026 PO/SC per agent — DM2 with ASCVD (ADA 2026 — favours SGLT2i / GLP-1 in DM + ASCVD)

Non-pharmacologic actions:
- Smoking cessation (NRT, varenicline, bupropion) per AHA/ASA 2021
- DASH-style diet, Na <2 g/day (AHA/ASA 2021)
- Aerobic exercise ≥150 min/wk (AHA/ASA 2021)
- Weight management (BMI <25) per AHA/ASA 2021
- Alcohol limit per AHA/ASA 2021
- Sleep apnoea treatment if confirmed (AHA/ASA 2021)
- Depression treatment if PHQ-9 >=10 (AHA/ASA 2021)
- Annual flu, pneumococcal, COVID, RSV vaccinations

AVOID / contraindication checks:
- Antithrombotic block if acute hemorrhage on CT (AHA/ASA 2021)
- DAPT no longer than 21d POINT (Johnston NEJM 2018)
- Ticagrelor block if bradyarrhythmia (Johnston NEJM 2020)
- Antithrombotic evaluate bleeding history (AHA/ASA 2021)

Monitoring

Regimen monitoring:
- daily neuro check x 24h if admitted (AHA/ASA 2021)
- CBC baseline and at 2 wks (AHA/ASA 2021)
- bleeding signs assessment at each visit (AHA/ASA 2021)

Setting (outpatient) monitoring:
- Home BP log; clinic visits q3 mo for first year, then q6 mo (AHA/ASA 2021)
- Lipid + A1c q6-12 mo (AHA/ASA 2021)
- Carotid imaging q6–12 mo if untreated stenosis (AHA/ASA 2021)
- AF screen with extended monitoring if cryptogenic (AHA/ASA 2021)

Follow-up plan: Neurology / vascular clinic at 1–2 wks per AHA/ASA 2021; PCP at 1–4 wks; cardiac rehab if appropriate; vaccinations; depression screen
- Close-out criterion: follow-up scheduled

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term secondary prevention per AHA/ASA 2021 — antithrombotic, statin, BP control, glucose control, lifestyle, AF screening

Disposition criteria:
- Continue lifelong secondary prevention per AHA/ASA 2021
- Specialty referrals as needed (AHA/ASA 2021)

Escalation triggers (move to higher acuity):
- Recurrent TIA / stroke → ED + escalate workup + reassess therapy per AHA/ASA 2021
- New AF on screening → switch to DOAC (AHA/ASA 2021)
- Untreated carotid stenosis crossing 50% threshold + symptomatic recurrence → vascular surgery referral (AHA/ASA 2021)

Patient Action Plan

**TIA / stroke recurrence action plan (BE-FAST)**
Personalised values: baseline_meds, allergy_list, PCP_contact, neurology_contact.

**Stable — no new neurologic symptoms; on full secondary prevention per AHA/ASA 2021** (green):
Triggers:
- No new weakness, speech change, vision change, dizziness, or balance problem (AHA/ASA 2021)
- BP at goal (<130/80 per AHA/ASA 2021)
- Taking all medications as prescribed (AHA/ASA 2021)
Actions:
- Take aspirin (or clopidogrel or DOAC) every day exactly as prescribed per AHA/ASA 2021
- Take statin every day (SPARCL)
- Take BP and DM medications as prescribed (AHA/ASA 2021)
- Daily home BP check (AHA/ASA 2021)
- Avoid smoking; limit alcohol; follow diet + exercise plan per AHA/ASA 2021
- Keep neurology + PCP appointments (AHA/ASA 2021)

**Caution — vascular risk drift or non-focal symptoms** (yellow):
Triggers:
- Home BP persistently ≥140/90 or running high (AHA/ASA 2021)
- Missed medication doses (AHA/ASA 2021)
- New non-focal symptoms (general dizziness, fatigue, headache) per AHA/ASA 2021
- New irregular pulse / palpitations (possible AF per AHA/ASA 2021)
Actions:
- Confirm medication adherence (AHA/ASA 2021)
- Check BP technique and recheck (AHA/ASA 2021)
- Avoid OTC meds that raise BP (NSAIDs, decongestants) per AHA/ASA 2021
- Call PCP / neurology within 24-48 h (AHA/ASA 2021)
Contact provider when:
- BP persistently above goal (AHA/ASA 2021)
- New irregular pulse (AF screen per AHA/ASA 2021)
- Missed multiple doses of antithrombotic (AHA/ASA 2021)

**Medical alert — call 911 immediately for BE-FAST** (red):
Triggers:
- B — Balance: sudden loss of balance or coordination (AHA/ASA 2021 BE-FAST)
- E — Eyes: sudden vision change in one or both eyes, double vision (AHA/ASA 2021 BE-FAST)
- F — Face: face drooping on one side, uneven smile (AHA/ASA 2021 BE-FAST)
- A — Arms: sudden weakness or numbness on one side (AHA/ASA 2021 BE-FAST)
- S — Speech: slurred speech, cannot speak, or trouble understanding (AHA/ASA 2021 BE-FAST)
- T — Time: note the time symptoms started — call 911 immediately (AHA/ASA 2021 BE-FAST)
- Sudden severe headache, confusion, or trouble swallowing (AHA/ASA 2021)
Actions:
- Call 911 / emergency services immediately — do NOT drive yourself (AHA/ASA 2021)
- Note the EXACT time symptoms started (last known well) per AHA/ASA 2021
- Do not eat or drink (AHA/ASA 2021)
- Do not take aspirin or any new medication unless told by 911 dispatcher (AHA/ASA 2021)
- Bring medication list (AHA/ASA 2021)
Contact provider when:
- Any BE-FAST symptom — call 911, do not wait (AHA/ASA 2021)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Persistent focal neurologic deficit at presentation (NIHSS >0) per AHA/ASA 2021
- [LIFE_THREATENING] Recurrent TIA or progression to stroke after starting therapy (AHA/ASA 2021)
- [LIFE_THREATENING] Hemorrhage on non-contrast CT (AHA/ASA 2021)

Citations

- 2021 AHA/ASA Stroke Prevention Guidelines (after stroke / TIA) + 2024 AHA Primary Prevention of Stroke [PMID:34024117](https://pubmed.ncbi.nlm.nih.gov/34024117/)
- Cited evidence (PMID 38813629) [PMID:38813629](https://pubmed.ncbi.nlm.nih.gov/38813629/)
- Cited evidence (PMID 23803136) [PMID:23803136](https://pubmed.ncbi.nlm.nih.gov/23803136/)
- Cited evidence (PMID 29766750) [PMID:29766750](https://pubmed.ncbi.nlm.nih.gov/29766750/)
- Cited evidence (PMID 32579952) [PMID:32579952](https://pubmed.ncbi.nlm.nih.gov/32579952/)

Last reconciled with current guidelines: 2026-05-10.
References