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neuro.tia.v1PRODUCTION
neuro.tia.v1

Transient Ischemic Attack

neurologyacuteadult
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Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Transient focal neurologic deficit fully resolved + tissue-based TIA confirmation requires DWI-negative MRI (AHA/ASA 2021)

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Advance rule
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Symptoms resolved at presentation + duration <24 h documented

Patient inputs (20)

ECG + telemetry ≥24 h for AF detection; consider 30-day MCT or ILR if cryptogenic (CRYSTAL-AF Sanna NEJM 2014 PMID 24963567)

ABCD2 / ABCD3-I age criterion ≥60 = +1 point; age guides anticoagulation bleed risk (AHA/ASA 2021)

Prior TIA flag — ABCD3 (CHANCE-2 Wang NEJM 2021 PMID 34708996) + dual TIA in 7 days adds urgency

LDL <70 (or <55 if very-high risk) target on high-intensity statin (SPARCL Amarenco NEJM 2006 PMID 16899775; 2026 ACC/AHA Lipid)

TIA defined as <24 h symptom duration; tissue-based definition requires DWI-negative MRI (AHA/ASA 2021)

DWI-positive on MRI re-classifies clinical TIA as minor stroke (~30% prevalence); routes to neuro.ischaemic-stroke.v1 (AHA/ASA 2021 Class I)

Identifies symptomatic carotid stenosis ≥50% (CEA/CAS within 14 d per NASCET/AHA/ASA 2021 Class I) and intracranial atherosclerosis

Baseline labs for antiplatelet/anticoag initiation; platelet count + INR + Cr (AHA/ASA 2021)

Hypoglycaemia is a common TIA mimic — correct FIRST (AHA/ASA 2021)

ABCD2 duration: ≥60 min = +2, 10-59 min = +1; >24 h re-classifies as stroke (AHA/ASA 2021)

ABCD2 clinical features: speech disturbance without weakness = +1 (AHA/ASA 2021)

ABCD2 clinical features: unilateral weakness = +2 (AHA/ASA 2021)

ABCD2 BP ≥140/90 = +1; chronic BP control reduces recurrent stroke (PROGRESS perindopril-indapamide; 2025 AHA/ACC HTN)

ABCD2 diabetes = +1; HbA1c <7% target post-TIA (AHA/ASA 2021; ADA 2026)

DOAC/warfarin/heparin on board alters Rx pathway; bleeding risk via HAS-BLED

TTE for LV thrombus / valvular source; TEE if PFO suspected in young patient (AHA/ASA 2021)

Diabetes secondary prevention HbA1c <7% (ADA 2026)

Alternative or adjunct to CTA for carotid stenosis screening (AHA/ASA 2021)

AF source mandates DOAC; timing 1-3-6-12 day rule by NIHSS severity (2024 ESC AF; ARISTOTLE Granger NEJM 2011 PMID 21870978)

CYP2C19 LOF allele → consider ticagrelor + ASA in place of clopidogrel + ASA (CHANCE-2 Wang NEJM 2021 PMID 34708996)

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Severity triggers (8)

8 need judgement
  • informationalseverehigh_risk_tia_abcd2_ge_4
    ABCD2 ≥4 OR ABCD3-I high-risk; or carotid stenosis ≥50% symptomatic; or AF detected; or crescendo TIA — admit + STAT workup + DAPT (AHA/ASA 2021 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecrescendo_recurrent_tia
    Crescendo TIA (≥2 episodes within 24 h) OR recurrent TIA within 7 d — admit always regardless of ABCD2 (AHA/ASA 2021 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretia_with_af_detected
    TIA + AF detected on ECG / telemetry / Holter / ILR → DOAC per 1-3-6-12 day rule by NIHSS severity (CHA2DS2-VASc auto-≥2 with TIA) (2024 ESC AF; ARISTOTLE PMID 21870978)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_carotid_stenosis_ge_50
    Symptomatic carotid stenosis ≥50% on ipsilateral side (NASCET measurement) → CEA/CAS within 14 d (AHA/ASA 2021 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredwi_positive_minor_stroke
    Clinically diagnosed TIA + DWI-positive infarct on MRI — re-classify as minor stroke; route to neuro.ischaemic-stroke.v1; eligible for DAPT × 21 d if NIHSS ≤3 (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatelow_risk_tia_abcd2_lt_4
    ABCD2 <4 + complete imaging negative + reliable follow-up — rapid-access TIA clinic within 24 h (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecryptogenic_tia_extended_monitoring
    Cryptogenic TIA after standard workup negative (no LAA, no CE, no SVO, no ODE) → 30-day MCT or implantable loop recorder per CRYSTAL-AF (Sanna NEJM 2014 PMID 24963567)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildtia_mimic_suspected
    TIA mimic suspected — seizure with Todd paralysis, complicated migraine aura, hypoglycemia, syncope, conversion disorder, vestibular migraine (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 TIA antiplatelet + lipid + BP + AF-anticoag bundle (AHA/ASA 2021)
axis: tia_acute_secondary_preventionstep 1 - Step 1 — Aspirin loading (immediate, AHA/ASA 2021 Class I)
Selected step "Step 1 — Aspirin loading (immediate, AHA/ASA 2021 Class I)" — TIA confirmed clinically; no active bleeding; no thrombolysis given (TIA already self-resolved)
  • aspirin
    first line
    antiplatelet_COX1
    162-325 mg PO loading × 1, then 81 mg PO daily • PO • load then daily
    triggers: tia_confirmed, no_active_bleed
    IST 1997 / CAST 1997 — early aspirin reduces recurrent stroke; AHA/ASA 2021 Class I
    rxcui 1191

outpatient playbook — drug actions (6)

  1. 1. aspirin 81 mg daily (post-DAPT taper)
    81 mg PO daily • PO • once daily
    trigger: Day 21 (POINT/CHANCE) OR day 30 (CHANCE-2/THALES) — drop to monotherapy
    AHA/ASA 2021 long-term antiplatelet for non-cardioembolic TIA
  2. 2. apixaban (lifelong if AF)
    5 mg PO BID • PO • BID
    trigger: AF source confirmed
    ARISTOTLE PMID 21870978; 2024 ESC AF
  3. 3. atorvastatin 80 mg daily
    80 mg PO daily • PO • once daily
    trigger: All TIA / minor stroke patients
    SPARCL PMID 16899775; 2026 ACC/AHA Lipid
  4. 4. ezetimibe ± PCSK9i if LDL >55 on max statin
    Ezetimibe 10 mg PO daily; evolocumab 140 mg SC q2 wk • PO / SC • daily / q2 wk
    trigger: LDL ≥55-70 despite max-tolerated statin
    IMPROVE-IT + FOURIER — adds toward LDL target (2026 ACC/AHA Lipid)
  5. 5. lisinopril + chlorthalidone
    Lisinopril 10-40 mg + chlorthalidone 12.5-25 mg PO daily • PO • daily
    trigger: BP ≥130/80
    2025 AHA/ACC HTN
  6. 6. varenicline / NRT / bupropion
    Per agent • PO / patch / lozenge • per agent
    trigger: Active tobacco use
    AHA/ASA 2021 Class I smoking cessation

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Transient focal neurological deficit fully resolved at presentation (AHA/ASA 2021); Transient aphasia / dysarthria resolved (AHA/ASA 2021); Transient hemiparesis / facial droop resolved (AHA/ASA 2021).

Objective

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

Assessment

**Transient Ischemic Attack** (neuro.tia.v1).
Phenotype framing: TIA vs minor stroke (DWI-positive → route to neuro.ischaemic-stroke.v1) vs mimic (seizure / migraine aura / hypoglycemia / syncope / conversion) vs ongoing stroke (re-classify if deficit persists)
Scope: Transient focal neurologic deficit fully resolved + tissue-based TIA confirmation requires DWI-negative MRI (AHA/ASA 2021)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute TIA antiplatelet + lipid + BP + AF-anticoag bundle (AHA/ASA 2021)** — step "Step 1 — Aspirin loading (immediate, AHA/ASA 2021 Class I)".
1. aspirin 162-325 mg PO loading × 1, then 81 mg PO daily PO load then daily (antiplatelet_COX1, first line) — IST 1997 / CAST 1997 — early aspirin reduces recurrent stroke; AHA/ASA 2021 Class I

Setting playbook (outpatient) — Rapid-access TIA clinic / stroke clinic follow-up at 7-14 d + 90 d + 12 mo: medication reconciliation, BP <130/80, LDL <55-70, DAPT taper at day 21, smoking cessation, AF surveillance, depression + cognitive screen, driving evaluation (AHA/ASA 2021)
2. aspirin 81 mg daily (post-DAPT taper) 81 mg PO daily PO once daily — Day 21 (POINT/CHANCE) OR day 30 (CHANCE-2/THALES) — drop to monotherapy (AHA/ASA 2021 long-term antiplatelet for non-cardioembolic TIA)
3. apixaban (lifelong if AF) 5 mg PO BID PO BID — AF source confirmed (ARISTOTLE PMID 21870978; 2024 ESC AF)
4. atorvastatin 80 mg daily 80 mg PO daily PO once daily — All TIA / minor stroke patients (SPARCL PMID 16899775; 2026 ACC/AHA Lipid)
5. ezetimibe ± PCSK9i if LDL >55 on max statin Ezetimibe 10 mg PO daily; evolocumab 140 mg SC q2 wk PO / SC daily / q2 wk — LDL ≥55-70 despite max-tolerated statin (IMPROVE-IT + FOURIER — adds toward LDL target (2026 ACC/AHA Lipid))
6. lisinopril + chlorthalidone Lisinopril 10-40 mg + chlorthalidone 12.5-25 mg PO daily PO daily — BP ≥130/80 (2025 AHA/ACC HTN)
7. varenicline / NRT / bupropion Per agent PO / patch / lozenge per agent — Active tobacco use (AHA/ASA 2021 Class I smoking cessation)

Non-pharmacologic actions:
- AHA "Get With The Guidelines" outcome documentation — mRS, smoking cessation, statin compliance, BP target, antithrombotic on board, AF screen completed (AHA/ASA 2021)
- Recurrent-symptom counselling — call 911 for any focal deficit, do NOT delay
- Sleep study if STOP-BANG ≥3 (AHA/ASA 2021)
- Aerobic exercise prescription 150 min/wk moderate intensity (AHA/ASA 2021 Class I)
- Mediterranean diet counselling (PREDIMED trial)
- Outpatient 30-day MCT or ILR placement if cryptogenic per CRYSTAL-AF (Sanna NEJM 2014 PMID 24963567)
- Vascular surgery follow-up + carotid duplex at 6 mo, 12 mo, then annually if CEA/CAS performed

AVOID / contraindication checks:
- DAPT_max_21d_to_avoid_bleeding_signal (POINT/CHANCE 21 d cap)
- CYP2C19_LOF_prefer_ticagrelor_over_clopidogrel (CHANCE 2 PMID 34708996)
- DOAC_first_line_unless_mechanical_valve_or_severe_mitral_stenosis (2024 ESC AF)
- Apixaban_renal_dose_2.5mg_BID_if_2_of_3_criteria (ARISTOTLE PMID 21870978)
- Statin_check_baseline_LFTs_and_repeat_at_4 6wk (2026 ACC/AHA Lipid)
- High_intensity_statin_first_line_post_TIA (SPARCL PMID 16899775)
- CEA_CAS_within_14d_for_symptomatic_carotid_>=50pct (NASCET/AHA/ASA 2021 Class I)

Monitoring

Regimen monitoring:
- Telemetry inpatient ≥24 h for AF detection (AHA/ASA 2021 Class I)
- Outpatient 30-day MCT or ILR if cryptogenic per CRYSTAL-AF (Sanna NEJM 2014 PMID 24963567)
- Lipid panel at 4-6 wk after statin start; q6-12 mo thereafter (2026 ACC/AHA Lipid)
- BP home log + clinic q3 mo until <130/80; then q6 mo (2025 AHA/ACC HTN)
- Renal function q6 mo on DOAC; q3 mo if CrCl 30-50 (2024 ESC AF)
- HbA1c q3 mo if DM until <7%, then q6 mo (ADA 2026)
- Carotid duplex 6 mo + 12 mo post CEA/CAS, then annually (AHA/ASA 2021)

Setting (outpatient) monitoring:
- Clinic visit 7-14 d post-discharge for medication reconciliation (AHA/ASA 2021)
- Stroke clinic 90 d + 12 mo (mRS, secondary prevention audit, AF surveillance)
- BP home log + clinic q3 mo until at goal, then q6 mo (2025 AHA/ACC HTN)
- Lipid panel at 4-6 wk after statin start then q6-12 mo (2026 ACC/AHA Lipid)
- HbA1c q3 mo if DM until controlled, then q6 mo (ADA 2026)
- Renal function q6 mo on DOAC; q3 mo if CrCl 30-50 (2024 ESC AF)
- PHQ-9 + MoCA at 90 d, 6 mo, 12 mo if minor-stroke phenotype (AHA/ASA 2021)

Follow-up plan: Secondary prevention: BP <130/80 (2025 AHA/ACC HTN); LDL <55-70 (2026 ACC/AHA Lipid); DOAC adherence; smoking cessation; HbA1c <7% if DM; mRS / NIHSS check; CEA/CAS surveillance if performed (AHA/ASA 2021)
- Close-out criterion: Secondary-prevention bundle on board + stroke clinic follow-up scheduled

Monitoring phase: In-patient telemetry ≥24 h for AF detection; outpatient — MCT or ILR if cryptogenic; recurrent symptoms → ED (AHA/ASA 2021)

Disposition

Current setting: outpatient — Rapid-access TIA clinic / stroke clinic follow-up at 7-14 d + 90 d + 12 mo: medication reconciliation, BP <130/80, LDL <55-70, DAPT taper at day 21, smoking cessation, AF surveillance, depression + cognitive screen, driving evaluation (AHA/ASA 2021)

Disposition criteria:
- Continue indefinite secondary-prevention regimen — no de-escalation of antiplatelet/anticoag unless explicit risk-benefit shift (AHA/ASA 2021)
- Transition to community-based exercise programs at 6-12 mo per functional status

Escalation triggers (move to higher acuity):
- Any new TIA-spectrum event → ED immediately (AHA/ASA 2021)
- BP persistently >140/90 despite 3-drug regimen → resistant HTN workup (cardio.htn.resistant.v1)
- AF newly detected on outpatient monitor → start DOAC per 2024 ESC AF
- PHQ-9 ≥15 OR suicidal ideation → urgent psych referral
- Statin intolerance → ezetimibe + PCSK9i (2026 ACC/AHA Lipid)
- DOAC bleeding → temporary hold, reversal if life-threatening (idarucizumab / andexanet), reassess

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] ABCD2 ≥4 OR ABCD3-I high-risk; or carotid stenosis ≥50% symptomatic; or AF detected; or crescendo TIA — admit + STAT workup + DAPT (AHA/ASA 2021 Class I)
- [SEVERE] Crescendo TIA (≥2 episodes within 24 h) OR recurrent TIA within 7 d — admit always regardless of ABCD2 (AHA/ASA 2021 Class I)
- [SEVERE] TIA + AF detected on ECG / telemetry / Holter / ILR → DOAC per 1-3-6-12 day rule by NIHSS severity (CHA2DS2-VASc auto-≥2 with TIA) (2024 ESC AF; ARISTOTLE PMID 21870978)

Citations

- 2021 AHA/ASA Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack + 2024 ESC AF + 2025 AHA/ACC HTN + 2026 ACC/AHA Dyslipidemia + ADA 2026 [PMID:34024117](https://pubmed.ncbi.nlm.nih.gov/34024117/)
- Cited evidence (PMID 17258668) [PMID:17258668](https://pubmed.ncbi.nlm.nih.gov/17258668/)
- Cited evidence (PMID 20934388) [PMID:20934388](https://pubmed.ncbi.nlm.nih.gov/20934388/)
- Cited evidence (PMID 27751555) [PMID:27751555](https://pubmed.ncbi.nlm.nih.gov/27751555/)
- Cited evidence (PMID 17928046) [PMID:17928046](https://pubmed.ncbi.nlm.nih.gov/17928046/)

Last reconciled with current guidelines: 2026-05-18.
References
  • 2021 AHA/ASA Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack + 2024 ESC AF + 2025 AHA/ACC HTN + 2026 ACC/AHA Dyslipidemia + ADA 2026 — PMID:34024117
  • Cited evidence (PMID 17258668) — PMID:17258668
  • Cited evidence (PMID 20934388) — PMID:20934388
  • Cited evidence (PMID 27751555) — PMID:27751555
  • Cited evidence (PMID 17928046) — PMID:17928046