• Aspirin (300 mg daily) should be started immediately, unless it is contraindicated or not tolerated, and continued at this dose until reviewed in secondary care:
• Do not delay initiating aspirin treatment in people with uncontrolled blood pressure.
• Consider gastroprotection (e.g. a proton pump inhibitor) if the person is at high risk of adverse gastrointestinal effects or experiences aspirin-induced dyspepsia.
• Consider clopidogrel (75 mg daily — unlicensed use) only if the person is allergic or cannot tolerate aspirin.
• Both aspirin and clopidogrel are contraindicated in people with active gastrointestinal bleeding or ulceration.
• For further information on antiplatelet therapy (including managing gastrointestinal issues), see the CKS topic on Antiplatelet treatment.
• For people who are already prescribed low-dose aspirin:
• Continue the current dose of aspirin until reviewed in secondary care.
• If non-compliance is suspected, start aspirin 300 mg daily immediately (see above).
• Check for unrecognized risk factors for transient ischaemic attack, such as atrial fibrillation.
• For people who have a transient ischaemic attack while on warfarin:
• Admit immediately for an urgent brain scan to exclude haemorrhagic stroke.
• Other measures for secondary prevention should be introduced as soon as the diagnosis is confirmed.

In depth

Use the ABCD² scoring system to help assess the risk of stroke early after a transient ischaemic attack:

• A — age: 60 years of age or more, 1 point.
• B — blood pressure at presentation: 140/90 mmHg or greater, 1 point.
• C — clinical features: unilateral weakness, 2 points; speech disturbance without weakness, 1 point.
• D — duration of symptoms: 60 minutes or longer, 2 points; 10–59 minutes, 1 point.
• D — presence of diabetes: 1 point.
• Points from the individual items are added to give the ABCD² score.
• People with a score of 4 or more are regarded as being at high risk of an early stroke.

In depth

• Consider admission if:
• The person has atrial fibrillation — they are at higher risk for early stroke.
• Refer immediately (the target is to be seen by a specialist and investigated within 24 hours of the start of symptoms) if:
• The person's ABCD2 score is 4 or more — they are at higher risk for early stroke.
• The person has had two or more transient ischaemic attacks (TIAs) within 1 week — they are at higher risk for early stroke.
• The person is on anticoagulation treatment — brain imaging is required to exclude intracranial bleeding.
• Consider immediate referral if:
• The person has recurrent TIAs more than 1 week apart — they are at higher risk for early stroke.
• Refer urgently (the target is to be seen by a specialist and investigated within 1 week of the onset of symptoms) if:
• The person presents sufficiently early and is at lower risk of an early stroke, that is has both:
• An ABCD2 score of 3 or less.
• No other TIAs within the past week.

In depth

Follow local arrangements on which tests should be done in primary care:

• For people with a transient ischaemic attack and at low risk for early stroke, consider arranging the following tests to be done before they are seen in secondary care:
• Blood tests:
• Full blood count.
• Urea and electrolytes.
• Glucose.
• Lipid profile.
• Liver function tests.
• Thyroid-stimulating hormone (TSH).
• Electrocardiography if there are signs of atrial fibrillation, such as an irregular pulse.

In depth

• Provide information about the mechanisms and causes of transient ischaemic attacks (TIAs).
• Advise on the need for people with a TIA to have immediate antithrombotic treatment to reduce the risk of having a stroke within the next few days or weeks. For most people, the appropriate treatment is aspirin.
• Explain to people that they need specialist assessment and treatment and that they need to be seen urgently, within 24 hours, if the imminent risk for a stroke is high:
• The assessment is to clarify the diagnosis (and revise it if necessary), determine the cause of the TIA, and decide what further investigations and treatments are needed.
• Everyone will need blood tests and electrocardiography (ECG). Many people will need a brain scan and/or a scan of their carotid arteries. Some people will need other tests, for example chest radiography, echocardiography, or ambulatory ECG monitoring.
• People with atrial fibrillation or artificial heart valves will usually need anticoagulation (if they not are already on it).
• Advise that, after the specialist assessment and treatment, they can reduce their risk of future stroke and other cardiovascular events by adopting a healthier lifestyle and taking drugs to reduce certain risk factors. For details, see Prevention.
• Advise on driving restrictions:
• The person should not drive until they have been assessed by a specialist (when definitive guidance will be given).
• Driving is not permitted until at least 1 month after a TIA.
• Return to driving should be discussed with the GP or stroke team.
• People who have had a TIA and hold a heavy goods vehicle licence must contact the Driver and Vehicle Licensing Agency.
• For more details, see Driving after a stroke or TIA.
• Additional information and advice is available from the Stroke Association:
• Stroke Information Service, The Stroke Association, 240 City Road, London EC1V 2PR
• Online: www.stroke.org.uk
• Helpline: 0845 3033 100 (calls charged at local rate, open Monday to Friday, 9 a.m. to 5 p.m.)

In depth