Recognition and management of transient ischaemic attack in primary care.

Not only do we advise our patients and offer interventions to control vascular risk factors but we are often the first port of call for patients seeking health care after a transient ischaemic attack (TIA). 1 The neurologist's definition of TIA has recently changed and patients must have had a transient clinical deficit suggesting focal brain or retinal dysfunction with a 'tissue' criterion of normal cerebral imaging. 2 This will rule out stroke, which can present clinically with transient symptoms. Urgent action is needed in primary care to ensure that stroke risk is minimised after TIA. niCe guidanCe and stroke risk Patients with TIA are in an accelerated phase of stroke risk, and those at highest risk of stroke within seven days of TIA can be predicted using the ABCD2 score, 3 calculated using the patients' age, blood pressure in the consultation, whether speech or weakness were present, the duration of the transient event, and the presence of diabetes. The high early risk of stroke can be reduced with urgent specialist assessment and interventions, 4 and consequently NICE guidance on the management of TIA in primary care recommends using the ABCD2 score to determine the urgency of specialist referral (most TIA clinics incorporate the ABCD2 score in their referral proforma), although little guidance is given on how to recognise TIA. The only intervention recommended for primary care, pending specialist confirmation of the diagnosis, is the prescription of aspirin. 5 Substantial questions therefore remain about the optimal management of TIA in primary care. When should We susPeCt transient isChaeMiC attaCk? There is no guidance on how we should be selecting patients with TIA from the background 'denominator' population with transient neurological symptoms. We have no reliable methods of detecting TIA at the initial consultation in primary care, a difficulty demonstrated in TIA clinic audit figures where at least 50% of patients referred from primary care do not have TIA. 6 Determining who we should suspect as having had a TIA is important as the current UK care model is based on urgent outpatient clinics, which have limited capacity. 5 As the time between symptom onset and definitive intervention should be within 24 hours for patients with TIA at highest predicted stroke risk, 5 delays in accessing specialist assessment should be minimal. However, this time limit for assessment is currently not met for the majority of high risk patients. 7 Reducing the …