national-clinical-guidelines-for-stroke-fourth-edition

National clinical guideline for stroke
B People with a suspected TIA, that is, they have no neurological symptoms at the time
of assessment (within 24 hours), should be assessed as soon as possible for their risk
of subsequent stroke by using a validated scoring system such as ABCD2 .
C Patients with suspected TIA who are at high risk of stroke (eg an ABCD2 score of 4 or
above) should receive:
● aspirin or clopidogrel (each as a 300 mg loading dose and 75 mg thereafter) and a
statin, eg simvastatin 40 mg started immediately
● specialist assessment and investigation within 24 hours of onset of symptoms
● measures for secondary prevention introduced as soon as the diagnosis is
confirmed including discussion of individual risk factors.
D People with crescendo TIA (two or more TIAs in a week), atrial fibrillation or those
on anticoagulants should be treated as being at high risk of stroke (as described in
recommendation 4.2.1C) even though they may have an ABCD2 score of 3 or below.
E Patients with suspected TIA who are at low risk of stroke (eg an ABCD2 score of 3 or
below) should receive:
● aspirin or clopidogrel (each as a 300 mg loading dose and 75 mg thereafter) and a
statin, eg simvastatin 40 mg started immediately
● specialist assessment and investigations as soon as possible, but definitely within 1
week of onset of symptoms
● measures for secondary prevention introduced as soon as the diagnosis is
confirmed, including discussion of individual risk factors.
F People who have had a TIA but present late (more than 1 week after their last
symptom has resolved) should be treated as though they are at a lower risk of stroke
(see recommendation 4.2.1E).
G Patients with TIA in atrial fibrillation should be anticoagulated with an agent that has
rapid onset in the TIA clinic once intracranial bleeding has been excluded and if there
are no other contraindications.
4.2.2 Sources
A Consensus; National Institute for Health and Clinical Excellence 2010d
B National Institute for Health and Clinical Excellence 2008b
C National Institute for Health and Clinical Excellence 2008b; Luengo-Fernandez et al
2009; Rothwell et al 2007
D National Institute for Health and Clinical Excellence 2008b
E National Institute for Health and Clinical Excellence 2008b; Luengo-Fernandez et al
2009; Rothwell et al 2007
F National Institute for Health and Clinical Excellence 2008b
G Consensus
4.2.3 Implications
To achieve these recommendations additional training of staff will be required so that
they are able to assess immediate risk in people presenting with a possible TIA, and to
significantly streamline the process of investigation. This may require additional
40 © Royal College of Physicians 2012