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Suspected transient ischaemic attack in a patient with atrial fibrillation — MSRA MCQ

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Hardall topics relevant for this examSuspected transient ischaemic attack in a patient with atrial fibrillationMSRA

A 76-year-old man attends general practice 18 hours after a 12-minute episode of expressive dysphasia and right-hand weakness. His symptoms resolved completely before he arrived home. He has no headache, seizure activity, head injury or recent similar episodes. Capillary glucose is 6.1 mmol/L. He is currently neurologically normal. He has hypertension, type 2 diabetes mellitus and paroxysmal atrial fibrillation. He declined anticoagulation previously. His ECG today confirms atrial fibrillation with a ventricular rate of 82 beats/minute. He takes ramipril and metformin. He has had no recent gastrointestinal bleeding, peptic ulcer disease or aspirin allergy. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Give aspirin 300 mg immediately and refer immediately for specialist TIA assessment

Explanation lettering: D = shown as A · A = shown as B · B = shown as C · E = shown as D · C = shown as E

This is a suspected TIA: he had abrupt, transient focal cortical neurological symptoms, has recovered fully, and hypoglycaemia has been excluded. NICE recommends giving aspirin 300 mg immediately, unless contraindicated, and immediate referral for specialist assessment, with assessment within 24 hours of symptom onset. His atrial fibrillation and high CHA2DS2-VASc risk make long-term anticoagulation likely, but this should follow urgent specialist assessment and confirmation of the diagnosis and secondary-prevention plan; it does not replace the immediate suspected-TIA pathway. A is attractive because atrial fibrillation is a likely cardioembolic source, but substituting immediate apixaban for aspirin and downgrading referral to routine assessment is inappropriate. C is wrong because CT is not routinely indicated for suspected TIA without features suggesting an alternative diagnosis. D is incorrect because ABCD2 must not be used to determine referral urgency. E provides an inadequate initial aspirin dose and delays time-critical specialist assessment.

Reference: NICE NG128: Stroke and transient ischaemic attack in over 16s: diagnosis and initial management, initial management of suspected and confirmed TIA (Updated 2022) — https://www.nice.org.uk/guidance/NG128/chapter/recommendations NICE NG128: Stroke and transient ischaemic attack in over 16s: diagnosis and initial management, imaging for suspected TIA (Updated 2022) — https://www.nice.org.uk/guidance/NG128/chapter/recommendations NICE NG196: Atrial fibrillation: diagnosis and management, stroke prevention (2021) — https://www.nice.org.uk/guidance/NG196/chapter/recommendations