Stratified, Urgent Care for Transient Ischemic Attack Results in Low Stroke Rates

Abstract

Background and Purpose-Transient ischemic attack (TIA) is a marker for early risk of stroke. No previous studies have assessed the use of urgent stroke prevention clinics for emergency department (ED) patients with TIA. We hypothesized that an ABCD2-based ED triaging tool for TIA with outpatient management would be associated with lower 90-day stroke rate than that predicted by ABCD2. Methods-A cohort of prospectively identified patients presenting with symptoms suggestive of TIA seen in 2 tertiary-careEDs. These patients were divided into 3 strata based on their ACBD2 score, and triage targets were set for each stratum. All patients received the same standard of care in the Stroke Clinic regardless of their risk score. Primary outcome was stroke by 90 days of index TIA. Secondary outcomes were subsequent TIA, myocardial infarction, or death. Results-One-thousand ninety-three patients met the inclusion criteria; 982 patients completed 90-day follow-up and comprised the final cohort. After stratification, 32%, 49%, and 19% of patients were categorized as low-, moderate-, or high-risk, respectively. The overall 90-day risk of stroke in all patients was 3.2%, compared with the ABCD2-predicted risk of 9.2%. Only 1.6% of patients with TIA/minor stroke were admitted from the ED. The risk of subsequent TIA, myocardial infarction, or death by 90 days was 5.5%, 0.1%, and 1.7%, respectively. Conclusion-Outpatient care in a rapid-access stroke prevention clinic using the ABCD2 score for triage resulted in a low 90-day stroke rate for patients in the ED with TIA. Benefit occurred without requiring admission for most patients.

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

“…Eleven were population-based studies including cohorts from the UK (Oxford), Ireland (Dublin), USA (Texas and Minnesota), Canada (Alberta) and northern Portugal. 9 23,127,129,131,135,136,143,149,153,159 and by both in four; 62,158,162,163 in three studies 120,138,155 this information was not reported.…”

“…telephone interviews, medical records, letters) in 11 studies, 65,131,[146][147][148]153,154,158,160,162,163 and was not reported in two studies.…”

“…121 The benefit of medical therapy to prevent recurrent stroke after TIA is greatest if given as early as possible after TIA. 24,122,153 Likewise, the benefit of endarterectomy for symptomatic carotid stenosis is highest when performed within 2 weeks after the index event and falls rapidly with increasing delay. 171 A deferred intervention would be futile, or at least of much reduced benefit, as the high-risk period without medical or surgical intervention will have passed.…”

“…Four studies assessed population-based cohorts, 132,140,144,151 three studies hospital-based cohorts, 142,155,160 nine studies patients from EDs, 87,134,135,143,149,153,158,162,163 and 10 studies patients from specialist stroke or neurology units. 62,[137][138][139]145,146,150,152,164,177 Full-text papers assessed (n = 61)…”

Isolated transient aphasia at emergency presentation is associated with a high rate of cardioembolic embolism

“…9,10 The rapid initiation of antiplatelet agents and early assessment in a dedicated stroke prevention clinic can cut this risk dramatically, and both interventions were used in our cohort, 14,21,22 as evidenced by a relatively low overall rate of stroke. Despite these interventions, patients with isolated aphasia in this study had double the rate of stroke at all time points assessed and a 7.3% rate of stroke at 90 days.…”