Latha G. Stead, MD, FACEP

Transient Ischemic Attack Transient Ischemic Attack Patient Update: Patient Update:

The Optimal Management of The Optimal Management of Emergency Department Emergency Department

Patients Patients With Suspected Cerebral With Suspected Cerebral

IschemiaIschemia

Latha G. Stead, MD, FACEP

Suspected TIA Patients in the Emergency Department: The Mayo Clinic Experience

Latha G. Stead, MD

Professor & Chair,

Division of Emergency Medicine Research

Mayo Clinic College of Medicine,

Rochester, Minnesota, USA.

Latha G. Stead, MD, FACEP

Disclosures

• Dr. Stead & Colleagues have no conflicts of interest or financial disclosures

Latha G. Stead, MD, FACEP

BACKGROUND

• TIA is a common ED presentation:1 to 3 of every 1000 ED visits in the United States.

• True incidence may be higher; many patients with TIAs never come to medical attention.

• Risk of subsequent cerebral infarction is significant and highest during the first 48 hrs.

• Because of this risk, many patients are hospitalized for diagnostic evaluation.

Latha G. Stead, MD, FACEP

Risk of stroke after TIA- the literature

After a TIA the risk of stroke is highest in the following days:

• 2-day risk ranging from 1.4% to 7.1% , with an estimated average of 3.7%

• 30-day risk ranging from 1.8% to 22.2%, with an estimated average of 7.5%

• 90-day risk ranging from 1.3% to 20.1%, with an estimated average of 10.0%

Latha G. Stead, MD, FACEP

BACKGROUND

• With rising costs and hospital bed shortage, TIA evaluation and managemnt becomes a conundrum.

• In this study, we sought to evaluate the feasibility of a protocol for evaluation of TIA in an Emergency Department observation unit (EDOU), and assess the risk of early stroke after such an evaluation.

Latha G. Stead, MD, FACEP

METHODS

• Prospective observational cohort study

• tertiary care academic medical center 79,000 annual ED visits

• study period: January 2004 - December 2006.

• study population: consecutive pts >18 yrs who presented to the ED with hx of signs or sxs suggestive of TIA.

Latha G. Stead, MD, FACEP

The Protocol

1. Determine time of onset of symptoms.

2. Order a head CT.

3. O2 by nasal cannula.

4. Check glucose levels at bedside.– If <60mg/dL, give 1 amp. Dextrose 50%.

5. Obtain an oral temperature. – If >38 C, give 1g Tylenol®.

6. Request Neurology consult.

Latha G. Stead, MD, FACEP

The Protocol contd.

7. Give 324 mg aspirin unless: intracranial hemorrhage, or true allergy.

8. ECG and laboratory tests (stroke panel)

9. Do not anticoagulate acutely.

10.Obtain bilateral carotid ultrasound.

11.Vital sign monitoring and neurological function assessment every 2 hr.

Latha G. Stead, MD, FACEP

Patient education

• Patients watch a video “Recognizing and Preventing Stroke” while in the EDOU.

• TIA/Stroke education materials provided by nurse.

Latha G. Stead, MD, FACEP

Patient disposition

• Patient discharged home with 1. TIA follow up neurology clinic appointment

within 72 hrs.

2. Prescription for aspirin or other antithrombotic

• Patient admitted to inpatient stroke service1. Endarterectomy

2. Anticoagualtion

Latha G. Stead, MD, FACEP

Results- demographics (n=418)

• Mean age 73.0 years +/SD 13.3 years.

• A little over one half (53%) are male

• Co-morbidities:– Hypertension 71.5%– diabetes mellitus 20.1%– prior TIA 19.6%– prior ischemic stoke 19.6% of the cohort.

Latha G. Stead, MD, FACEP

Results- TIA subtype

Latha G. Stead, MD, FACEP

Results- risk of early ischemic stroke (IS)

• 4 pts had IS w/in 2 d; incidence = 0.96% (2 in admitted gr; 2 in d/h gr.)

• 5 pts had IS w/in 7 d; incidence = 1.2%2 in admitted gr; 3 in d/h gr.)

• 8 pts had IS w/in 30 d; incidence = 1.9% (3 in admitted gr; 5 in d/h gr.)

• There was no clinical or statistical significance for any of the results.

Cost effectiveness

• EDOU mean cost: $1709

• Inpatient mean cost: $3600

Latha G. Stead, MD, FACEP

Conclusions

• TIA can be evaluated in the EDOU

• Such management appears to be just as safe as inpatient mgmt

• It is more cost effective

Latha G. Stead, MD, FACEP

PERFORMANCE OF RISK STRATIFICATION SCORES

Latha G. Stead, MD, FACEP

BACKGROUND

• A score derived in the Oxfordshire Community Stroke Project, the ABCD and the California score were able to identify individuals at higher early risk of stroke after a TIA .

• All combinations of individual components from the California and ABCD score were used to create the ABCD2 score.

Latha G. Stead, MD, FACEP

BACKGROUND

• The ABCD2 score is composed of:• Age >=60 yrs (1 point)• sBP >=140mmHg or dBP >90mmHg (1 point)• Clinical features

– Unilateral weakness (2 points)– Isolated speech disturbance (1 point)

• Duration of symptoms– >= 60 min. (2 points)– 10 to 59 min. (1 point)– < 10 min. (0 points)

• Diabetes (present = 1point)

Latha G. Stead, MD, FACEP

• We extended this study to a cohort of 637 consecutive TIA patients who presented to our ED from December 2001 to 2006.

Latha G. Stead, MD, FACEP

OBJECTIVE

• Study the performance of the ABCD2 score in predicting short term risk of subsequent stroke following a TIA.

Latha G. Stead, MD, FACEP

RESULTS

• Distribution of ABCD2 score (%) was as follows:

0.22.7

9.1

17.7

27.0 25.7

13.7

3.9

0 1 2 3 4 5 6 7

Latha G. Stead, MD, FACEP

RESULTS• There were a total of 15 strokes within 90 days following TIA.

• Incidence of short term risk of ischemic stroke according to ABCD2 score:

ABCD2 score7 days 30 days 90 days

  Stroke No stroke Stroke No stroke Stroke No stroke

N= 6 N= 631 N=12 N= 625 N=15 N= 622

Low (0-3) 2 187 4 185 4 185

Interm (4-5) 1 335 4 332 7 329

High (6-7) 3 109 4 108 4 108

7 day risk of subsequent stroke

2

6

10.9

1.10.3

2.7

0

2

4

6

8

10

12

low intermediate high

ABCD2 ED cohort Our ED chort

90 day risk of subsequent stroke

3.7

9.9

17.5

2.1 2.13.6

0

2

4

6

8

10

12

14

16

18

20

low intermediate high

ABCD2 ED cohort Our ED cohort

Latha G. Stead, MD, FACEP

RESULTS

• There was no relationship between ABCD2 score at presentation and subsequent stroke (p=0.48) following TIA at 7 or 90 days.

Latha G. Stead, MD, FACEP

DISCUSSION

• Our overall incidence of stroke is comparable to ED Oxfordshire & California cohorts

• Possible explanations for this lower incidence of stroke after TIA in our cohort:– Timely intervention and efficient secondary stroke

prevention strategies.– Referral bias

Latha G. Stead, MD, FACEP

CONCLUSION

• In our population, with the nature of our ED and neurological evaluation, the ABCD2 score was not a predictor of subsequent stroke at 7 and 90 days after TIA

Latha G. Stead, MD, FACEP

Thank You !www.ferne.org

<Stead.Latha@mayo.edu>

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