latha g. stead, md, facep transient ischemic attack patient update: the optimal management of...
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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
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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.
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Latha G. Stead, MD, FACEP
Disclosures
• Dr. Stead & Colleagues have no conflicts of interest or financial disclosures
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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.
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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%
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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.
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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.
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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.
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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.
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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.
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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
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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.
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Latha G. Stead, MD, FACEP
Results- TIA subtype
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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.
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Cost effectiveness
• EDOU mean cost: $1709
• Inpatient mean cost: $3600
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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
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Latha G. Stead, MD, FACEP
PERFORMANCE OF RISK STRATIFICATION SCORES
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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.
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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)
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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.
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Latha G. Stead, MD, FACEP
OBJECTIVE
• Study the performance of the ABCD2 score in predicting short term risk of subsequent stroke following a TIA.
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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
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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
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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
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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
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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.
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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
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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
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Latha G. Stead, MD, FACEP
Thank You !www.ferne.org
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