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Prise en charge du patient d’AIT ou de l’AVC non débilitant en clinique externe

5e édition
2015 MISE À JOUR
juin 2015

La 5e édition des Recommandations canadiennes pour les pratiques optimales de soins de l’AVC sur les soins de l’AVC en phase hyperaiguë (2015) est publiée dans l’International Journal of Stroke et est accessible en ligne gratuitement. Afin d’accéder aux recommandations spécifiques pour : Prise en charge du patient d’AIT ou de l’AVC non débilitant en clinique externe et tous les autres chapitres des recommandations sur les soins de l’AVC en phase hyperaiguë, veuillez cliquer sur ce lien, qui vous dirigera vers les recommandations en ligne dans l’Internal Journal of Stroke : http://onlinelibrary.wiley.com/doi/10.1111/ijs.12551/full.

Pour la version française de ces recommandations, veuillez ouvrir l’annexe au lien suivant : http://onlinelibrary.wiley.com/store/10.1111/ijs.12551/asset/supinfo/ijs12551-sup-0001-si.zip?v=1&s=cdf3d494242426450aaa522f104ace17857f037a

Tous les autres renseignements connexes, y compris les indicateurs de rendement, les ressources de mise en l’œuvre, les résumés des données probantes et les références, sont accessibles au www.pratiquesoptimales.ca, et non pas sur le site de l’International Journal of Stroke. Veuillez cliquer sur les sections appropriées de notre site Web pour le contenu additionnel.

Justification

L’objectif de la prise en charge en milieu extrahospitalier de l’AIT et de l’AVC ischémique non invalidant est une évaluation et une prise en charge rapides visant à réduire le risque d’une récidive potentiellement plus grave.

Il existe des données claires indiquant que les AIT ou les AVC mineurs sont des états instables qui représentent un avertissement quant au risque élevé d’AVC, d’un autre événement vasculaire ou de décès. Le risque de récidive d’AVC après un AIT est de 10 à 20 % dans les 90 premiers jours et ce risque va en décroissant : la moitié des AVC surviennent en effet dans les deux premiers jours qui suivent l’apparition initiale des symptômes. Le risque d’AVC à sept jours après un AIT peut atteindre plus que 10 % chez les patients victimes d’un AIT, qui présentent des facteurs de risque multiples. Il est prouvé que l’amorce en temps opportun de traitements en vue de la prévention secondaire et l’endartériectomie carotidienne peuvent réduire sensiblement le risque d’un AVC majeur après un AIT ou un AVC ischémique non invalidant initiaux.

Exigences pour le système

  • Éducation du public et des dispensateurs de soins de santé sur l’urgence de procéder à l’évaluation et à la prise en charge de l’AIT et de l’AVC ischémique non invalidant afin de réduire le risque d’une récidive potentiellement plus grave. Les patients et leur famille ont également besoin d’activités continues d’éducation et de soutien en matière de prévention et de prise en charge de l’AVC.
  • Sensibilisation et formation des médecins qui travaillent dans des milieux de soins primaires, secondaires et tertiaires, afin de leur transmettre les connaissances nécessaires à la prise en charge des patients victimes d’un AIT ou d’un AVC ischémique non invalidant.
  • Processus et protocoles dans les milieux de soins de santé communautaires et les établissements de soins actifs qui permettent d’accéder rapidement aux épreuves diagnostiques et aux experts requis dans la prise en charge des patients victimes d’un AIT ou d’un AVC mineur.
  • Cliniques de prévention de l’AVC établies et accessibles ou programmes de prévention des maladies vasculaires plus généraux dans toutes les collectivités, et des fournisseurs de soins de santé au courant de ces services et programmes. Ressources figurant sur des listes aisément accessibles aux médecins de première ligne et autres dispensateurs de soins de santé et mises à jour chaque année.
  • Consultations ou évaluations nouvelles de tout AVC ischémique présumé chez un enfant admis en service d’urgence pédiatrique. Processus de référence établi pour tous les hôpitaux avec l’établissement spécialisé en pédiatrie le plus proche.
Indicateurs de rendement

  1. Proportion des patients victimes d’un AVC en phase aigu ou d’un AIT qui reçoivent leur congé de l’urgence ou d’un séjour à l’hôpital, puis qui sont réadmis avec un nouveau diagnostic d’AVC ou d’AIT moins de 90 jours après le congé des soins actifs pour le premier épisode (prioritaire).
  2. Délai entre la première visite pour des soins médicaux (soins primaires ou urgence) et l’évaluation par un spécialiste en AVC (en clinique ou autre cadre de soins).
  3. Délai entre la première visite pour des soins médicaux et l’imagerie cérébrale (TDM/IRM), l’imagerie vasculaire (Doppler des artères cervicales, angiographie CT, ARM) et un électrocardiogramme.

Notes sur la mesure des indicateurs

  • L’accès aux données et leur qualité lors de la première rencontre et des dates et heures de l’orientation.
  • Données de soins primaires : facturation des médecins. Il faut se fier à la classification internationale des maladies (codes CIM) et non au diagnostic du médecin qui peut être moins précis.
  • Les mesures liées à d’autres recommandations visant la prévention sont également applicables, mais ne sont pas répétées ici.
Ressources pour la mise en œuvre et outils d’application des connaissances

Information à l’intention des dispensateurs de soins de santé

Information à l’intention du patient

Résumé des données probantes

Evidence Table 1 Outpatient Management of TIA and Non-disabling Stroke

The risk of recurrent stroke among patients presenting with TIA or minor stroke is as high as 10% within the first week of symptom onset. A systematic review by Giles & Rothwell (2007) pooled the results from 18 studies published between 1997 and 2007 to obtain estimates of risk. Overall, the reported risk of stroke at days 2 and 7 were 3.1% and 5.2%; however, the rates of recurrence were highly variable. The authors suggested that the observed heterogeneity among studies could be attributed to differences in study method, treatment and setting. Among patients seen urgently by specialist stroke services, the risk estimates were the lowest (0.6% at day 2 and 0.9% at day 7), while the highest rates of recurrence were observed in population-based studies with face to face follow-up. The risks of stroke risk at days 2 and 7 were 6.7% and 10.4%, respectively. More recently, Perry et al. (2014) examined stroke risk in 3,906 patients admitted to 8 emergency departments with TIA over a 5-year period. In this cohort, 86 patients (2.2%) developed subsequent stroke within 7 days and 132 (3.4%) at 90 days. Purroy et al. (2012) reported recurrent stroke in 2.6% of patients within 7 days and 3.9% within 90 days among 1137 patients admitted to 30 centers in Spain with TIA. Following the first 30 days, the risk of recurrent stroke appears to decline.

Several tools are available to assess the likelihood of recurrent stroke in patients presenting with TIA. Purroy et al. (2012) evaluated 8 different tools and reported that ABCD3 and ABCD3V were the best predictors of stroke at 7 and 90 days. The corresponding areas under the ROC curve (AUC) were 0.66 (p=0.004) and 0.69 (p<0.001) at day 7 and 0.61 (p=0.015) and 0.63 (p=0.003), at day 90. All other tools, including the California Risk Score, ABCD, ABCD2, ABCDI, ABCD2I, SPI-II and ESRS were unable to predict stroke risk beyond chance alone (p>0.05) at either days 7 or 90. Perry et al. (2014) identified 13 independent predictor of stroke recurrence within 7 days and used them to develop the Canadian TIA Score. The AUC for this tool was 0.77 (95% CI 0.73-0.82). The strongest predictors of stroke were established antiplatelet therapy, initial diastolic blood pressure ≥110 mm Hg, and initial blood glucose ≥15 mmol/L.

Given that they have been found to be the first point of contact with the healthcare system, it is particularly important for healthcare personnel at non-emergent health centers, such as family physician’s offices to refer patients presenting with symptoms of a suspected stroke or TIA to facilities that can provide appropriate assessment and diagnostic services, Using data from the first 1,000 participants from the Oxford Vascular Study, Chandratheva et al. (2010) reported that 72.1% of patients with minor stroke and 77.3% of patients with TIA, first saw a general practitioner as their first point of contact with the healthcare system. In the same study, only 31.6% of patients correctly identified the cause of their symptoms. Among persons with TIA, a failure to recognize symptoms was associated with delays in seeking medical attention. The median delay in persons correctly recognizing their symptoms was 2.33 hours, compared with 7.25 hours for patients who did not (p=0.005). Other factors that were associated with treatment delays were lack of motor or speech symptoms, shorter duration of TIA, an ABCD2 score<5, a MMSE score of >24, no prior history of stroke and weekend onset. Among persons with suspected stroke, surprisingly, a failure to correctly recognize symptoms was not associated with treatment delays. The only factor that was associated with treatment delays was a history of atrial fibrillation.

Patients who are referred urgently to a TIA clinic for further assessment and treatment following stroke or minor, non-disabling stroke have a reduced risk of recurrent stroke, myocardial infarction and death. The benefit of early treatment following minor stroke or TIA to reduce secondary stroke was evaluated in the EXPRESS study (Rothwell et al. 2007), in which 591 participants from the Oxford Vascular Study, who were not admitted to hospital following minor stroke or TIA, were referred to the EXPRESS clinic. This clinic offered patients more timely access to outpatient services. In phase I of the study (2002-2004), appointments were required to access services, causing delays, while in phase 2 (2004-2007), patients did not need an appointment and treatments (aspirin and clopidogrel) were initiated immediately (median delay 1 day vs. 20 days). The risk of recurrent stroke was significantly lower in patients who were referred to the clinic during Phase 2 (2.1% vs. 10.3%, p=0.0001). Additional reporting from the EXPRESS study (Luengo-Fernandez et al. 2009), which focused on resource utilization, found that hospital admissions for recurrent stroke were lower in phase 2 (5 vs. 25, p=0.001), resulting in significant reductions in both the total number of hospital bed-days (672 vs. 1957 days, p=0.017) and costs. A lower than expected stroke recurrence was also found in the SOS-TIA study (Lavallée et al. 2007). The SOS-TIA clinic was a hospital-based clinic with 24-h access, designed to ensure rapid assessment and treatment. Leaflets were distributed to primary care physicians in the region to inform of the clinics existence. Of the 1085 patients seen over a 2-year period, 53% were seen within 24 hours of symptom onset. The 90-day risk of stroke for all patients in the study was lower than the expected risk based on the ABCD2 score (1.24% vs. 5.96%). The risk of stroke for all patients at one year was 1.95%.

Detecting atrial fibrillation (AF) after a stroke or TIA is important since it is a major risk factor for subsequent stroke and, once identified, can be effectively treated. However, AF is under-diagnosed because it is frequently paroxysmal and asymptomatic, and patients do not routinely undergo prolonged screening. A prospective cohort study that compared the effectiveness of serial ECGs and Holter monitoring for the identification of AF in patients post stroke found that both methods were equally effective in identifying cases that were not present on a baseline assessment (Douen et al. 2008). Together, serial ECG’s and Holter monitoring identified 18 new cases of AF after baseline ECG assessment in the 144 patients included in the study. The majority of these cases were identified within 72 hours (83%). The results from two recent RCTs demonstrate the benefits of enhanced monitoring using insertable or portable devices to detect AF. In the EMBRACE trail (Gladstone et al. 2014), a 30-day ambulatory cardiac event monitor was found to be superior to repeat 24-hour Holter monitoring in identifying AF in 572 patients aged 52 to 96 years (mean=72.5 years) without known AF, who had sustained a cryptogenic ischemic stroke or TIA within the previous 6 months. Atrial fibrillation lasting ≥30 seconds was detected in 16.1% of patients, using the cardiac event monitor compared with 3.2% of patients in the Holter group (absolute difference, 12.9%; 95% CI 8.0 to 17.6; p<0.001; number needed to screen= 8). The cardiac event monitor was also superior for identifying AF lasting longer than ≥2.5 minutes (9.9% vs. 2.5%, absolute difference, 7.4%, 95% CI, 3.4 to 11.3; p<0.001). By 90 days, oral anticoagulant therapy had been prescribed for more patients in the intervention group (18.6% vs. 11.1%, p=0.01). Similar findings were reported in the CRYSTAL-AF trial (Sanna et al. 2014) when patients (mean age of 61.5 years) received long-term monitoring with an insertable cardiac monitor (ICM). At 6 months, the rate of detection of AF was significantly higher among patients assigned to the ICM group (8.9% vs. 1.4%, HR=6.4, 95% CI 1.9- 21.7, p<0.001), compared with those who received standard monitoring using ECG monitoring on a schedule at the discretion of their treating physician. The results at 12 months were comparable (12.4% vs. 2.0%, HR=7.3, 95% CI 2.6- 20.8, p<0.001). Flint et al. (2012) followed 239 patients with cryptogenic ischemic stroke who underwent outpatient cardiac monitoring using an electrocardiographic loop recorder for 30 days. Paroxysmal atrial fibrillation (PAF) was detected in 26 patients (11.0%; 95% CI: 7.6% to 15.7%) who were previously undiagnosed. Most patients (45%) had their PAF detected within the first 10 days, 31% from day 11 to 20 and 24% from day 21 to 30.