Text Size:    +   -

Outpatient Management of TIA and Non-Disabling Stroke

5th Edition
2015 UPDATE
June 2015

The Canadian Stroke Best Practice Recommendations for Hyperacute Stroke Care, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Outpatient Management of TIA and Non-Disabling Stroke and all other sections of the Hyperacute Stroke Care recommendations, please click on this URL which will take you to the recommendations online in the IJS: http://onlinelibrary.wiley.com/doi/10.1111/ijs.12551/full

For the French version of these recommendations, open the appendix at this link :  http://onlinelibrary.wiley.com/store/10.1111/ijs.12551/asset/supinfo/ijs12551-sup-0001-si.zip?v=1&s=cdf3d494242426450aaa522f104ace17857f037a

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

Rationale

The goal of outpatient management of transient ischemic attack and non-disabling ischemic stroke is rapid assessment and management to reduce the risk of a recurrent, possibly more serious, event.

There is clear evidence that transient ischemic attacks or minor strokes are unstable conditions that warn of high risk of future stroke, other vascular events, or death. The risk of recurrent stroke after a transient ischemic attack is 10 to 20 percent within 90 days, and the risk is “front-loaded”, with half of the strokes occurring in the first two days following initial symptom onset. The seven-day risk of stroke following a transient ischemic attack can be higher than 10 percent in patients with multiple risk factors. Timely initiation of secondary prevention medical therapy and carotid endarterectomy has been shown to significantly reduce the risk of major stroke after an initial transient ischemic attack or non-disabling stroke.

 

 

 

 

 

System Implications

  • Education for the public and healthcare providers about the urgency of assessment and management of transient ischemic attack or non-disabling ischemic stroke is critical to reduce the risk of recurrent, potentially more serious events. Patients and families will also require ongoing education and support related to prevention and management of stroke.
  • Education and training for physicians who work in primary, secondary, and tertiary care settings to gain the knowledge to manage patients with transient ischemic attack or non-disabling ischemic stroke.
  • Processes and protocols in community healthcare settings and acute healthcare facilities to enable rapid access to diagnostic tests and expertise for patients with transient ischemic attack or minor stroke.
  • Established and accessible stroke prevention clinics, or broader vascular prevention programs in all communities, and healthcare practitioners who are aware of these programs. These resources should be listed, easily accessible to primary care physicians and healthcare providers, and updated annually.
  • Any suspicion of pediatric stroke warrants an emergent consult or assessment in a pediatric emergency department. All hospitals should have a referral process established with the closest specialized pediatric facility.

 

 

 

 

 

Performance Measures

  1. Proportion of acute stroke and TIA patients who are discharged alive from an emergency department or after an inpatient stay and then readmitted to hospital with a new stroke diagnosis within 90 days of index acute care discharge (core).
  2. Time from first encounter with medical care (primary care or emergency department) to assessment by a stroke expert (in clinic or other setting).
  3. Time from first encounter with medical care to brain imaging (CT/MRI) and vascular imaging (Doppler of cervical arteries, CT or MR angiography) and electrocardiogram.

Measurement Notes

  • Data access and quality with respect to timing of first encounter and referral dates and times.
  • Primary care data from physician billing. This should rely on International Classification of Diseases (ICD) codes and not on physician descriptions of diagnoses, as these may be less accurate.
  • Measures from other prevention recommendations in this document also apply applicable to this recommendation but are not repeated here.

 

 

 

 

 

 

Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information

Patient Information

 

 

 

Summary of the Evidence, Evidence Tables and References

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.