management of e.d. patients who present with a transient ischemic attack or

Management of E.D. Management of E.D. Patients who Present Patients who Present

with a Transient with a Transient Ischemic Attack Ischemic Attack

oror

Can We Safely Send Can We Safely Send TIA Patients Home TIA Patients Home

From the E.D. ??From the E.D. ??

Edward P. Sloan, MD, MPH

Associate Professor

Department of Emergency Medicine

University of Illinois College of MedicineChicago, IL

Attending PhysicianEmergency Medicine

University of Illinois HospitalOur Lady of the Resurrection Hospital

Chicago, IL


Global ObjectivesGlobal Objectives

• Maximize patient outcomeMaximize patient outcome• Utilize health care resources wellUtilize health care resources well

• Optimize evidence-based medicineOptimize evidence-based medicine• Enhance ED practiceEnhance ED practice


Sessions ObjectivesSessions Objectives

• TIA patient casesTIA patient cases• Review key conceptsReview key concepts• Consider relevant questionsConsider relevant questions• Examine treatment optionsExamine treatment options• Develop reasonable Rx strategiesDevelop reasonable Rx strategies• Answer the questionAnswer the question


Case Presentation…

• 64 year old presents to ED • Trouble using L hand• “Couldn’t grasp cup of coffee or key” • Symptoms lasted for about 30 minutes• Spontaneous resolution, now no sx

• Hx DM, smoker• No recent illness


Case Presentation…

• 75 year old presents to ED • Slurred speech and dim vision• No motor symptoms• Symptoms lasted for 45-60 minutes• Paramedics called by family • Speech slow, but resolving now

• Hx “heart trouble”, “bad blood vessels”


ED TIA Patients: ED TIA Patients: Key ConceptsKey Concepts

• Neurological sx common, variable

• TIA: Sx due to cerebral ischemia

• Some TIA pts have infarcts

• A minimal work-up is required

• Therapies must be provided

• CVAs will occur following TIAs

• In-hospital CVAs allow tPA use


Clinical QuestionsClinical Questions

• How do TIA patients present?• How is CNS ischemia assessed?• How are cerebral infarcts Dx’d?• What work-up must be done?• What therapies must be provided?• How often will CVAs occur?• How do we assess admit benefits?


How do TIA Pts Present?

• Multiple symptoms

• Motor, sensory or speech problems

• Specific cerebrovascular distribution

• Loss of function• Loss of vision

• Not wavy lines, as in a migraine

• All sx occur & resolve at same time


How TIA Pts Do Not Present

• Loss in global cerebral function• Confusion

• Transient global amnesia

• Positive symptoms (ringing in ears)

• Sx that come and go differently


What Are TIA Mimics?

• Metabolic abnormalities• Glucose, Hb, hydration, medications

• Cephalgia• Migraine or temporal arteritis

• Seizure disorders• Akinetic seizure or partial lobe epilepsy

• CNS space-occupying lesions

• ENT, ophthomologic pathology


How is CNS Ischemia Caused?

• Atrial fibrillation

• Carotid artery disease

• Brain large or small artery disease


How is CNS Ischemia Dx’d?

• Careful history and physical• Labs to rule out metabolic causes• CT to rule out mass lesions• Resolution of symptoms

• TIAs: most last < 30-60 minutes• TIA: < 24 hrs not clinically useful


How Are CNS Infarcts Dx’d?

• Cerebral infarcts are present in TIA pts AT THE TIME OF THE INITIAL ED EVALUATION

• CT: 15-20% cerebral infarction rate• MRI: ~50% have ischemic injury• MRI: ~25% have cerebral infarction


Cerebral Infarction & TIAs

• Transient Sx presentation does not mean the absence of a CVA

• Cerebral infarction will have occurred in some TIA pts by the time the symptoms have resolved

• Subsequent CVA isn’t the issue• The key is to diagnose “cerebral

infarction with transient signs”


CVAs and AMIs

• Resolution of chest pain does not mean a myocardial infarction has not occurred: get an EKG!

• Resolution of TIA sx does not mean a cerebral infarction has not occurred: get a CT or MRI!


TIA Sx and Chest Pain

CNSCNS CardiacCardiac

Non-specificNon-specific

symptomssymptoms

““Neuro Sx”Neuro Sx” Chest PainChest Pain

Significant Significant symptomssymptoms

TIATIA Unstable Unstable anginaangina

Acute Acute infarctioninfarction

TIA Sx and CT TIA Sx and CT or MRI Dx or MRI Dx

UA Sx and UA Sx and EKG, lab DxEKG, lab Dx


CNS and Cardiac Ischemia

• Cardiac ischemia: PCI, medical Rx

• CNS Ischemia: fewer interventions• Intervention need can be assessed

in the Emergency Department• Once non-CNS causes excluded,

there is the possibility to send the patient home for outpatient Rx


What Work-up Must Be Done?

• Careful history and physical• Can the distribution be determined?

• Is the pt neurologically intact?

• CT or MRI• Is there a mass lesion?

• Is there a cerebral infarct?


What Work-up Must Be Done?

• Carotid artery imaging• To rule out carotid artery stenosis• Doppler US, MRA or CT angiography• 83-86% sensitive for a 70% + lesion

• Electrocardiography• Is there atrial fibrillation?• Is echocardiography useful??


What Rx Must Be Provided?

• Antithrombotics• Heparin

• Oral anticoagulation

• Antiplatelet therapy

• Carotid endarterectomy

• Risk factor management


Antithrombotics

• Useful in cardioembolic causes

• Long-term oral warfarin in afib

• Short-term heparin in afib??

• LMW heparin??


Antiplatelet Therapy

• Useful in non-cardioembolic causes

• Aspirin 50-325 mg/day

• Clopidogrel or ticlopidine

• Aspirin plus dipyridamole

• Latter two if ASA intolerant or

if TIA while on ASA

• Anticoagulation not recommended


Carotid Endarterectomy

• Useful in good surgical candidates

• Lesions of 70% + stenosis

• TIA within past two years

• 50-69% lesion, consider risk• Patient surgical risk, stroke risk

• Institutional expertise

• Timing of surgery not clarified


Risk Factor Management

• HTN: BP below 140/90

• DM: fasting glucose < 126 mg/dl

• Hyperlipidemia: LDL < 100 mg/dl

• Stop smoking!

• Exercise 30-60 min, 3x/week

• Avoid excessive alcohol use

• Weight loss: < 120% of ideal weight


How Often Will CVAs Occur?

• 25% have already had an infarct!

• They most likely will be the patients who go on to develop a symptomatic stroke with persistent & worsening Sx

• Risk stratify and find these pts!!


How Often Will Sx CVAs Occur?

• How many will develop persistent cerebral infarction symptoms?

• Kaiser-Permanente Study• 1707 TIA CA patients

• 10.5% stroke rate at 90 days

• 50% within 48 hours after ED visit

• Johnston SC et al, JAMA, Dec 13, 2000. 284:2901-2906


TIA Short-term Prognosis

• Acute stroke risk is correlated with 5 risk factors• Age > 60, DM, Sx > 10min

• Weakness and speech Sx

• Low risk pts: less stroke risk

• Lower risk acutely and over time


Early stroke risk predicted by RF


How Do We Assess Risk?How Do We Assess Risk?

• Lifestyle risk factors

• Co-morbid illnesses

• Vasculopathy assessment

• Sx duration: longer is worse

• Sx type: non-retinal Sx worse


Benefits of AdmissionBenefits of Admission

• Expeditious

• Complete evaluation likely

• Risk factor management easier

• Lifestyle modification possible

• Patient education more extensive

• Rapid assessment if CVA occurs


Benefits of DischargeBenefits of Discharge

• Cost containment

• Patient ease and comfort

• Hospital infection risk

• Outcome has not been addressed


Why Go Which Route?Why Go Which Route?

• Patient preference• Practitioner preference• Ease with which work-up can be

completed from E.D.• Patient compliance • Institutional preference• Observation unit availability• Reimbursement issues


The tPA IssueThe tPA Issue

• “Why not do an out-pt work-up, there’s nothing we can do in the hospital anyways!”

• If persistent recurrent Sx occur, tPA can be given within minutes

• This is an important issue

• It does not, however, drive the standard of care


What Do We Tell Patients?

• You had a small stroke

• You will likely have another stroke in the future, possibly very soon

• You must take an aspirin daily

• You must have further tests done

• You must see your MD tomorrow

• You must return if these Sx recur!


What Do We Document?What Do We Document?

• The exact Sx and their resolution

• A detailed neurological exam

• Normal speech, vision, and gait

• Normal labs, CT (MRI), EKG, and carotid doppler (MRA)

• Comprehension of pt instructions

• New meds, clear follow-up plan


What Do We Document?What Do We Document?

• Assessment of risk

• Rational for disposition

• If outpatient disposition, state clearly that the patient is at low risk for subsequent CVA


An Answer to the QuestionAn Answer to the Question

• Yes

• It is possible to send home low risk TIA patients for outpatient observation, further assessment, and continued therapies

• Doing so does not fall below a reasonable standard of care


Some Thoughts to PonderSome Thoughts to Ponder

• Outpatient approach is work

• E.D. throughput delayed

• Poorly connected pts may suffer

• Patients need to stop and think

• Admission costs may be justified• If RF and lifestyle changes enhanced

• If subsequent stroke risk reduced


More Thoughts to PonderMore Thoughts to Ponder

• Does subsequent stroke risk change based on disposition?

• This must be studied prospectively

• E.D. observation unit evaluation?

• A surgical approach to a medical problem: EM physicians can get the job done quickly


ConclusionsConclusions

• Many TIA pts have cerebral infarcts

• Acute Dx and Rx reqs are limited

• Risk stratification can take place

• An outpatient approach is possible

• It is a reasonable standard of care

• Prospective evaluation of optimal approach is needed


RecommendationsRecommendations

• Do a comprehensive E.D. work-up• Identify pts with a cerebral infarct • Admit those at highest risk• Disposition others based on

consideration of all factors• Assess best practice via an

observation unit study

Questions?Questions?

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management of e.d. patients who present with a transient ischemic attack or

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