TRANSIENT ISCHEMIC ATTACK (TIA)
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1 TRANSIENT ISCHEMIC ATTACK (TIA) AND MINOR STROKE Dr. Leanne K. Casaubon, MD MSc FRCPC Associate Professor, University of Toronto Director, TIA and Minor Stroke (TAMS) Unit University Health Network - Toronto Western Hospital Toronto West Regional Stroke Centre
2 FACULTY/PRESENTER DISCLOSURE Faculty: Dr. Leanne K. Casaubon Relationships with commercial interests: Speaker Honoraria: Bayer Consulting Fees: Medtronic (SURTAVI Study neurologic outcomes assessor), Bayer (ad board), Covidien Canada (ad board) Other: NoNO Inc. (site PI for FRONTIER Trial)
3 MITIGATING POTENTIAL BIAS There is no potential bias to mitigate related to this presentation All recommendations are based on evidence that is accepted within the profession 3
4 OBJECTIVES Discuss the importance of rapid-access TIA and minor (non-disabling) stroke care Describe best practices for triaging TIA and minor stroke 4
5 TIA AND RISK OF STROKE Risk of stroke following TIA 5-8% in 30 days (stroke or death 9% - 12%) Risk front-loaded half within 48 hours Risk is higher if high-risk etiology Carotid artery stenosis > 50% Atrial fibrillation Up to 30% in 90 days Risk of stroke with MRI diffusion changes 5 Johnston. JAMA. 2000;284:2901; Gladstone. CMAJ. 2004;170:1099; Boulanger. Stroke. 2007;38:2367
6 Amarenco et al. NEJM ;16:1533 TIA AND RISK OF STROKE UPDATE TIAregistry.org ( cohort) 4789 patients; 1/3 minor stroke 78.4% seen by stroke specialists < 24 hours of onset 6
7 Amarenco et al. NEJM ;16:1533 TIA AND RISK OF STROKE UPDATE Days Stroke Risk (%) Infarct on imaging, large artery athero, and ABCD 2 of 6-7: = risk Risk lower than previous studies is stroke risk truly less than thought? Note significant changes in care in recent years and specialist-based care model 7
8 HOW TO IDENTIFY HIGH-RISK PATIENTS? TIA diagnosis can be challenging TIA/stroke mimics (diagnosis in up to 45% of clinic visits) Risk prediction scores: ABCD, ABCD2, ABCD2I Current tools have limitations 8
9 Adapted from Johnston. Lancet 2007;369:283 ABCD 2 SCORE AND STROKE RISK Low Score 2-day Risk 7-day Risk 90-day Risk % 1.2 % 3.1 % Moderate % 5.9 % 9.8 % High % 11.7 % 17.8 % 9
10 Perry et al. CMAJ. 2011;183:1137 PROSPECTIVE ASSESSMENT OF ABCD 2 SCORE SHOWED POOR PERFORMANCE 2,056 patients seen by Emergency Department (ED) MDs 10
11 Coutts et al. Ann Neurol RISK STRATIFICATION VIA IMAGING TIA or minor stroke (NIHSS < 3) seen within 12 hours (n = 120) MRI within 24 hours for diffusion-weighted imaging (DWI) 3-month stroke risk 11.7% overall 4.3% if no DWI+ lesion 10.8% if DWI+ lesion alone 32.6% if both DWI+ lesion + vessel occlusion/ stenosis 11
12 Coutts et al. Stroke RISK STRATIFICATION VIA IMAGING CATCH Study Compared CT/CTA to MRI CT/CTA+ = visible infarct and/or symptomatic arterial lesion stroke risk with: Persisting symptoms CT/CTA+ DWI+ CT/CTA and MRI similar association with stroke risk 12
13 SUMMARY OF POTENTIAL HIGH-RISK FEATURES Patient demographic characteristics Time from onset or last symptoms 48 hours: highest risk Clinical features (sudden onset): Motor or speech: highest risk Monocular visual loss or field defect: increased risk Significant gait difficulty:?increased risk Persistent focal symptoms on presentation or positive imaging 13
14 U P D A T E
15 Adapted from P. Lindsay, HSF CSBPR 2017: VERY HIGH RISK Transient, fluctuating or persistent unilateral motor weakness (face, arm and/or leg), or speech disturbance. OR transient, fluctuating or persistent symptoms such as hemibody sensory loss, acute monocular visual loss, binocular diplopia, hemivisual loss, or dysmetria, without motor weakness or speech disturbance 1. Immediate transport via EMS to the closest emergency department with capacity for advanced stroke care (brain imaging, tpa capability) 2. Urgent brain imaging (CT or MRI) and noninvasive vascular imaging (CTA or MRA from aortic arch to vertex) as soon as possible within 24 hours. 15
16 CSBPR 2017: HIGH AND MODERATE RISK Transient, fluctuating or persistent unilateral weakness or speech disturbance. Transient, fluctuating or persistent symptoms such as hemibody sensory loss, acute monocular visual loss, binocular diplopia, hemivisual loss, or dysmetria, without motor weakness or speech disturbance. Within 24 hours of first contact with healthcare system: comprehensive clinical evaluation and investigations, including brain and vascular imaging, by a healthcare professional with stroke expertise. Within 2 weeks of first contact with the healthcare system: comprehensive clinical evaluation and investigations, including brain and vascular imaging, by a healthcare professional stroke expertise. 16 Adapted from P. Lindsay, HSF
17 Adapted from P. Lindsay, HSF CSBPR 2017: LOWER RISK Patient who presents more than 2 weeks following a suspected TIA or non-disabling stroke. 1. Within 1 month of first contact with the healthcare system: should be seen by a healthcare professional with expertise in neurology or stroke for evaluation. 17
18 SUMMARY OF ACUTE MANAGEMENT Brain and vascular imaging (cervical and intracranial) Brain CT (or MRI) and CTA (or MRA) Carotid ultrasound (only if for immediacy of access + anterior circulation) ECG 18
19 Wang et al. NEJM Johnston et al. NEJM SUMMARY OF ACUTE MANAGEMENT Antiplatelet therapy initial ASA 160mg to chew Short-term dual antiplatelets (TIA/minor stroke): - CHANCE ASA+clopidogrel vs. ASA: HR 0.68 (95% CI ) No significant excess bleeding - POINT (new) 4881 patients; 269 sites ASA+clopidogrel vs. ASA: HR 0.75 (95% CI ) Increased major bleeding 0.9% vs. 0.4% (controls) Already on ASA, consider change of antiplatelet long-term 19
20 SUMMARY OF ACUTE MANAGEMENT Anticoagulation, if indicated Without obvious or significant size of infarct immediately Suspected/proven minor stroke swallowing screen before giving anything orally 20
21 SUMMARY OF ACUTE MANAGEMENT Refer to clinician with stroke expertise Evaluation/management of vascular risk factors Additional investigations to evaluate for TIA/stroke etiology Echocardiogram Holter monitor/prolonged cardiac monitoring Functional assessment for rehab needs (minor stroke) REFLECTIVE QUESTION: Would you consider hospital admission for suspected higher-risk patients or ambulatory care? 21
22 CARE MODELS FOR PATIENTS WITH HIGH-RISK TIA/MINOR STROKE
23 Ontario Health Technology Assessment Series; Vol. 15: No. 3, pp. 1 45, Feb 2015 SYSTEMATIC REVIEW OF TIA CARE MODELS 13 studies (12 observational; 1 small RCT), Outcomes stroke/death at: 2, 7, 30, and 90 days, 1 year Majority compared outpatient TIA clinics to standard care Demonstrated benefit of specialized clinics Few compared ED or outpatient TIA care to inpatient care 23
24 Ross. Ann Emerg Med. 2007; Martinez-Martinez. Eur J Neurol AMBULATORY VERSUS INPATIENT CARE MODELS Limited data; variation in study designs ED observational unit vs. inpatient care (USA) Median LOS: 25.6 hours (ED) vs hours (inpatient) Stroke: 9.3% in ED cohort and 6.8% inpatient Specialized TIA clinic versus inpatient care (Spain) Included low to moderate risk patients (ABCD 2 5) 90-day stroke rates 2.4% clinic vs 1.2% inpatient, p=
25 CANADIAN EXPERIENCE WITH CARE MODELS FOR TIA/MINOR STROKE PATIENTS
26 BC Stroke Strategy. Evaluation of TIA Rapid Assessment Clinics TIA CARE ACROSS CANADA British Columbia Stroke Rapid Assessment Unit (Victoria) Provincial restructuring of TIA/minor stroke care Improved access to timely care within < 48 h Alberta TIARA Clinic (Calgary): evaluated rapid-assessment protocols for TIA/minor stroke; focus on imaging evaluation 26
27 Webster et al. Stroke. 2011;42:3176 TIA CARE IN ONTARIO Ontario Stroke Registry (OSR) analysis; 16,468 patients ( ) Patients referred from ED to a Stroke Prevention Clinic (SPC) versus not referred Outcome crude 1-year mortality Results: 7.2% (referred) vs. 9.6% (not referred), p=0.001 Hazard ratio (HR) for death 0.74 (95% CI ) 27
28 Ontario SEQC Report ACCESS TO STROKE PREVENTION CLINICS (SPC) Ontario SPC Report 2013 evaluation of best practice care Only 17.5% emergent cases seen within 24 hours 14.5% urgent cases seen within 72 hours Recommendations for centres with SPC: Adopt triage algorithm/protocol Work with local ED to ensure appropriate referrals 28
29 Kapral et al. Neurology GRADIENT OF BENEFIT OF CARE MODELS: INPATIENT SPC NON-REFERRED OSR analysis; 8,540 patients with TIA Fiscal Years 2008/09 and 2010/11 Compared inpatient versus outpatient care Admitted patients compared to those referred to SPC compared to no referral 29
30 Kapral et al. Neurology GRADIENT OF BENEFIT OF CARE MODELS: INPATIENT SPC NON-REFERRED Process outcomes: Improved care processes 30
31 Kapral et al. Neurology GRADIENT OF BENEFIT OF CARE MODELS: INPATIENT SPC NON-REFERRED Clinical outcomes: Improved outcomes 31
32 THE TIA AND MINOR STROKE (TAMS) UNIT Inpatient episode of care adapted into a day-unit stay Comprehensive evaluation and management Engagement of stroke nurse practitioners (NP) Same-day access to allied health Focus on patient/family/ caregiver education (Photo: LK Casaubon) (Photo: LK Casaubon) At University Health Network-Toronto Western Hospital Generously funded by an Ontario MOHLTC AFP Innovation Fund Award
33 RESULTS STUDY COHORT TAMS patients: 359 seen during the pilot phase 33.9% with TIA (79.5% had ABCD 2 3) 29.2% with minor stroke 36.9% with non-tia/non-stroke Inpatient cohort: 71 TIA and 266 minor stroke Matched pairs: 45 TIA; 83 minor stroke 33
34 RESULTS TAMS UNIT PATIENTS HAD: Shorter ED length of stay: 5.2 vs. 9.7 hours (controls), p< Urgent access to care: median time to TAMS visit < 24h from ED visit; 14.4% same-day; 85% within 3 days No difference in recurrent/new strokes at 30 days Fewer deaths at 3 months and 1 year Better access to tests: 100% vascular imaging; Holter (initial visit) 73% vs. 32% (controls), p< Optimal prevention strategies: 95.4% vs. 97.6% (controls), p= avoided hospital admissions over two years; control group median length of stay 6 days (TIA 3 days; minor stroke 7 days) 34
35 RECOMMENDATIONS FOR HIGH-RISK TIA AND MINOR STROKE PATIENT CARE With respect to the location of care, OHTAC [Ontario Health Technology Advisory Committee] recommends that: such immediate care be provided at a specialized TIA/minor stroke clinic Feb. 2015
36 36
37 CONCLUSION TIA/minor stroke can have high but modifiable risk of future stroke Initial care is through the Emergency Department for highest-risk patients Comprehensive care should be completed in rapid-access TIA/minor stroke clinics/units REFLECTIVE QUESTION: At your institution, is there anything further you/your team can do to improve access to care for high-risk TIA/minor stroke patients? 37
38 PLEASE COMPLETE THE ONLINE EVALUATION Your feedback is important to us! Your feedback will allow the Cardiovascular and Stroke Summit Planning Committee to evaluate the 2018 Summit, to provide feedback to the speakers, & develop future educational events Scan QR code OR Go to link: 38
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