The advent of thrombolysis and acute stroke units

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1 Population-Based Study of Behavior Immediately After Transient Ischemic Attack and Minor Stroke in 1000 Consecutive Patients Lessons for Public Education Arvind Chandratheva, MRCP; Daniel S. Lasserson, MA, MBBS, MRCP, MRCGP; Olivia C. Geraghty, MRCP; Peter M. Rothwell, MD, PhD, FRCP, FMedSci; on behalf of the Oxford Vascular Study Background and Purpose Most guidelines now recommend that patients with minor stroke or high-risk transient ischemic attack (TIA) are assessed within 24 hours of their event, but the feasibility of this depends on patients behavior. We studied behavior immediately after TIA and minor stroke according to clinical characteristics, patients perception of the nature of the event, and their predicted stroke risk. Methods In a population-based study in Oxfordshire, UK, with face-to-face interview of 1000 consecutive patients with TIA and minor stroke (National Institutes of Health Stroke Scale 5) from 2002 to 2007 (Oxford Vascular Study), we studied delay in seeking medical attention and identified patients who did not seek attention after an initial event and only presented after a recurrent stroke. Results Of 1000 patients (459 TIAs, 541 minor strokes), 300 (67%) with TIA and 400 (74%) with minor stroke sought medical attention within 24 hours and 208 (47%) and 234 (46%), respectively, sought attention within 3 hours. Most patients (77%) first sought attention through their primary care physician. In patients with TIA, incorrect recognition of symptoms, absence of motor or speech symptoms, shorter duration of event, lower ABCD 2 score, no history of stroke or atrial fibrillation, and weekend presentation were associated with significantly longer delays. However, age, sex, social class, and educational level were all unrelated to either correct recognition of symptoms or to delay in seeking attention. Of 129 patients with TIA or minor stroke who had a recurrent stroke within 90 days, 41 (31%) did not seek medical attention after their initial event. These patients were more likely to have had a TIA (P 0.003), shorter duration of event (P 0.02), and a history of TIA (P 0.09) and less likely to have had motor (P 0.004) or speech symptoms (P 0.04) compared with those patients who sought medical attention for their initial event. Conclusion Approximately 70% of patients do not correctly recognize their TIA or minor stroke, 30% delay seeking medical attention for 24 hours, regardless of age, sex, social class, or educational level, and approximately 30% of early recurrent strokes occur before seeking attention. Without more effective public education of all demographic groups, the full potential of acute prevention will not be realized. (Stroke. 2010;41: ) Key Words: educational campaigns epidemiology minor stroke prevention risk factors transient ischemic attack The advent of thrombolysis and acute stroke units prompted interest in the delays between symptom onset and treatment for major acute ischemic stroke, 1 5 and in knowledge of stroke among the general public and at-risk populations. 6 9 In contrast, equivalent studies of transient ischemic attack (TIA) and minor stroke are lacking, perhaps because there has previously been less concern about delays to treatment. However, with data on the high risk of stroke during the hours and days after a TIA, the ability to identify very high-risk individuals with simple clinical scores, 13,14 and the evidence that early instigation of preventive treatments is highly effective, it is essential to better understand patient perceptions and behavior after TIA and minor stroke and hence the barriers to rapid presentation. Existing studies have shown that knowledge of TIA among the general public was poor and delays to seeing a physician after TIA are common There has been only 1 previous prospective population-based study of behavior of patients Received December 17, 2009; final revision received February 5, 2010; accepted February 8, From the Stroke Prevention Research Unit (A.C., O.C.G., P.M.R.), Department of Clinical Neurology, University of Oxford, John Radcliffe Hospital, Oxford, UK; and the Department of Primary Health Care (D.S.L.), University of Oxford, Oxford, UK. Correspondence to Peter M. Rothwell, MD, PhD, FRCP, FMedSci, John Racliffe Hospital, Radcliffe Infirmary, Woodstock Road, Oxford, UK OX2 6H3. peter.rothwell@clneuro.ox.ac.uk 2010 American Heart Association, Inc. Stroke is available at DOI: /STROKEAHA

2 Chandratheva et al Behavior Immediately After TIA and Minor Stroke 1109 immediately after TIA, but only 138 patients were assessed, delay was assessed categorically, minor strokes were excluded, and the characteristics of patients who had a TIA but only sought medical attention after an early recurrent stroke were not analyzed in detail. 21 A recent systematic review of delays to seeking medical attention after TIA 22 highlighted the lack of high-quality data and the need for more research. To determine the feasibility of targets requiring patients with TIA or minor stroke to be assessed within 24 hours of their event, we studied the initial perceptions and actions of patients in a population-based cohort of incident and recurrent TIA and stroke. We also aimed to identify potential factors associated with delays in seeking medical attention so that appropriate action may be instigated to achieve shorter delays. Methods The Oxford Vascular Study (OXVASC) is a population-based study of all acute vascular events, including stroke and TIA, in approximately individuals of all ages registered with 63 general practitioners in Oxfordshire, UK. This article includes the first 1000 consecutive incident or recurrent TIA and minor stroke cases (April 1, 2002, to April 24, 2007). The OXVASC study methods have been described elsewhere. 29,30 Briefly, multiple overlapping methods of hot and cold pursuit were used to achieve near complete ascertainment of all individuals with TIA or stroke These include: (1) a daily, rapid access TIA clinic to which participating general practitioners and the local accident and emergency department refer all individuals with suspected TIA or stroke whom they would not normally admit directly to a hospital; (2) daily searches of admissions to the medical, stroke, neurology, and other relevant wards; (3) daily searches of the local accident and emergency department attendance register; (4) monthly searches of general practitioner diagnostic coding and hospital discharge codes; and (5) monthly searches of all cranial and carotid imaging studies performed in local hospitals. Thus, our final analysis included inpatients, emergency department and eye hospital attendees, and those who were assessed at home in addition to those who attended the OXVASC dedicated daily hospital clinic. All patients were consented and seen by study physicians as soon as possible after initial presentation to determine: (1) their initial perception of the cause of their symptoms; (2) their immediate response; and (3) dates and times of symptom onset when medical attention was sought and the first contact with medical services. In a minority of patients for whom we did not know precise timing such as those presenting late or with cognitive impairment, we derived timing from ambulance sheets, general practitioner referral letters, and consultation notes. Baseline characteristics were recorded in all patients and assessments were made for severity of event (using the National Institutes of Health Stroke Scale). Minor stroke was defined as National Institutes of Health Stroke Scale 5. Demographic data, risk factors, and symptomatology were also recorded, including the main known independent risk factors for early recurrent stroke. 13,14,32 Social class was coded using the standard occupational classification scheme 33 and educational level was stratified into basic (compulsory standard education up to age 16), further (education to age 18), and higher (university degree). All cases were subsequently reviewed by the study senior neurologist (P.M.R.) and classified as TIA or stroke or other condition using standard definitions All patients presenting with stroke were asked about recent symptoms of TIA. In patients with multiple TIAs, the most recent event before presentation was studied. Analysis We determined the delay from symptom onset to first seeking medical attention in relation to whether the patients correctly Table 1. The First Contact With Healthcare Services in Patients With TIA or Minor Stroke TIA (n 459) No. of Patients (%) Minor Stroke (n 541) No. of Patients (%) General practitioner 355 (77.3) 390 (72.1) Emergency department 70 (12.9) 105 (19.4) National Health Service Direct 7 (1.5) 6 (1.1) District nurse 0 1 (0.2) Eye hospital 9 (2.0) 10 (1.8) Inpatient at time of event 6 (1.3) 22 (4.1) Other physician clinic 12 (2.6) 5 (0.9) Ship s doctor 0 2 (0.4) identified the cause of their symptoms, demographic data, risk factors, symptomatology, and the day on which the presenting TIA occurred. Delay was also related to the predicted early risk of stroke using the ABCD 2 score. 13 A separate analysis was performed of those patients who did not seek medical attention for their initial symptoms and only presented for medical attention after their recurrent stroke (within 3 months). To determine if behavior had changed over the duration of the study period, we performed a separate analysis of delays to presentation by year of the study. Results Of 1000 consecutive eligible patients, 459 presented after TIA and 541 after minor stroke. Data were available on all cases from the first medical provider. In 18 (3.9%) patients with TIA and 37 (6.8%) patients with minor stroke not seen in the OXVASC clinic (ie, seen by the general practitioners only, by doctors out of the area, in the eye hospital, or admitted direct to the hospital), the exact time to call for attention had not been recorded and could not be recalled by the patient on subsequent questioning. We had complete data on all remaining 945 patients. Mean (SD) age of these patients was 73 (12.2) years, and 335 (35%) were aged 80 years. Forty-one patients presented with a stroke but had had a TIA (29 cases) or minor stroke (12 cases) during the previous 90 days for which they had not sought medical attention, accounting for 32% of all patients with recurrent stroke within 90 days of a TIA or minor stroke in the whole study population. The first healthcare provider contacted by patients after the event (Table 1) was the family practitioner in 355 (77%) patients with TIA and 390 (72%) patients with minor stroke, the main hospital emergency department in 70 (15%) patients with TIA and 105 (19%) patients with minor stroke, and National Health Service Direct (a 24-hour national telephone advice service) in 7 (1.5%) patients with TIA and 6 (1.1%) patients with minor stroke. Three hundred (67%) and 400 (74%) patients with TIA and minor stroke, respectively, sought medical attention within 24 hours and 208 (47%) and 234 (46%) patients, respectively, sought medical attention within 3 hours. Table 2 shows median delay to seeking medical attention in relation to patient demographics, perceptions, risk factors for early stroke, and other vascular risk factors. Patients with TIA with a lower predicted early risk of stroke were more likely to delay than those at higher risk, particularly those with absence of motor and speech symptoms (P 0.001), duration

3 1110 Stroke June 2010 Table 2. Delay to Seeking Medical Attention Stratified by Demographic, Clinical Characteristics, and Vascular Risk Factors TIA (n 441) Minor Stroke (n 504) No. of Median (IQR) No. of Median (IQR) Patients (%) Delay, hours P Patients (%) Delay, hours P Mean age, years 72.7 (12.7) 73.3 (12.2) Male 201 (44%) 4.00 ( ) (52%) 3.50 ( ) Female 258 (56%) 4.88 ( ) 243 (48%) 7.00 ( ) Correct recognition Yes 143 (32%) 2.33 ( ) (31%) 5.00 ( ) No 297 (67%) 7.25 ( ) 346 (69%) 4.00 ( ) Age 60 years 71 (16%) ( ) (14%) 7.25 ( ) Age years 216 (49%) 4.00 ( ) 251 (50%) 6.50 ( ) Age 80 years 153 (35%) 3.25 ( ) 183 (36%) 3.00 ( ) Blood pressure, mm Hg 140/ (29%) 3.75 ( ) (24%) 3.29 ( ) / (71%) 4.58 ( ) 384 (76%) 5.00 ( ) Motor symptoms Yes 198 (45%) 1.59 ( ) (60%) 3.50 ( ) No 241 (55%) ( ) 201 (40%) 6.08 ( ) Speech symptoms Yes 190 (43%) 2.22 ( ) (44%) 3.50 ( ) No 250 (57%) ( ) 282 (56%) 6.25 ( ) TIA duration 10 minutes 84 (19%) ( ) minutes 146 (33%) 4.13 ( ) 60 minutes 210 (48%) 2.00 ( ) Diabetes Yes 58 (13%) 6.25 ( ) (12%) 7.71 ( ) No 382 (87%) 4.00 ( ) 446 (88%) 4.00 ( ) ABCD 2 5 Yes 183 (42%) 1.75 ( ) (71%) 4.50 ( ) No 257 (58%) ( ) 147 (29%) 4.00 ( ) Previous TIA Yes 76 (17%) ( ) (12%) 7.82 ( ) No 364 (83%) 3.50 ( ) 444 (88%) 3.50 ( ) Previous stroke Yes 54 (12%) 1.04 ( ) (17%) 3.50 ( ) No 386 (88%) 5.21 ( ) 417 (83%) 4.00 ( ) Hypertension Yes 232 (53%) 3.00 ( ) (59%) 3.50 ( ) No 208 (47%) 6.00 ( ) 207 (41%) 6.80 ( ) Previous myocardial infarction Yes 51 (12%) 2.00 ( ) (11%) 2.00 ( ) No 389 (88%) 4.33 ( ) 448 (89%) 4.88 ( ) Atrial fibrillation Yes 74 (17%) 2.21 ( ) (17%) 2.00 ( ) No 366 (83%) 5.00 ( ) 416 (83%) 5.63 ( ) (Continued)

4 Chandratheva et al Behavior Immediately After TIA and Minor Stroke 1111 Table 2. Continued TIA (n 441) Minor Stroke (n 504) No. of Patients (%) Median (IQR) Delay, hours P No. of Patients (%) Median (IQR) Delay, hours Mini-Mental State Examination (18%) 2.00 ( ) (32%) 3.00 ( ) (82%) 4.42 ( ) 277 (68%) 6.50 ( ) Educational level Basic 287 (73%) 3.00 ( ) (74%) 5.00 ( ) Further 54 (14%) 4.00 ( ) 69 (15%) 5.00 ( ) Higher 53 (13%) 6.00 ( ) 49 (11%) 8.50 ( ) Social class 1 35 (9%) ( ) 64 (14%) 8.43 ( ) 2 95 (24%) ( ) 102 (22%) 1.50 ( ) (38%) 3.00 ( ) 194 (42%) 5.00 ( ) 4 82 (21%) 1.58 ( ) 46 (10%) 9.75 ( ) 5 34 (9%) 3.50 ( ) 55 (12%) ( ) *Ninety-four patients had no educational level recorded. Eighty-five patients had no social class recorded. IQR indicates interquartile range. P of event 60 minutes (P 0.001). and age 60 years (P 0.075). There was no association between the other components of the ABCD 2 score. Prior stroke (P 0.006) and atrial fibrillation (P 0.057) tended to be associated with less delay, but prior TIA, myocardial infarction, hypertension, and history of smoking were not. Interestingly, patients with TIA without cognitive impairment (Mini-Mental State Examination 24) had longer delays to seeking medical attention than those with (P 0.016), although they were more likely to be alone at the time of their event (71 of 287 versus 8 of 67, P 0.02). Only atrial fibrillation (P 0.004) was associated with shorter delays in seeking medical attention after minor stroke. In patients with TIA, occurrence on the weekend was associated with the longest delays (median delay, 25.1 versus 3.0 hours; P ; Table 3). In patients with TIA and patients with minor stroke, there was no significant difference in delay to seeking medical attention if the analysis was stratified by year of the study (P 0.61). Among those patients who did seek medical attention, 457 (99.6%) patients with TIA and 535 (98.9%) patients with minor stroke were able to recall their initial perception of the cause of their symptoms or were with a spouse or caregiver who was able to. In 145 (32%) patients with TIA and 161 (30%) patients with minor stroke, their initial impression was correct. The remaining 312 (68%) patients with TIA and 374 (69%) patients with minor stroke did not know the cause of their symptoms or assumed incorrect causes. Incorrect recognition of symptoms in patients presenting with TIA was associated with longer median (interquartile range) delays to seeking medical attention (7.3 versus 2.3 hours, P 0.005), but no significant association was seen in patients with minor stroke. Patients with TIA who did not correctly recognize their symptoms were less likely to call emergency services (40 of 312 versus 29 of 145, P 0.05). However, in patients with TIA with low-risk characteristics such as absence of motor or speech symptoms, shorter duration of event and ABCD 2 score 5, who tended as a group to respond slower, incorrect recognition of symptoms was not associated with any additional delay. Thus, when adjusted for clinical characteristics, correct recognition of symptoms was not a significant determinant of delay in seeking attention after either a TIA or a minor stroke. Table 4 shows clinical and demographic characteristics of the 41 patients who presented with a stroke but had a recent Table 3. Delay to Seeking Medical Attention Stratified by Day of the Week Day TIA (n 459) No. of Patients (%) Median Delay, hours Minor Stroke (n 541) No. of Patients (%) Median Delay, hours Monday 61 (13%) 3.50 ( ) 72 (13%) 2.92 ( ) Tuesday 82 (18%) 1.17 ( ) 82 (15%) 3.79 ( ) Wednesday 50 (11%) 3.75 ( ) 64 (12%) 2.50 ( ) Thursday 75 (16%) 3.00 ( ) 78 (14%) 5.50 ( ) Friday 53 (12%) 4.75 ( ) 71 (13%) 5.00 ( ) Saturday 56 (12%) ( ) 68 (13%) 2.92 ( ) Sunday 62 (14%) ( ) 69 (13%) ( )

5 1112 Stroke June 2010 Table 4. Demographics, Clinical Characteristics, and Vascular Risk Factors in Patients With Stroke Who Did Not Seek Medical Attention for a Preceding TIA or Minor Stroke Presented to the Hospital With Stroke But Had a Preceding TIA or Minor Stroke for Which Medical Attention Was Not Sought (n 41) TIA and Minor Stroke n 1000 P Mean age, years (SD) 74 (12.2) 73 (12.4) TIA 29 (71%) 459 (46%) Minor stroke 12 (29%) 541 (54%) Male sex 18 (43.9%) 482 (48%) 0.59 Mean systolic blood pressure (SD) (26.5) (29.3) 0.10 Mean diastolic blood pressure (SD) 85.4 (12.1) 82.7 (14.7) 0.08 ABCD 2 score (TIA) (0.2%) (7%) 24 (5%) 2 5 (12%) 63 (14%) 3 10 (24%) 82 (18%) 4 7 (17%) 107 (23%) 5 8 (20%) 99 (22%) 6 6 (15%) 75 (16%) 7 2 (5%) 8 (2%) Duration of TIA 10 minutes 11 (38%) 89 (19%) minutes 9 (31%) 153 (33%) minutes 9 (31%) 217 (47%) 0.09 Diabetes 9 (22%) 153 (15%) 0.25 Motor symptoms 12 (29.3%) 525 (53%) Speech symptoms 11 (27%) 428 (43%) 0.04 Previous myocardial infarction 2 (5%) 116 (12%) 0.18 Previous angina 4 (10%) 159 (16%) 0.29 Previous TIA 10 (24%) 145 (15%) 0.09 Previous stroke 6 (15%) 146 (15%) 1.00 Hypertension 20 (49%) 563 (56%) 0.34 Current smoker 8 (20%) 140 (14%) 0.32 Social class* (11%) (13%) 207 (23%) 3 manual 7 (23%) 190 (21%) 3 nonmanual 11 (37%) 170 (19%) 4 6 (20%) 133 (15%) 5 2 (7%) 94 (10%) *One hundred fourteen patients did not have a social class recorded. preceding TIA or minor stroke for which they did not seek medical attention. These patients were more likely to have had a TIA (P 0.003), shorter duration event (P 0.02), and a history of TIA (P 0.09) but less likely to have motor (P 0.004) or speech symptoms (P 0.04) compared with those who sought attention for their initial TIA or minor stroke. The number of patients who correctly recognized their initial symptoms was not systematically recorded in these cases because they were ascertained at the point of their recurrent stroke. Discussion In a telephone survey of randomly sampled US adults, Johnston and colleagues found that only 8.6% could identify a typical symptom of a TIA 18 and in a Swiss urban community survey, even less (2.8%) identified TIA as a disease requiring urgent medical attention. 20 Given that public knowledge of the symptoms of stroke is much better, 6,8,9 it is likely that this low level of knowledge was at least partly due to poor recognition of the term TIA itself. Indeed, the same study found that among those with a history of TIA,

6 Chandratheva et al Behavior Immediately After TIA and Minor Stroke % recalled seeing a physician within 24 hours, 18 although only one third of patients who had a TIA during follow-up in the Asymptomatic Carotid Artery Study in the early 1990s reported it to medical attention within 3 days. 19 We found that approximately 70% of patients in our population did not correctly recognize their TIA or minor stroke and approximately 30% delayed seeking medical attention for 24 hours. Higher risk patients tended to contact health services most quickly, but 30% of early recurrent strokes still occurred before any attempt to do so. Correct recognition of symptoms was associated with seeking medical attention more quickly in patients with TIA, but not in patients with minor stroke. We did not collect detailed data on the severity of events at onset, but it is possible that severe initial deficits were more common in patients who recovered quickly than in those with persisting minor stroke. Presence of motor or speech symptoms and shorter duration of event was associated with shorter delays to calling for medical attention in those patients with TIA who did not correctly recognize their symptoms, although patients with TIA at highest predicted stroke risk were more likely to respond quickly. Despite correct recognition of TIA being associated with shorter delays to seeking medical attention, the low proportion of patients attending the emergency department (TIA 15%, minor stroke 19%) indicates a lack of public awareness that a TIA is a medical emergency and also perhaps the longstanding emphasis on primary care-led services in the United Kingdom. Public education should therefore emphasize the need to seek urgent medical attention in addition to symptom recognition. The lack of perception of urgency is perhaps best illustrated by patient behavior after events occurring on Fridays, weekends, and public holidays. Whether the same patterns of behavior after TIA would be observed in other populations or healthcare systems is uncertain. More encouraging was the observation that patients at higher predicted stroke risk were more likely to act like in an emergency due apparently to the influence of weakness and prolonged symptom duration on behavior. As expected, these symptoms were also particularly frequent in those patients who had an early recurrent stroke before seeking medical attention. However, even in patients with ABCD 2 scores 4, approximately 20% have pathology that might require urgent treatment, 34 highlighting the importance of public education campaigns focusing on seeking urgent medical attention rather than purely symptom recognition. Although we think that our observations are valid, our methods did have some potential shortcomings. First, we will undoubtedly have underestimated the extent of the lack of awareness of the need to seek medical attention by studying cohorts, all of whom did eventually report their symptoms. An unknown proportion of patients with TIA never seek medical attention. Second, it is possible that some patients reporting of initial perceptions and actions was influenced by the knowledge that they were attending a TIA clinic or were participating in a study of TIA. However, such knowledge would probably have tended to lead to exaggeration of our estimates of correct recognition of symptoms and emergency action. Moreover, we were able to validate much of the reported behavior against what was documented by primary care and the emergency department and we found very few inconsistencies. Third, the setting of the study, Oxfordshire, UK, is a county with slightly low social deprivation and slightly higher educational levels on average than the rest of the United Kingdom, although such differences would be expected to lead to higher rates of health awareness and a greater propensity to use emergency services. Fourth, we did not have exact data on timings of event and on delays to seeking medical attention in all patients because of factors such as dysphasia and cognitive impairment. Reliable data were, however, available in 95% of patients, of whom over 37% were aged 80 years, and so there is unlikely to have been substantial inclusion bias. Fifth, from a clinical point of view, it could be argued that the results of patients with TIA and those with minor stroke should be pooled because they have similar early risk, receive similar treatment, and the majority will be managed in the outpatient setting in the United Kingdom, but importantly, they do appear to behave differently and we felt these striking differences merited separate evaluation. Moreover, although there have been many previous studies of delays in seeking attention after acute stroke, very few have studied TIA separately. Finally, TIAs and minor strokes before major disabling strokes might have been underreported because some patients were unable to give an account of previous TIA or minor stroke and corroborative accounts were not always available. Our findings suggest a need for more public education, although awareness campaigns have not always had predictable effects. 35 The most appropriate content of public education campaigns is also uncertain. To date, most campaigns have focused on symptom recognition, but we found that even when patients correctly recognized the event, they often did not seek attention urgently, suggesting that public education should focus more strongly on the need to seek medical attention as soon as possible. Targeting of public education might be also informed by our finding that delays in seeking medical attention were unrelated to age, sex, social class, or educational level. In conclusion, patients with TIA or minor stroke often delay seeking medical attention. The clinical impact of such delay is counterbalanced partly by the fact that patients with TIA at higher predicted risk of stroke tend to present more urgently, but many patients still have a recurrent stroke before seeking medical attention after a TIA or minor stroke. Without more effective public education, the full potential of acute prevention will not be realized. Acknowledgments We thank all primary care practices and physicians who collaborated with the Oxford Vascular Study, details of which have been published previously. 19,20 The study was funded by he UK Medical Research Council, the National Institute of Health Research, the Stroke Association, the Dunhill Medical Trust, and the National Institute of Health Research Biomedical Research Centre, Oxford, UK. None. Disclosures

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