Management of E.D. Patients who Present with a Transient Ischemic Attack or

Can We Safely Send TIA Patients Home From the E.D. ??

Edward P. Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL

Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Hospital Chicago, IL

Edward P. Sloan, MD, MPH Global Objectives Maximize patient outcome Maximize patient outcome Utilize health care resources well Utilize health care resources well Optimize evidence-based medicine Optimize evidence-based medicine Enhance ED practice Enhance ED practice

Edward P. Sloan, MD, MPH Sessions Objectives TIA patient cases TIA patient cases Review key concepts Review key concepts Consider relevant questions Consider relevant questions Examine treatment options Examine treatment options Develop reasonable Rx strategies Develop reasonable Rx strategies Answer the question Answer the question

Edward P. Sloan, MD, MPH 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

Edward P. Sloan, MD, MPH Case Presentation… 75 year old presents to ED Slurred speech and dim vision No motor symptoms Symptoms lasted for minutes Paramedics called by family Speech slow, but resolving now Hx “heart trouble”, “bad blood vessels”

Edward P. Sloan, MD, MPH ED TIA Patients: Key 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

Edward P. Sloan, MD, MPH Clinical 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?

Edward P. Sloan, MD, MPH 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 the astonis hing results

Edward P. Sloan, MD, MPH 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

Edward P. Sloan, MD, MPH 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

Edward P. Sloan, MD, MPH How is CNS Ischemia Caused? Atrial fibrillation Carotid artery disease Brain large or small artery disease

Edward P. Sloan, MD, MPH 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 < minutes TIA: < 24 hrs not clinically useful

Edward P. Sloan, MD, MPH 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

Edward P. Sloan, MD, MPH 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”

Edward P. Sloan, MD, MPH 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!

Edward P. Sloan, MD, MPH TIA Sx and Chest PainCNSCardiac Non-specificsymptoms “Neuro Sx” Chest Pain Significant symptoms TIA Unstable angina Acute infarction TIA Sx and CT or MRI Dx UA Sx and EKG, lab Dx

Edward P. Sloan, MD, MPH 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

Edward P. Sloan, MD, MPH 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?

Edward P. Sloan, MD, MPH 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??

Edward P. Sloan, MD, MPH What Rx Must Be Provided? Antithrombotics Heparin Oral anticoagulation Antiplatelet therapy Carotid endarterectomy Risk factor management

Edward P. Sloan, MD, MPH Antithrombotics Useful in cardioembolic causes Long-term oral warfarin in afib Short-term heparin in afib?? LMW heparin??

Edward P. Sloan, MD, MPH Antiplatelet Therapy Useful in non-cardioembolic causes Aspirin mg/day Clopidogrel or ticlopidine Aspirin plus dipyridamole Latter two if ASA intolerant or if TIA while on ASA Anticoagulation not recommended

Edward P. Sloan, MD, MPH 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

Edward P. Sloan, MD, MPH Risk Factor Management HTN: BP below 140/90 DM: fasting glucose < 126 mg/dl Hyperlipidemia: LDL < 100 mg/dl Stop smoking! Exercise min, 3x/week Avoid excessive alcohol use Weight loss: < 120% of ideal weight

Edward P. Sloan, MD, MPH 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!!

Edward P. Sloan, MD, MPH 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, :

Edward P. Sloan, MD, MPH 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

Edward P. Sloan, MD, MPH Early stroke risk predicted by RF

Edward P. Sloan, MD, MPH How Do We Assess Risk? Lifestyle risk factors Co-morbid illnesses Vasculopathy assessment Sx duration: longer is worse Sx type: non-retinal Sx worse

Can We Safely Send TIA Patients Home From the E.D. ??

Edward P. Sloan, MD, MPH Benefits of Admission Expeditious Complete evaluation likely Risk factor management easier Lifestyle modification possible Patient education more extensive Rapid assessment if CVA occurs

Edward P. Sloan, MD, MPH Benefits of Discharge Cost containment Patient ease and comfort Hospital infection risk Outcome has not been addressed

Edward P. Sloan, MD, MPH 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

Edward P. Sloan, MD, MPH The 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

Edward P. Sloan, MD, MPH 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!

Edward P. Sloan, MD, MPH 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

Edward P. Sloan, MD, MPH 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

Can We Safely Send TIA Patients Home From the E.D. ??

Edward P. Sloan, MD, MPH An 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

Edward P. Sloan, MD, MPH Some 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

Edward P. Sloan, MD, MPH More 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

Edward P. Sloan, MD, MPHConclusions 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

Edward P. Sloan, MD, MPHRecommendations 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?