Delay between symptom onset and clinic attendance following TIA and minor stroke: the BEATS study

Atrial fibrillation, transient ischaemic attack and stroke in older people. A themed collection in age and ageing journal

With an increase in the ageing population, there is a rise in the burden of cardiovascular disease. Age and Ageing have compiled collections of their key cardiovascular themed papers. The first Age and Ageing Cardiovascular Collection focussed on blood pressure, coronary heart disease and heart failure. In this second collection, publications since 2011 were selected with emphasis on atrial fibrillation, transient ischaemic attack (TIA) and stroke. The prevalence of TIA and stroke increases as people get older. In this commentary we summarise studies published in Age and Ageing that bring to the fore the need for a multidisciplinary, person-centred approach to care, conscientious identification of risk factors and their management and prevention strategies, which will inform policy ultimately reducing the burden of cost placed by stroke care on healthcare financing. Read the latest Cardiovascular Collection here.

An International Report on the Adaptations of Rapid Transient Ischaemic Attack Pathways During the COVID-19 Pandemic

BACKGROUND

This report aims to describe changes that centres providing transient ischaemic attack (TIA) pathway services have made to stay operational in response to the SARS-CoV-2 pandemic.

METHODS

An international cross-sectional description of the adaptions of TIA pathways between 30th March and 6th May 2020. Experience was reported from 18 centres with rapid TIA pathways in seven countries (Australia, France, UK, Canada, USA, New Zealand, Italy, Canada) from three continents.

RESULTS

All pathways remained active (n = 18). Sixteen (89%) had TIA clinics. Six of these clinics (38%) continued to provide in-person assessment while the majority (63%) used telehealth exclusively. Of these, three reported PPE use and three did not. Five centres with clinics (31%) had adopted a different vascular imaging strategy.

CONCLUSION

The COVID pandemic has led TIA clinics around the world to adapt and move to the use of telemedicine for outpatient clinic review and modified investigation pathways. Despite the pandemic, all have remained operational.

Contribution of Onset-to-Alarm Time to Prehospital Delay in Patients with Ischemic Stroke

BACKGROUND

Stroke is a leading cause of death and disability. Tissue plasminogen activator (tPA) improves the clinical outcome when administered properly; however, the most important factor to receive tPA is time. The main reason for late hospital arrival is a considerable delay in onset-to-alarm time (OAT), comprising more than 50% of the onset-to-door time.

AIMS

To identify the factors associated with a delay in OAT and evaluate its contribution to onset-to-door time in ischemic stroke patients.

METHODS

Prospective cohort of stroke patients admitted to the UANL University Hospital. OAT was defined as the time from identification of stroke symptoms to the decision to seek medical attention.

RESULTS

A total of 189 patients were included. Mean age was 61 ± 13 years, 62% were men. One-hundred and one patients had a short OAT, but only 20.9% arrived during the first 3 hours after stroke onset. Being employed (P = 0032; odds ratio [OR] 2.784, 95% confidence interval [CI] 1.091-7.104), attributing symptoms to stroke (P = 0016; OR 3.348, 95% CI 1.254-8.936), and perceiving stroke symptoms as severe (P = 0031;OR 2.428, 95% CI 1.083-5.445) were associated with a shorter OAT.

CONCLUSIONS

OAT consumes a considerable amount of the onset-to-door time. It is necessary to increase stroke knowledge and emphasize the severity of stroke, regardless of the severity of its clinical manifestations to reduce the prehospital delay, especially in countries with limited access to treatment with an extended time frame.

Delay in patients suspected of transient ischaemic attack: a cross-sectional study

OBJECTIVES

Suspected transient ischaemic attack (TIA) necessitates an urgent neurological consultation and a rapid start of antiplatelet therapy to reduce the risk of early ischaemic stroke following a TIA. Guidelines for general practitioners (GPs) emphasise the urgency to install preventive treatment as soon as possible. We aimed to give a contemporary overview of both patient and physician delay.

METHODS

A survey at two rapid-access TIA outpatient clinics in Utrecht, the Netherlands. All patients suspected of TIA were interviewed to assess time delay to diagnosis and treatment, including the time from symptom onset to (1) the first contact with a medical service (patient delay), (2) consultation of the GP and (3) assessment at the TIA outpatient clinic. We used the diagnosis of the consulting neurologist as reference.

RESULTS

Of 93 included patients, 43 (46.2%) received a definite, 13 (14.0%) a probable, 11 (11.8%) a possible and 26 (28.0%) no diagnosis of TIA. The median time from symptom onset to the visit to the TIA service was 114.5 (IQR 44.0-316.6) hours. Median patient delay was 17.5 (IQR 0.8-66.4) hours, with a delay of more than 24 hours in 36 (38.7%) patients. The GP was first contacted in 76 (81.7%) patients, and median time from first contact with the GP practice to the actual GP consultation was 2.8 (0.5-18.5) hours. Median time from GP consultation to TIA service visit was 40.8 (IQR 23.1-140.7) hours. Of the 62 patients naïve to antithrombotic medication who consulted their GP, 27 (43.5%) received antiplatelet therapy.

CONCLUSIONS

There is substantial patient and physician delay in the process of getting a confirmed TIA diagnosis, resulting in suboptimal prevention of an early ischaemic stroke.

Temporal Trends in Emergency Medical Services and General Practitioner Use for Acute Stroke After Australian Public Education Campaigns

Background and Purpose- The Australian Stroke Foundation ran annual paid advertising between 2004 and 2014, using the FAST (Face, Arm, Speech, Time) campaign from 2006 and adding the message to call emergency medical services in 2007. In this study, we examined temporal trends in emergency medical services use and referrals from general practitioners in the Australian state of Victoria to evaluate the impact of these campaigns. Methods- Using data from 33 public emergency departments, contributing to the Victorian Emergency Minimum Dataset, we examined trends in emergency department presentations for 118 000 adults with an emergency diagnosis of stroke or transient ischemic attack between 2003 and 2015. Annual trends were examined using logistic regression using a precampaign period (January 2003 to August 2004) as reference and adjusting for demographic variables. Results- Compared with the precampaign period, significant increases in emergency medical services use were seen annually between 2008 and 2015 (all P<0.001, eg, 2015; adjusted odds ratio, 1.16; 95% CI, 1.10-1.23). In contrast, a decrease was seen in patients presenting via general practitioners across all campaign years (all P<0.001, eg, 2015; adjusted odds ratio, 0.48; 95% CI, 0.44-0.53). Conclusions- Since the Stroke Foundation campaigns began, a greater proportion of stroke and transient ischemic attack patients are presenting to hospital by emergency medical services and appear to be bypassing their general practitioners.

Patient delay in TIA: a systematic review

Background

Patients who suffer a transient ischemic attack (TIA) have a high short-term risk of developing ischemic stroke, notably within the first 48 h. Timely diagnosis and urgent preventive treatment substantially reduce this risk. We conducted a systemic review to quantify patient delay in patients with (suspected) TIA, and assess determinants related to such delay.

Methods

A systematic review using MEDLINE and EMBASE databases up to March 2017 to identify studies reporting the time from onset of TIA symptoms to seeking medical help.

Results

We identified nine studies providing data on patient delay, published between 2006 and 2016, with 7/9 studies originating from the United Kingdom (UK). In total 1103 time-defined TIA patients (no remaining symptoms > 24 h), and 896 patients with a minor stroke (i.e., mild remaining symptoms > 24 h) were included (49.1% men, mean age 72.2 years). Patient’s delay of more than 24 h was reported in 33.1–44.4% of TIA patients, with comparable proportions for minor stroke patients. Delays were on average shorter in patients interviewed at the emergency department than among patients seen at TIA outpatient clinics. Univariably associated with a shorter delay were (1) a longer duration of symptoms, (2) motor symptoms, (3) a higher ABCD2 score, and (4) correct patient’s recognition as possible ischemic cerebrovascular event.

Conclusions

More than a third of patients experiencing a TIA delays medical attention for more than a day, thus critically extending the initiation of stroke preventive treatment. There still seems to be insufficient awareness among lay people that symptoms suggestive of TIA should be considered as an emergency. Additional data and multivariable analyses are needed to define main determinants of patient delay.

Causes of delayed arrival with acute ischemic stroke beyond the window period of thrombolysis

Context:

Early thrombolytic therapy in acute ischemic stroke has proven to reduce the associated morbidity. Many factors are in play, delaying the arrival of patients.

Aim:

To ascertain the factors causing delay in patients with acute ischemic stroke presenting beyond the window period of thrombolysis in and around Chennai, Tamil Nadu, India.

Subjects and Methods:

An observational cross-sectional study involving 200 patients with acute ischemic stroke at Sri Ramachandra Medical College, Chennai, India between June 2015 and July 2016 was conducted. The data was collected by direct interview using a questionnaire designed to study factors such as age, family structure, residence, distance from the hospital, education status, wake-up stroke, transport, symptoms, knowledge about symptoms, seriousness of symptoms, waiting on symptoms, insurance and point of admission. Data was analyzed for means, frequencies, percentages and multiple linear regression analysis was performed to identify factors independently influencing delayed arrival.

Results:

Mean age of the cohort was 58.08 years: 142 men and 58 women. Mean time of delayed arrival was 13.6 hours. Multiple linear regression analysis revealed that seriousness of symptoms (P = 0.001), residence (P = 0.001), point of admission (P = 0.033) and wake-up stroke (P = 0.005) were statistically significant predictors of delayed arrival.

Conclusion:

Patients not perceiving their symptoms to be serious, residing in a rural area, not arriving to the emergency, and having a stroke while awake were all the significant predictors of pre-hospital delay in our study. Awareness among the masses about symptom recognition and early arrival to a tertiary care center will reduce the delay and associated morbidity. Primary care physicians notably play a significant role in educating patients at risk, identifying the symptoms of stroke and referring them for thrombolysis.

Access to Thrombolysis for Non-Resident and Resident Stroke Patients-A Registry-Based Comparative Study from Berlin

Objectives

Stroke can happen to people away from home. It is unknown whether non-resident and resident stroke patients have equal access to thrombolysis.

Materials and methods

Consecutive patients cared for by the Stroke Emergency Mobile between 2011 and 2016 after prompting suspicion of acute stroke during the emergency call were included in our registry. Patients were categorized as residents or non-residents based on their main address. Clinical characteristics, thrombolysis rates, and time intervals from symptom onset/last seen well to alarm and to thrombolysis were compared between groups adjusting for age, pre-stroke modified Rankin Scale (mRS) score, and National Institutes of Health Stroke Scale (NIHSS) score.

Results

Of 4,254 patients for whom a stroke dispatch was activated, 2,451 had ischemic or hemorrhagic strokes, including 73 non-residents. Non-resident stroke patients were younger (median 69.4 vs. 76.6 years, p < 0.001), had less pre-stroke disability (mRS ≥ 2:17.8 vs. 47.5%, p < 0.001) and less severe strokes (median NIHSS 4 vs. 5, p = 0.02). Thrombolysis rates were higher in non-residents (30.9 vs. 22.0% of ischemic stroke patients, p = 0.04) and emergency calls were made faster (symptom onset/last-seen-well-to-alarm time 35 vs. 144 min, p = 0.04). A lower proportion of non-residents had unknown time of symptom onset (21.9 vs. 46.4%, p < 0.001). For patients with known time of symptom onset, thrombolysis rates, and prehospital delays were similar among non-residents and residents.

Conclusion

In this study, non-resident stroke patients had higher rates of thrombolysis than residents. This may be explained by a lower proportion of patients with unknown time of symptom onset.

Receptionist rECognition and rEferral of Patients with Stroke (RECEPTS): unannounced simulated patient telephone call study in primary care

Background

Stroke is a leading cause of morbidity and mortality. Timely recognition and referral are essential for treatment.

Aim

To examine the ability of receptionists in general practices to recognise symptoms of stroke and direct patients to emergency care.

Design and setting

Unannounced simulated patient telephone calls and prospective cross-sectional survey study in general practices in the Birmingham and Solihull area.

Method

A total of 52 general practices participated in a total of 520 simulated telephone calls, with 183 receptionists completing questionnaires. Logistic regression analyses were used to examine likelihood of referral for immediate care by ease of vignette recognition and number of common stroke symptoms present.

Results

General practice receptionists correctly referred 69% of simulated calls for immediate care. Calls classed as ‘difficult’ to recognise were less likely to be immediately referred. Compared with ‘easy’ calls: ‘difficult’ calls odds ratio (OR) 0.15, 95% confidence interval (CI) = 0.08 to 0.26; ‘moderate’ calls OR 0.55, 95% CI = 0.32 to 0.92. Similarly, calls including one or two ‘FAST’ symptoms were less likely to be referred immediately (compared with three FAST symptoms: one symptom OR 0.30, 95% CI = 0.13 to 0.72; two symptoms OR 0.35, 95% CI = 0.15 to 0.83).

Conclusion

General practice receptionists refer patients with stroke for immediate care when they present with several symptoms; however, they are less likely to refer patients presenting with only one symptom or less common symptoms of stroke. Optimum management of acute stroke in primary care requires interventions that improve receptionists’ knowledge of lesser-known stroke symptoms.

Differences Between New Immigrants From the Former Soviet Union and Veteran Residents in Knowledge, Perception, and Risk Factors of Stroke

BACKGROUND

Stroke is the fourth most common cause of death in developed countries and a leading cause of acquired disability in adults. Awareness of risk factors and warning signs for stroke has a considerable impact on early arrival at the hospital and early thrombolytic treatment. Delays in seeking medical treatment following the onset of stroke symptoms have been shown to be more common among ethnic minorities.

OBJECTIVE

The aim of the current study was to examine stroke awareness and knowledge among new immigrants from the Former Soviet Union (IFSUs) compared with veteran residents (VRs).

METHODS

The study was conducted by students of the nursing master of arts program. Data were collected during March 2010 and June 2014. Trained registered nurses conducted interviews, using a structured, pretested, open-ended questionnaire. Participants were recruited by a snowball method from among the interviewers' friends and family members, 40 years or older with no history of stroke.

RESULTS

A total of 643 Israelis, 420 VRs (65.3%) and 223 IFSUs (34.7%), were interviewed; 40.7% were men, with a mean age of 52.6 (SD, 9.3) years. Compared with VRs, IFSUs were more likely to report previous myocardial infarction (P = .022), hypertension (P < .001), and diabetes (P = .012). The mean number of stroke warning signs reported by IFSUs was higher than that reported by VRs (P = .031). When asked about risk factors for stroke, IFSUs more often stated hypertension (P = .03), whereas VRs more often reported family history (P = .03). Immigrants from the Former Soviet Union were more aware of strategies for the prevention of stroke than VRs (P = .02). The preferred sources of information about stroke for IFSUs, as distinguished from VRs, were personal doctors (P = .001) and radio programs (P = .03).

CONCLUSIONS

Veteran residents showed lower levels of knowledge about stroke. Educational campaigns aimed at increasing knowledge of stroke among Israel's general population in Israel, as well as culturally targeting specific subgroups, are recommended.

Service factors causing delay in specialist assessment for TIA and minor stroke: a qualitative study of GP and patient perspectives

OBJECTIVE

To understand how service factors contribute to delays to specialist assessment following transient ischaemic attack (TIA) or minor stroke.

DESIGN

Qualitative study using semistructured interviews, analysis by constant comparison.

SETTING

Leicester, UK.

PARTICIPANTS

Patients diagnosed with TIA or minor stroke, at hospital admission or in a rapid-access TIA clinic (n=42), general practitioners (GPs) of participating patients if they had been involved in the patients' care (n=18).

DATA

Accounts from patients and GPs of factors contributing to delay following action to seek help from a healthcare professional (HCP).

RESULTS

The following categories of delay were identified. First, delay in assessment in general practice following contact with the service; this related to availability of same day appointments, and the role of the receptionist in identifying urgent cases. Second, delays in diagnosis by the HCP first consulted, including GPs, optometrists, out-of-hours services, walk-in centres and the emergency department. Third, delays in referral after a suspected diagnosis; these included variable use of the ABCD(2) (Age, Blood pressure, Clinical features, Duration, Diabetes) risk stratification score and referral templates in general practice, and referral back to the patients' GP in cases where he/she was not the first HCP consulted.

CONCLUSIONS

Primary and emergency care providers need to review how they can best handle patients presenting with symptoms that could be due to stroke or TIA. In general practice, this may include receptionist training and/or triage by a nurse or doctor. Mechanisms need to be established to enable direct referral to the TIA clinic when patients whose symptoms have resolved present to other agencies. Further work is needed to improve diagnostic accuracy by non-specialists.

Improving post-stroke recovery: the role of the multidisciplinary health care team

Stroke is a leading cause of serious, long-term disability, the effects of which may be prolonged with physical, emotional, social, and financial consequences not only for those affected but also for their family and friends. Evidence for the effectiveness of stroke unit care and the benefits of thrombolysis have transformed treatment for people after stroke. Previously viewed nihilistically, stroke is now seen as a medical emergency with clear evidence-based care pathways from hospital admission to discharge. However, stroke remains a complex clinical condition that requires health professionals to work together to bring to bear their collective knowledge and specialist skills for the benefit of stroke survivors. Multidisciplinary team working is regarded as fundamental to delivering effective care across the stroke pathway. This paper discusses the contribution of team working in improving recovery at key points in the post-stroke pathway.