1
|
Chekol Abebe E, Mengstie MA, Seid MA, Gebeyehu NA, Adella GA, Kassie GA, Gesese MM, Tegegne KD, Anley DT, Feleke SF, Zemene MA, Dessie AM, Tesfa NA, Moges N, Chanie ES, Kebede YS, Bantie B, Dejenie TA. Comparison of circulating lipid profiles, D-dimer and fibrinogen levels between hypertensive patients with and without stroke. Metabol Open 2023; 19:100252. [PMID: 37559716 PMCID: PMC10407734 DOI: 10.1016/j.metop.2023.100252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/13/2023] [Accepted: 07/09/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Stroke is one of the leading causes of global mortality and disability, particularly in hypertensive patients. This study aimed to compare lipid profile, fibrinogen, and D-dimer levels between hypertensive patient with and without stroke. METHODS This was a facility-based cross-sectional study conducted from November 2022 to January 2023 among 115 hypertensive patients (70 patients without stroke and 45 with stroke) who had follow-up at Yikatit 12 Hospital Medical College, Ethiopia. All data analyses were done using SPSS version 25.0 and comparisons of variables between groups were made using the Chi-square test, independent sample t-test, and Mann-Whitney U test. Multiple logistic regression analysis was done to identify predictors of stroke among hypertensive patients. A p-value <0.05 was assumed to be statistically significant for all statistical tests. RESULTS Significantly elevated levels of TC, LDL-C, D-DI, and fibrinogen were observed in the stroke group than in the non-stroke group (p-value<0.05). The mean values of TC, D-DI, and fibrinogen were significantly higher in patients with ischemic stroke compared to those with hemorrhagic stroke. Duration of hypertension (AOR: 1.21; CI: 1.10, 2.09), TC (AOR:1.07; CI: 1.01, 1.22), D-DI (AOR: 1.15; CI: 1.05, 1.69) and fibrinogen (AOR:1.19; CI: 1.10, 2.89) were identified to be independent predictors of stroke in hypertensive patients. CONCLUSION The circulating levels of TC, LDL-C, D-DI and fibrinogen in hypertensive patients with stroke were significantly higher than in those without stroke. But only TC, D-DI, and fibrinogen were found to be predictors of stroke in hypertensives. Considerably higher TC, D-DI, and fibrinogen levels were also seen in patients with ischemic stroke than in those with hemorrhagic stroke. This confirms the key roles of dyslipidemia (hypercholesterolemia) and aberrant hemostatic activation to stroke development, notably ischemic stroke.
Collapse
Affiliation(s)
- Endeshaw Chekol Abebe
- Department of Biochemistry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Misganaw Asmamaw Mengstie
- Department of Biochemistry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mohammed Abdu Seid
- Department of Physiology, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Natnael Atnafu Gebeyehu
- Department of Midwifery, College of Medicine and Health Science, Wolaita Sodo University, Sodo, Ethiopia
| | - Getachew Asmare Adella
- Department of Reproductive Health and Nutrition, School of Public Health, Woliata Sodo University, Sodo, Ethiopia
| | - Gizachew Ambaw Kassie
- Department of Epidemiology and Biostatistics, School of Public Health, Woliata Sodo University, Sodo, Ethiopia
| | - Molalegn Mesele Gesese
- Department of Midwifery, College of Medicine and Health Science, Wolaita Sodo University, Sodo, Ethiopia
| | - Kirubel Dagnaw Tegegne
- Department of Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Denekew Tenaw Anley
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Sefineh Fenta Feleke
- School of Medicine, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Melkamu Aderajew Zemene
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Anteneh Mengist Dessie
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Natnael Amare Tesfa
- School of Medicine, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Natnael Moges
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Ermias Sisay Chanie
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Yenealem Solomon Kebede
- Department of Medical Laboratory Science, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Berihun Bantie
- Department of Comprehensive Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tadesse Asmamaw Dejenie
- Department of Medical Biochemistry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| |
Collapse
|
2
|
Kandiyali R, Lasserson DS, Whiting P, Richards A, Mant J. Predictive values of referrals for transient ischaemic attack from first-contact health care: a systematic review. Br J Gen Pract 2017; 67:e871-80. [PMID: 29158247 DOI: 10.3399/bjgp17X693677] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 06/19/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Over 150 000 cases of suspected transient ischaemic attack (TIA) are referred to outpatient clinics in England each year. The majority of referrals are made by GPs. AIM This study aimed to identify how many patients referred to a TIA clinic actually have TIA (that is, calculate the positive predictive value [PPV] of first-contact healthcare referral) and to record the alternative diagnoses in patients without TIA, in order to determine the optimal service model for patients with suspected TIA. DESIGN AND SETTING A systematic review of TIA clinic referrals from first-contact health professionals (GPs and emergency department [ED] doctors) was undertaken. METHOD Four databases were searched using terms for TIA and diagnostic accuracy. Data on the number of patients referred to a TIA clinic who actually had a TIA (PPVs) were extracted. Frequencies of differential diagnoses were recorded, where reported. Study quality was assessed using the QUADAS-2 tool. RESULTS Nineteen studies were included and reported sufficient information on referrals from GPs and ED doctors to derive PPVs (n = 15 935 referrals). PPVs for TIA ranged from 12.9% to 72.5%. A formal meta-analysis was not conducted due to heterogeneity across studies. Of those not diagnosed with TIA, approximately half of the final diagnoses were of neurological or cardiovascular conditions. CONCLUSION This study highlights the variation in prevalence of true vascular events in patients referred to TIA clinics. For patients without a cerebrovascular diagnosis, the high prevalence of conditions that also require specialist investigations and management are an additional burden on a care pathway that is primarily designed to prevent recurrent stroke. Service commissioners need to assess whether the existing outpatient provision is optimal for people with pathologies other than cerebrovascular disease.
Collapse
|
3
|
Pedersen KB, Madsen C, Sandgaard NCF, Diederichsen ACP, Bak S, Brandes A. Subclinical atrial fibrillation in patients with recent transient ischemic attack. J Cardiovasc Electrophysiol 2018; 29:707-714. [PMID: 29478291 DOI: 10.1111/jce.13470] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/06/2018] [Accepted: 01/26/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a major risk factor of stroke, but the association between AF and transient ischemic attack (TIA) is less clear. Despite this, patients with TIA are included in stroke trials. AIMS To determine the 1-year incidence of AF in TIA patients using an insertable cardiac monitor (ICM); second, to determine factors associated with incident AF in these patients. METHODS Prospective cohort study of patients with TIA with normal standard electrocardiogram (ECG) and 72-hour Holter monitoring (HM). Exclusion criteria were as follows: age < 18 or > 81 years; prior AF/stroke; ongoing oral anticoagulation therapy or contraindication for it; significant carotid artery stenosis; uncertain TIA diagnosis. Eligible patients received an ICM and were followed for 12 months. RESULTS From November 2013 to October 2015, 809 patients were diagnosed with TIA. In total, 235 patients were eligible. Nine (3.8%) of these had AF on standard ECG or HM. Of the remaining patients, 121 refused ICM implantation. In total, 105 patients (median age 65.4 years [range 27.1-80.8], 46% males) received an ICM, which revealed AF in 7 (6.7%). Factors associated with new-onset AF were a history of recurrent TIA (odds ratio [OR] 11.5, 95% confidence interval [CI] 2.1-63.6) and heart failure (OR 12.7, 95% CI 1.71-96.83). CONCLUSIONS The 1-year incidence of AF in TIA patients with normal ECG and HM was 6.7% using an ICM. Factors associated with development of AF were recurrent TIA and heart failure.
Collapse
Affiliation(s)
| | - Charlotte Madsen
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | | | | | - Søren Bak
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
4
|
Pedersen KB, Chemnitz A, Madsen C, Sandgaard NCF, Bak S, Brandes A. Low Incidence of Atrial Fibrillation in Patients with Transient Ischemic Attack. Cerebrovasc Dis Extra 2016; 6:140-149. [PMID: 27898406 PMCID: PMC5216214 DOI: 10.1159/000451035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 08/24/2016] [Indexed: 12/20/2022] Open
Abstract
Background Atrial fibrillation (AF) is a major cause of stroke. Therefore, all patients with ischemic stroke or transient ischemic attack (TIA) should be examined with 12-lead electrocardiogram (ECG) and continuous monitoring to detect AF. Current guidelines recommend at least 24 h continuous ECG monitoring, which is primarily based on studies investigating patients with ischemic stroke. The aim of our study was to investigate the diagnostic yield of 12-lead ECG and Holter monitoring in patients with TIA. Methods We retrospectively investigated all patients diagnosed with TIA at Odense University Hospital, Denmark, from January 1, 2014 to December 31, 2014. TIA was a clinical diagnosis according to the WHO definition. Patients received admission ECG and 72-hour Holter monitoring after discharge. Results 171 patients without known AF were diagnosed with TIA. Four (2.3%) were diagnosed with AF on admission ECG. Another 2 (1.2%) were diagnosed with AF on Holter monitoring. In total, 6 patients (3.5%) were diagnosed with AF. Patients with AF were significantly older (mean age 79.4 [95% CI 65.1-93.6] years) than patients without AF (mean age 67.6 [95% CI 65.6-69.5] years) but otherwise showed no difference in baseline characteristics. Conclusion In this retrospective study, patients with TIA had a low incidence of AF detected with ECG and 72-hour Holter monitoring. Prospective studies are needed to confirm these findings.
Collapse
|
5
|
Wardlaw J, Brazzelli M, Miranda H, Chappell F, McNamee P, Scotland G, Quayyum Z, Martin D, Shuler K, Sandercock P, Dennis M. An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation. Health Technol Assess 2014; 18:1-368, v-vi. [PMID: 24791949 DOI: 10.3310/hta18270] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment. OBJECTIVES Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention? DATA SOURCES Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion. REVIEW METHODS Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios. RESULTS The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective. LIMITATIONS Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity. CONCLUSIONS Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Miriam Brazzelli
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hector Miranda
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zahid Quayyum
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Duncan Martin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsten Shuler
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
6
|
Clarey J, Lasserson D, Levi C, Parsons M, Dewey H, Barber PA, Quain D, McElduff P, Sales M, Magin P. Absolute cardiovascular risk and GP decision making in TIA and minor stroke. Fam Pract 2014; 31:664-9. [PMID: 25208544 PMCID: PMC5926454 DOI: 10.1093/fampra/cmu054] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Transient ischaemic attacks (TIA) and minor strokes (TIAMS) have the same pathophysiological mechanism as stroke and carry a high risk of recurrent ischaemic events. Diagnosis of TIAMS can be challenging and often occurs in general practice. Absolute cardiovascular risk (ACVR) is recommended as the basis for vascular risk management. Consideration of cardiovascular risk in TIAMS diagnosis has been recommended but its utility is not established. OBJECTIVES Firstly, to document the ACVR of patients with incident TIAMS and with TIAMS-mimics. Secondly, to evaluate the utility of ACVR calculation in informing the initial diagnosis of TIAMS. METHODS The International comparison of Systems of care and patient outcomes in minor Stroke and TIA (InSiST) study is an inception cohort study of patients of 17 Australian general practices presenting as possible TIAMS. An expert panel determines whether participants have had TIAMS or TIAMS-mimics. ACVR was calculated at baseline for each participating patient. In this cross-sectional baseline analysis, ACVR of TIAMS and TIAMS-mimics were compared univariately and, also, when adjusted for age and sex. The diagnostic utility of ACVR was evaluated via receiver operating characteristic (ROC) curves. RESULTS Of 179 participants, 87 were adjudicated as TIAMS. The presence of motor and speech symptoms and body mass index were associated with a diagnosis of TIAMS. ACVR was associated with TIAMS diagnosis on univariate analysis, but not when age- and sex-adjusted. ACVR did not significantly improve area under ROC curves beyond that of age and sex. CONCLUSION In patients presenting with transient or minor neurological symptoms, calculation of ACVR did not improve diagnostic accuracy for TIAMS beyond that of age and sex.
Collapse
Affiliation(s)
- Jamie Clarey
- Discipline of General Practice, University of Newcastle, Newcastle, Australia
| | - Daniel Lasserson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher Levi
- Centre for Translational Neuroscience, University of Newcastle, Newcastle, Department of Neurology, John Hunter Hospital, Newcastle
| | - Mark Parsons
- Department of Neurology, John Hunter Hospital, Newcastle, School of Medicine and Public Health, University of Newcastle, Newcastle
| | - Helen Dewey
- Department of Medicine - Austin Health, University of Melbourne, Melbourne, Australia
| | - P Alan Barber
- Centre for Brain Research Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand and
| | - Debbie Quain
- School of Medicine and Public Health, University of Newcastle, Newcastle
| | - Patrick McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle
| | - Milton Sales
- General Practice Training valley to coast, Newcastle, Australia
| | - Parker Magin
- Discipline of General Practice, University of Newcastle, Newcastle, Australia, Centre for Translational Neuroscience, University of Newcastle, Newcastle, General Practice Training valley to coast, Newcastle, Australia.
| |
Collapse
|
7
|
Lasserson DS, Mant D, Hobbs FDR, Rothwell PM. Validation of a TIA Recognition Tool in Primary and Secondary Care: Implications for Generalizability. Int J Stroke 2013; 10:692-6. [DOI: 10.1111/ijs.12201] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 08/25/2013] [Indexed: 12/13/2022]
Abstract
Background In spite of public education campaigns, patients with transient ischemic attack still present to primary care where accurate recognition of transient ischemic attack is essential so that specialist referral can be expedited to reduce stroke risk. The complex task of diagnosing transient ischemic attack is challenging in time-limited settings in primary care yet the potential for a transient ischemic attack recognition tool to improve diagnosis has not been determined. Aims We set out to examine the potential utility in primary care of the only existing transient ischemic attack recognition tool. Methods All primary care referrals with suspected transient ischemic attack from a total population of 91 000 people were analyzed over a four-year period from 2002 to 2006. Clinical and research records from the transient ischemic attack clinic and consultation notes and referral letters from primary care physicians were used to populate the Dawson recognition score. Results Of 513 referrals, 209 (47%) had a clinic confirmed diagnosis of transient ischemic attack. Agreement between primary care assessments and specialist assessments was greater for speech disturbance (kappa 0·68) than for unilateral facial weakness (0·58) and unilateral limb weakness (0·51). The Dawson score had greater accuracy in diagnosing all transient ischemic attack in specialist assessments than in primary care assessments (c statistics 0·80 vs. 0·70, P < 0·0001) and performed particularly poorly in primary care for detecting posterior circulation territory transient ischemic attack with a c statistic (95% confidence interval) of 0·52 (0·43–0·61). Conclusion The Dawson transient ischemic attack recognition score is less accurate in primary care than in its derivation setting of specialist care. Improving the recognition of transient ischemic attack by providers of first contact health care requires derivation of rules in the clinical setting in which they are to be used.
Collapse
Affiliation(s)
- Daniel S. Lasserson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Stroke Prevention Unit, Nuffield Department of Clinical Neuroscience, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK
| | - David Mant
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - F. D. Richard Hobbs
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter M. Rothwell
- Stroke Prevention Unit, Nuffield Department of Clinical Neuroscience, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK
| |
Collapse
|
8
|
Edwards D, Fletcher K, Deller R, McManus R, Lasserson D, Giles M, Sims D, Norrie J, McGuire G, Cohn S, Whittle F, Hobbs V, Weir C, Mant J. RApid Primary care Initiation of Drug treatment for Transient Ischaemic Attack (RAPID-TIA): study protocol for a pilot randomised controlled trial. Trials 2013; 14:194. [PMID: 23819476 PMCID: PMC3716929 DOI: 10.1186/1745-6215-14-194] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 06/14/2013] [Indexed: 11/23/2022] Open
Abstract
Background People who have a transient ischaemic attack (TIA) or minor stroke are at high risk of a recurrent stroke, particularly in the first week after the event. Early initiation of secondary prevention drugs is associated with an 80% reduction in risk of stroke recurrence. This raises the question as to whether these drugs should be given before being seen by a specialist – that is, in primary care or in the emergency department. The aims of the RAPID-TIA pilot trial are to determine the feasibility of a randomised controlled trial, to analyse cost effectiveness and to ask: Should general practitioners and emergency doctors (primary care physicians) initiate secondary preventative measures in addition to aspirin in people they see with suspected TIA or minor stroke at the time of referral to a specialist? Methods/Design This is a pilot randomised controlled trial with a sub-study of accuracy of primary care physician diagnosis of TIA. In the pilot trial, we aim to recruit 100 patients from 30 general practices (including out-of-hours general practice centres) and 1 emergency department whom the primary care physician diagnoses with TIA or minor stroke and randomly assign them to usual care (that is, initiation of aspirin and referral to a TIA clinic) or usual care plus additional early initiation of secondary prevention drugs (a blood-pressure lowering protocol, simvastatin 40 mg and dipyridamole 200 mg m/r bd). The primary outcome of the main study will be the number of strokes at 90 days. The diagnostic accuracy sub-study will include these 100 patients and an additional 70 patients in whom the primary care physician thinks the diagnosis of TIA is possible, rather than probable. For the pilot trial, we will report recruitment rate, follow-up rate, a preliminary estimate of the primary event rate and occurrence of any adverse events. For the diagnostic study, we will calculate sensitivity and specificity of primary care physician diagnosis using the final TIA clinic diagnosis as the reference standard. Discussion This pilot study will be used to estimate key parameters that are needed to design the main study and to estimate the accuracy of primary care diagnosis of TIA. The planned follow-on trial will have important implications for the initial management of people with suspected TIA. Trial registration ISRCTN62019087
Collapse
Affiliation(s)
- Duncan Edwards
- General Practice and Primary Care Research Unit, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Kirkpatrick S, Locock L, Giles MF, Lasserson DS. Non-focal neurological symptoms associated with classical presentations of transient ischaemic attack: qualitative analysis of interviews with patients. PLoS One 2013; 8:e66351. [PMID: 23776662 DOI: 10.1371/journal.pone.0066351] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 05/08/2013] [Indexed: 12/26/2022] Open
Abstract
Background Improving the recognition of transient ischaemic attack (TIA) at initial healthcare contact is essential as urgent specialist assessment and treatment reduces stroke risk. Accurate TIA detection could be achieved with clinical prediction rules but none have been validated in primary care. An alternative approach using qualitative analysis of patients' experiences of TIA may identify novel features of the TIA phenotype that are not detected routinely, as such techniques have revealed novel early features of other important conditions such as meningococcaemia. We sought to determine whether the patient's experience of TIA would reveal additional deficits that can be tested prospectively in cohort studies to determine their additional diagnostic and prognostic utility at the first healthcare contact. Methodology and Findings Qualitative semi-structured interviews with 25 patients who had experienced definite TIA as determined by a stroke specialist; framework analysis to map symptoms and key words or descriptive phrases used against each individual, with close attention to the detail of the language used. All interview transcripts were reviewed by a specialist clinician with experience in TIA/minor stroke. Patients described non-focal symptoms consistent with higher function deficits in spatial perception and awareness of deficit, as well as feelings of disconnection with their immediate surroundings. Of the classical features, weakness and speech disturbance were described in ways that did not meet the readily recognisable phenotype. Conclusion/Significance Analysis of patients' narrative accounts reveals a set of overlooked features of the experience of TIA which may provide additional diagnostic utility so that providers of first contact healthcare can recognise TIA more easily. Future research is required in a prospective cohort of patients presenting with transient neurological symptoms to determine how frequent these features are, what they add to diagnostic information and whether they can refine measures to predict stroke risk.
Collapse
|
10
|
Benavente L, Calleja S, Larrosa D, Vega J, Mauri G, Pascual J, Lahoz CH. Long term evolution of patients treated in a TIA unit. Int Arch Med 2013; 6:19. [PMID: 23635082 PMCID: PMC3716896 DOI: 10.1186/1755-7682-6-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 04/13/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transient ischemic attacks (TIA) entail a high risk of stroke recurrence, which depends on the etiology. New organizational models have been created, but there is not much information about the long-term evolution of patients managed according to these premises. Our aim is to refer the follow-up of patients attended according to our model of TIA Unit. METHODS TIA Unit is located in the Emergency Department and staffed by vascular neurologists. Patients admitted during the Neurology night shift stayed in such Unit <48h with complete etiological study. Preventive treatment is instituted in patients discharged to a high resolution Neurology consult, in order to review in <2 weeks and subsequent follow-up. RESULTS During a year 161 patients were attended, being admitted to the hospital 8.6%. A total of 1470 hospital days were avoided. Recurrence at 90 days was of 0.6%. Mean follow-up was 18.14 ± 8.02 months (0-34), total recurrence 6.2% (70% cardioembolic strokes). There were no complications derived from treatment. Cardiological events were recorded in 10.6%, neoplastic in 5%, cognitive impairment in 11%. There were 3 deaths unrelated nor to the stroke or its treatment. CONCLUSIONS This model allows an early diagnosis and treatment of TIA, preventing recurrences of stroke in a long term. It detects atherothrombotic strokes, most of them admitted to the hospital, and it shows a greater difficulty for detecting all cardioembolic strokes. TIA Unit appeared to be safe in using anticoagulation therapy, as the follow-up shows. It shows the same quality of management than hospital admission, with a significant saving in hospital stays.
Collapse
Affiliation(s)
- Lorena Benavente
- Neurology Department, University Hospital “Central de Asturias”, C/Julián Clavería s/n, 33006, Oviedo, Spain
| | - Sergio Calleja
- Neurology Department, University Hospital “Central de Asturias”, C/Julián Clavería s/n, 33006, Oviedo, Spain
| | - Davinia Larrosa
- Neurology Department, University Hospital “Central de Asturias”, C/Julián Clavería s/n, 33006, Oviedo, Spain
| | - Juan Vega
- Neurology Department, University Hospital “Central de Asturias”, C/Julián Clavería s/n, 33006, Oviedo, Spain
| | - Gerard Mauri
- Neurology Department, University Hospital “Central de Asturias”, C/Julián Clavería s/n, 33006, Oviedo, Spain
| | - Julio Pascual
- Neurology Department, University Hospital “Central de Asturias”, C/Julián Clavería s/n, 33006, Oviedo, Spain
| | - Carlos H Lahoz
- Neurology Department, University Hospital “Central de Asturias”, C/Julián Clavería s/n, 33006, Oviedo, Spain
| |
Collapse
|
11
|
Magin P, Lasserson D, Parsons M, Spratt N, Evans M, Russell M, Royan A, Goode S, McElduff P, Levi C. Referral and Triage of Patients with Transient Ischemic Attacks to an Acute Access Clinic: Risk Stratification in an Australian Setting. Int J Stroke 2013; 8 Suppl A100:81-9. [DOI: 10.1111/ijs.12014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Transient ischemic attacks and minor stroke entail considerable risk of completed stroke but this risk is reduced by prompt assessment and treatment. Risk can be stratified according to the ABCD2 prediction score. Current guidelines suggest specialist assessment and treatment within 24 h for high-risk event (ABCD2 score 4–7) and seven-days for low-risk event (ABCD2 score ≤ 3). Aims The study aims to establish paths to care and outcomes for patients referred by general practitioners and emergency departments to an Australian acute access transient ischemic attack service. Methods This is a prospective audit. Primary outcomes were time from event to referral, from referral to clinic appointment, and from event to appointment. ABCD2 score was calculated for each event. Time from event was modeled using Cox proportional hazards regression. Results There were 231 clinic attendees (general practitioner: 127; emergency department: 104). Mean time from event to referral was 9·2 days (SD 23·7, median 2), from referral to being seen in the clinic was 13·6 days (SD 19·0, median 7), and from event to being seen in the clinic was 17·2 days (SD 27·1, median 10). Of low-risk patients, 38·5% were seen within seven-days of event. Of high-risk patients, 36·7% were seen within one-day. ABCD2 score was not a significant predictor of any time interval from event to clinic attendance. There were no completed strokes prior to clinic attendance. Conclusions Times from event to clinic assessment were in excess of current recommendations and risk stratification was suboptimal, though short-term outcomes were good. Improvements in referral mechanisms may enhance risk-stratification and triage.
Collapse
Affiliation(s)
- Parker Magin
- Discipline of General Practice, University of Newcastle, Callaghan, NSW, Australia
| | - Daniel Lasserson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Parsons
- Discipline of Medicine, University of Newcastle, Callaghan, NSW, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Neil Spratt
- Discipline of Medicine, University of Newcastle, Callaghan, NSW, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Malcolm Evans
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Michelle Russell
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Angela Royan
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Susan Goode
- Discipline of General Practice, University of Newcastle, Callaghan, NSW, Australia
| | - Patrick McElduff
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW, Australia
| | - Christopher Levi
- Discipline of Medicine, University of Newcastle, Callaghan, NSW, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| |
Collapse
|
12
|
Mavaddat N, Savva GM, Lasserson DS, Giles MF, Brayne C, Mant J. Transient neurological symptoms in the older population: report of a prospective cohort study--the Medical Research Council Cognitive Function and Ageing Study (CFAS). BMJ Open 2013; 3:bmjopen-2013-003195. [PMID: 23883888 PMCID: PMC3731761 DOI: 10.1136/bmjopen-2013-003195] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Transient ischaemic attack (TIA) is a recognised risk factor for stroke in the older population requiring timely assessment and treatment by a specialist. The need for such TIA services is driven by the epidemiology of transient neurological symptoms, which may not be caused by TIA. We report prevalence and incidence of transient neurological symptoms in a large UK cohort study of older people. DESIGN Longitudinal cohort study SETTING The Medical Research Council Cognitive Function and Aging Study (CFAS) is a population representative study based on six centres across England and Wales. PARTICIPANTS Random samples of people in their 65th year were obtained from Family Health Service Authority lists. The participation rate was 80% (n=13 004). Interview at baseline included questions about stroke and three transient neurological symptoms, repeated in a subsample after 2 years. Patients were flagged for mortality. MAIN OUTCOME MEASURES Prevalence and 2-year incidence of transient neurological symptoms. RESULTS In 11 903 participants without a history of stroke, 271 (2.3%) reported transient problems with speech, 872 (7.6%) with sight and 596 (5.1%) weakness in a limb with 1456 (12.7%) reporting at least one symptom. Of those reinterviewed (n=6748), 675 (9.8%) reported at least one symptom over 2 years. CONCLUSIONS Lifetime prevalence and incidence of transient neurological symptoms in people aged 65 years and over is high and is substantially greater than the incidence of TIA in hospital-based and population-based studies. These high rates of transient neurological symptoms in the community in the older population should be considered when planning TIA services.
Collapse
Affiliation(s)
- Nahal Mavaddat
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Laboratory, Worts Causeway, Cambridge, UK
| | - George M Savva
- School of Nursing Sciences, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Daniel S Lasserson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Matthew F Giles
- Stroke Prevention Research Unit, Department of Clinical Neurology,John Radcliffe Hospital, NIHR Biomedical Research Centre, Oxford University,Oxford, UK
| | - Carol Brayne
- Department of Public Health and Primary Care, University of Cambridge, Institute of Public Health, Cambridge, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Laboratory, Worts Causeway, Cambridge, UK
| |
Collapse
|
13
|
Cameron AC, Dawson J, Quinn TJ, Walters M, McInnes GT, Morrison D, Sloan W, Lees KR. Long-Term Outcome following Attendance at a Transient Ischemic Attack Clinic. Int J Stroke 2011; 6:306-11. [DOI: 10.1111/j.1747-4949.2011.00591.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background and purpose Many patients who attend transient ischemic attack clinics have a noncerebrovascular diagnosis. The long-term outcomes in this group are not well described. We evaluated these in a cohort referred to a transient ischemic attack clinic with a suspected transient ischemic attack. Methods Patients were clinically classified as having stroke or a transient ischemic attack or a noncerebrovascular diagnosis (nontransient ischemic attack). Follow-up was via electronic record linkage. The primary endpoint was cardiovascular death or a major cardiovascular event. Secondary outcomes included incident neurological disease (excluding stroke or transient ischemic attack) and the need for permanent pacemaker insertion. Outcomes in the transient ischemic attack and nontransient ischemic attack cohorts were compared using Cox's proportional hazards models. Mortality outcomes were further compared with those in a contemporary control group of individuals with hypertension. Results Of the 3533 patients who attended the transient ischemic attack clinic, 53·5% had a transient ischemic attack. Of these, 769 (40·7%) suffered a cardiovascular endpoint, compared with 458 (27·9%) with a nontransient ischemic attack (hazard ratio 1·53, 95% confidence interval 1·36–1·72). The risk remained higher but was attenuated following adjustment (hazard ratio 1·21, 95% confidence interval 1·05–1·41). Cardiovascular mortality in both groups was higher than that in hypertensive controls. The risk of a subsequent nonstroke neurological event was higher in those without a transient ischemic attack. Conclusions Patients without a transient ischemic attack referred to a transient ischemic attack clinic have a high risk of future vascular events that exceeds risk in a cohort with hypertension. All patients attending transient ischemic attack clinics should undergo assessment of their cardiovascular risk and the use of methods to reduce this risk should be explored.
Collapse
Affiliation(s)
- Alan C. Cameron
- Division of Cardiovascular and Medical Sciences, Gardiner Institute, Faculty of Medicine, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Division of Cardiovascular and Medical Sciences, Gardiner Institute, Faculty of Medicine, University of Glasgow, Glasgow, UK
| | - Terence J. Quinn
- Division of Cardiovascular and Medical Sciences, Gardiner Institute, Faculty of Medicine, University of Glasgow, Glasgow, UK
| | - M.R. Walters
- Division of Cardiovascular and Medical Sciences, Gardiner Institute, Faculty of Medicine, University of Glasgow, Glasgow, UK
| | - Gordon T. McInnes
- Division of Cardiovascular and Medical Sciences, Gardiner Institute, Faculty of Medicine, University of Glasgow, Glasgow, UK
| | - David Morrison
- Division of Community-Based Sciences, Faculty of Medicine, University of Glasgow, Glasgow, UK
| | - William Sloan
- Division of Community-Based Sciences, Faculty of Medicine, University of Glasgow, Glasgow, UK
| | - Kennedy R. Lees
- Division of Cardiovascular and Medical Sciences, Gardiner Institute, Faculty of Medicine, University of Glasgow, Glasgow, UK
| |
Collapse
|
14
|
Abstract
Vestibular migraine is a chameleon among the episodic vertigo syndromes because considerable variation characterizes its clinical manifestation. The attacks may last from seconds to days. About one-third of patients presents with monosymptomatic attacks of vertigo or dizziness without headache or other migrainous symptoms. During attacks most patients show spontaneous or positional nystagmus and in the attack-free interval minor ocular motor and vestibular deficits. Women are significantly more often affected than men. Symptoms may begin at any time in life, with the highest prevalence in young adults and between the ages of 60 and 70. Over the last 10 years vestibular migraine has evolved into a medical entity in dizziness units. It is the most common cause of spontaneous recurrent episodic vertigo and accounts for approximately 10% of patients with vertigo and dizziness. Its broad spectrum poses a diagnostic problem of how to rule out Menière's disease or vestibular paroxysmia. Vestibular migraine should be included in the International Headache Classification of Headache Disorders (ICHD) as a subcategory of migraine. It should, however, be kept separate and distinct from basilar-type migraine and benign paroxysmal vertigo of childhood. We prefer the term "vestibular migraine" to "migrainous vertigo," because the latter may also refer to various vestibular and non-vestibular symptoms. Antimigrainous medication to treat the single attack and to prevent recurring attacks appears to be effective, but the published evidence is weak. A randomized, double-blind, placebo-controlled study is required to evaluate medical treatment of this condition.
Collapse
Affiliation(s)
- Michael Strupp
- Department of Neurology and Integrated Center for Research and Treatment of Vertigo, Dizziness and Ocular Motor Disorders, Ludwig-Maximilians University, Münich, Germany.
| | | | | |
Collapse
|
15
|
Abstract
The introduction of thrombolysis for the treatment of acute ischaemic stroke has increased the importance of prompt and accurate diagnosis. Research has shown a high rate of misdiagnosis of acute stroke in the community by paramedics and primary care doctors (PCDs). In this study, referral letters for presumed acute stroke or Transient Ischaemic Attack (TIA) were audited to assess the diagnostic accuracy of PCDs and the quality of the referral letters. In 30 % of cases, the diagnosis of stroke was correct. Important stroke mimics included sepsis, delirium and functional disorders. PCDs may benefit from a stroke recognition tool to increase diagnostic accuracy.
Collapse
Affiliation(s)
- A Mcneill
- Senior House Officer, Central Newcastle Medical Rotation, Freeman Hospital, Freeman Road, High Heaton, Newcastle-upon-Tyne, UK
| |
Collapse
|