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

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Management of E.D. Patients who Present with a
Transient Ischemic Attack or
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Can We Safely Send TIA Patients Home From the
E.D. ??
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Edward P. Sloan, MD, MPHAssociate
ProfessorDepartment of Emergency
MedicineUniversity of Illinois College of
MedicineChicago, IL
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Attending PhysicianEmergency MedicineUniversity
of Illinois HospitalOur Lady of the
Resurrection HospitalChicago, IL
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Global Objectives

• Maximize patient outcome
• Utilize health care resources well
• Optimize evidence-based medicine
• Enhance ED practice

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Sessions Objectives

• TIA patient cases
• Review key concepts
• Consider relevant questions
• Examine treatment options
• Develop reasonable Rx strategies
• Answer the question

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Case Presentation

• 64 year old presents to ED
• Trouble using L hand
• Couldnt grasp cup of coffee or key
• Symptoms lasted for about 30 minutes
• Spontaneous resolution, now no sx
• Hx DM, smoker
• No recent illness

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Case Presentation

• 75 year old presents to ED
• Slurred speech and dim vision
• No motor symptoms
• Symptoms lasted for 45-60 minutes
• Paramedics called by family
• Speech slow, but resolving now
• Hx heart trouble, bad blood vessels

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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

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Clinical Questions

• How do TIA patients present?
• How is CNS ischemia assessed?
• How are cerebral infarcts Dxd?
• What work-up must be done?
• What therapies must be provided?
• How often will CVAs occur?
• How do we assess admit benefits?

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How do TIA Pts Present?
the astonishing results

• 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

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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

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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

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How is CNS Ischemia Caused?

• Atrial fibrillation
• Carotid artery disease
• Brain large or small artery disease

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How is CNS Ischemia Dxd?

• Careful history and physical
• Labs to rule out metabolic causes
• CT to rule out mass lesions
• Resolution of symptoms
• TIAs most last lt 30-60 minutes
• TIA lt 24 hrs not clinically useful

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How Are CNS Infarcts Dxd?

• 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

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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 isnt the issue
• The key is to diagnose cerebral infarction with
  transient signs

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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!

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TIA Sx and Chest Pain
CNS Cardiac
Non-specific symptoms Neuro Sx Chest Pain
Significant symptoms TIA Unstable angina
Acute infarction TIA Sx and CT or MRI Dx UA Sx and EKG, lab Dx
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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

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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?

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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??

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What Rx Must Be Provided?

• Antithrombotics
• Heparin
• Oral anticoagulation
• Antiplatelet therapy
• Carotid endarterectomy
• Risk factor management

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Antithrombotics

• Useful in cardioembolic causes
• Long-term oral warfarin in afib
• Short-term heparin in afib??
• LMW heparin??

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Antiplatelet Therapy

• Useful in non-cardioembolic causes
• Aspirin 50-325 mg/day
• Clopidogrel or ticlopidine
• Aspirin plus dipyridamole
• Latter two if ASA intolerant or
• if TIA while on ASA
• Anticoagulation not recommended

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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

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Risk Factor Management

• HTN BP below 140/90
• DM fasting glucose lt 126 mg/dl
• Hyperlipidemia LDL lt 100 mg/dl
• Stop smoking!
• Exercise 30-60 min, 3x/week
• Avoid excessive alcohol use
• Weight loss lt 120 of ideal weight

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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!!

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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, 2000.
  2842901-2906

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TIA Short-term Prognosis

• Acute stroke risk is correlated with 5 risk
  factors
• Age gt 60, DM, Sx gt 10min
• Weakness and speech Sx
• Low risk pts less stroke risk
• Lower risk acutely and over time

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Early stroke risk predicted by RF
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How Do We Assess Risk?

• Lifestyle risk factors
• Co-morbid illnesses
• Vasculopathy assessment
• Sx duration longer is worse
• Sx type non-retinal Sx worse

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

• Expeditious
• Complete evaluation likely
• Risk factor management easier
• Lifestyle modification possible
• Patient education more extensive
• Rapid assessment if CVA occurs

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Benefits of Discharge

• Cost containment
• Patient ease and comfort
• Hospital infection risk
• Outcome has not been addressed

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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

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The tPA Issue

• Why not do an out-pt work-up, theres 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

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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!

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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

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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

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

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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

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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

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Conclusions

• 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

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Recommendations

• 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

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Questions?
www.FERNE.org edsloan_at_uic.edu 312 413 7490