TIA Hotline ASPIRE Project and TIA Management

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TIA Hotline (ASPIRE Project) and TIA Management

• Thomas Jeerakathil BSc, MD, MSc, FRCP(C)
• February 23rd, 2009
• Telehealth Presentation

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Objectives

• What is a TIA and what isnt?
• How can we differentiate high risk from low risk
  TIAs? What are the data?
• How urgently should TIA patients receive
  diagnosis, assessment, investigation and
  management?
• How to facilitate rapid assessment of TIA? The
  ASPIRE Project and the TIA Hotline.

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Patient 1

• Jerome is a 85 year old male with HT, CHF,
  hyperlipidemia.
• Complains of three spells in the previous four
  days that have been referred as TIAs
• Spells involve loss of consciousness
• Are these TIAs?

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Diagnosing spells

• Phenomenology before, during, after the event
• Was the event witnessed? What did witnesses
  observe?
• What is the setting? (vascular risk factors,
  elderly, young without risk factors)

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Patient 1

• Upon rising from seated to standing patient
  develops a sense of dizziness and unsteadiness
  and feels very light-headed
• Then experiences blurring of the vision starting
  peripherally and loses consciousness

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Patient 1

• Upon rising from seated to standing patient
  develops a sense of dizziness and unsteadiness
  and feels very light-headed
• Then experiences blurring of the vision starting
  peripherally and loses consciousness
• Syncope

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Top 6 symptoms likely to be a TIA-1

• Sudden onset, lasting minutes to hours, resolves
• 6. Vertigo only if present with brainstem symtoms
  
• 5. Hemibody numbness
• 4. Double vision, crossed numbness or weakness,
  slurred speech, ataxia of gait

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Top 6 symptoms likely to be a TIA - 2

• 3. Speech disturbance for a defined period of
  time (definite dysarthria, muteness or marked
  word finding difficulty, paraphasic speech)
• 2. Monocular or hemifield visual loss (not
  blurring of entire visual field)
• 1. Hemibody weakness

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Top 7 symptoms unlikely to be a TIA

• 7. Postural dizziness alone
• 6. Tingling of all 4 extremities
• 5. Syncopal events
• 4. Momentary word finding trouble that is not new
• 3. Positional and recurrent numbness of one limb
• 2. Scintillating or flashing visual disturbances

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Symptoms unlikely to be a TIA - 2

• 1. Almost anything with hyperventilation or chest
  pain (but make sure it isnt cardiac!)

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How do we identify high risk TIA?
Coutts et al. Annals of Neurology 2005
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90 Day Prognosis after ED Dx of TIA

• 180 / 1707 (10.5) patients had stroke
• 91 occurred in first 2 days
• Age gt 60, DM, Sx gt 10 min, weakness, speech
• 428 (25.1) had some adverse event
• More than half occurred in first 4 days

Johnston SC, JAMA 20002842901-2906
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Independent Risk Factors for Stroke Following TIA

• Independent risk factors for stroke following
  suspected TIA include
• Age gt 60 years
• Diabetes mellitus
• Motor weakness
• Speech impairment
• Symptom duration gt 10 minutes

Johnston et al. JAMA 20002842901-6.
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• ABCD rule for stratifying risk after TIA assign
  points
• Age gt 60 1
• BP during event gt 140 systolic or gt 90 diastolic
  1
• Clinical features unilateral weakness 2
  speech disturbance without weakness 1 other 0
• Duration of symptoms (minutes) gt 60 2 10-59
  1 lt 10 0
• Rothwell, Lancet 2005 366 2936

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ABCD 2 Score Diabetes added and scores 1 extra
point
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Predictive Value of the ABCD2 progostic score
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Alberta TIA Study

• Identified all ED diagnoses of stroke across
  Alberta for 1 fiscal year using admin data
• 2285 TIAs
• 2 day stroke rate 1.4 (readmissions)
• 7 day stroke rate 6.7
• 30 day stroke rate 9.5
• 1 year stroke rate 15 stroke or death 21
• ASPIRE Consensus meeting Aug 2008
• Data for ABCD symptoms/scores applied to Alberta
  population

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ABCD

• ABCD 2005 3 groups
• Derivation (prob and def TIA) (n209) 18
  strokes
• Validation cohort (prob and def TIA) (n190)
  20 strokes
• Referal population for validation cohort (all
  referrals) (n378) 20 strokes

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ABCD2

• ABCD2 2007
• Evaluated ABCD and California rule each in 6
  different populations
• Created a combined ABCD2 score
• 6 study groups

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Symptoms ABCD2

• 6 study groups 4809 patients 442 strokes
• Derivation cohorts
• California ED 1707
• Oxford popln based 209
• Validation cohorts
• California ED2 1069
• California clinic 962
• Oxford popln based -547
• Oxford clinic 315

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Prognostic scores for screening caution advised
Highest scores
medium scores
recurrent stroke
Most events actually occur in those of medium
risk! So be careful of too high a cutoff.
lowest scores
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Impression

• Either ABCD2 gt4 OR Speech or motor symptoms can
  identify high risk symptoms
• They have similar sensitivity (88-100) and
  specificity (31-52) to identify high risk stroke
  patients
• ASPIRE Consensus group choose these cutoffs for
  TIA Triaging within Alberta

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How urgently should high risk TIA patients be
assessed?Does it make a difference?
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Express Study
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Express Study
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ASPIRE TIA Triaging Consensus

• Urgent triage and assessment of TIA province-wide
  deserves evaluation within Alberta
• TIA Triaging algorithm created at Aug 2008
  meeting
• Facilitate urgent access using a TIA Hotline
• Backing of the APSS and the Educational Strategy
  of the APSS
• Pocket cards have been produced

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Hotline process

• North - every TIA hotline call will result in
  contact with a Telestroke Neurologist
• South - TIAs will be screened by operator using
  risk algorithm
• High or medium risk or if refering physician
  requests it still - Stroke Neurologist
• Low risk and if no specific request - fax
  referral in to clinic

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ASPIRE Data

• The TIA Hotline and TIA Triaging Strategy overlap
  with APSS Educational Strategy as well as Pillar
  1 - quality improvement
• Data will be tracked by TIA Hotlines (SARC in the
  south and the CCL/UCL in the north)
• Stroke Prevention Clinic referral forms will be
  faxed to a central number to track all TIAs that
  come to referral across the province

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ASPIRE Outcomes

• Rate of recurrent stroke determined by
  presentations to emergency departments and
  admissions to hospital will be tracked using
  administrative data
• Two years pre compared to two years post
  implementation
• Is the TIA Hotline/Triaging strategy effective?
  Is it worth the cost and effort?
• Ongoing feedback and refinement

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TIA Hotline go live dates

• North including Red Deer (1-888-282-4825)
• Goes live March 16, 2009
• South excluding Red Deer (1-800-661-1700)
• Goes live March 16th, 2009

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THANK YOU!
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