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Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic

  • Gregory W. Hosier (a1), Stephen J. Phillips (a2), Steve P. Doucette (a3), Kirk D. Magee (a4) and Gordon J. Gubitz (a2)...

Abstract

Objectives

1) To evaluate whether transient ischemic attack (TIA) management in emergency departments (EDs) of the Nova Scotia Capital District Health Authority followed Canadian Best Practice Recommendations, and 2) to assess the impact of being followed up in a dedicated outpatient neurovascular clinic.

Methods

Retrospective chart review of all patients discharged from EDs in our district from January 1, 2011 to December 31, 2012 with a diagnosis of TIA. Cox proportional hazards models, Kaplan-Meier survival curve, and propensity matched analyses were used to evaluate 90-day mortality and readmission.

Results

Of the 686 patients seen in the ED for TIA, 88.3% received computed tomography (CT) scanning, 86.3% received an electrocardiogram (ECG), 35% received vascular imaging within 24 hours of triage, 36% were seen in a neurovascular clinic, and 4.2% experienced stroke, myocardial infarction, or vascular death within 90 days. Rates of antithrombotic use were increased in patients seen in a neurovascular clinic compared to those who were not (94% v. 86.3%, p<0.0001). After adjustment for age, sex, vascular disease risk factors, and stroke symptoms, the risk of readmission for stroke, myocardial infarction, or vascular death was lower for those seen in a neurovascular clinic compared to those who were not (adjusted hazard ratio 0.28; 95% confidence interval 0.08–0.99, p=0.048).

Conclusion

The majority of patients in our study were treated with antithrombotic agents in the ED and investigated with CT and ECG within 24 hours; however, vascular imaging and neurovascular clinic follow-up were underutilized. For those with neurovascular clinic follow-up, there was an association with reduced risk of subsequent stroke, myocardial infarction, or vascular death.

Objectifs

L’étude visait, d’une part, à examiner si la prise en charge des accidents ischémiques transitoires (AIT) au service des urgences de la région sanitaire Nova Scotia Capital District Health Authority respectait les recommandations canadiennes en matière de pratiques exemplaires, et, d’autre part, à évaluer l’incidence du suivi dans un service de consultations externes, spécialisé en maladies neurovasculaires.

Méthode

Les auteurs ont procédé à un examen rétrospectif des dossiers de tous les patients chez qui avait été posé un diagnostic d’AIT et qui avaient reçu leur congé du SU, dans la région mentionnée, et ce, du 1er janvier 2011 au 31 décembre 2012. La mortalité et le taux de réadmission au bout de 90 jours ont été calculés à l’aide de modèles de risques proportionnels de Cox, de la méthode d’estimation de Kaplan-Meyer et d’analyses appariées de propension.

Résultats

Sur 686 patients examinés au SU pour un AIT, 88,3% ont été soumis à une tomodensitométrie (TDM); 86,3%, à un ECG; 35%, à un examen par imagerie vasculaire dans les 24 heures suivant le triage et 36% ont été vus dans un service de consultations spécialisé en maladies neurovasculaires; 4,2% ont subi un accident vasculaire cérébral (AVC) ou un infarctus du myocarde (IM) ou ont succombé à une maladie vasculaire au bout de 90 jours. Le taux d’utilisation d’antithrombotiques était plus élevé chez les patients qui avaient été vus au service de consultations spécialisé enmaladies neurovasculaires que chez ceux qui n’avaient pas été vus (94% contre 86,3%; p<0,0001). Après rajustement selon l’âge, le sexe, les facteurs de risque de maladie vasculaire et les symptômes d’AVC, le risque de réadmission pour un AVC, un IM ou une mort par maladie vasculaire était plus faible chez les patients qui avaient été vus au service de consultations spécialisé enmaladies neurovasculaires que chez ceux qui n’avaient pas été vus (rapport de risque rajusté : 0,28; IC à 95% : 0,08-0,99; p=0,048).

Conclusions

La plupart des patients retenus dans l’étude ont été traités par des antithrombotiques au SU et ont été soumis à une TDM et à un ECG dans les 24 heures; toutefois, le recours aux examens par imagerie vasculaire et au service de consultations spécialisé enmaladies neurovasculaires pour le suivi a fait défaut. Une association a été établie entre le suivi au service de consultations spécialisé enmaladies neurovasculaires et une réduction du risque ultérieur d’AVC, d’IM ou de mort par maladie vasculaire.

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Copyright

Corresponding author

Correspondence to: Gregory Hosier, Dalhousie University, 5850 College Street, Halifax, NS B3H 4R2; Email: gregory.hosier@dal.ca

References

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Keywords

Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic

  • Gregory W. Hosier (a1), Stephen J. Phillips (a2), Steve P. Doucette (a3), Kirk D. Magee (a4) and Gordon J. Gubitz (a2)...

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