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

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

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

3. Edward P. Sloan, MD, MPHAssociate ProfessorDepartment of Emergency MedicineUniversity of Illinois College of MedicineChicago, IL

4. Attending PhysicianEmergency MedicineUniversity of Illinois HospitalOur Lady of the Resurrection HospitalChicago, IL

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

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

7. Case Presentation… 64 year old presents to ED Trouble using L hand “Couldn’t grasp cup of coffee or key” Symptoms lasted for about 30 minutes Spontaneous resolution, now no sx Hx DM, smoker No recent illness

8. 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”

9. 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

10. Clinical Questions How do TIA patients present? How is CNS ischemia assessed? How are cerebral infarcts Dx’d? What work-up must be done? What therapies must be provided? How often will CVAs occur? How do we assess admit benefits?

11. How do TIA Pts Present? 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 Compare the results with a conventional training protocol. Most people do at least two exercises per muscle group, perform three sets and perhaps 12 or 15 reps per set. Allowing just five seconds per rep, that makes for at least 36 minutes of exercise per workout. This is usually done three times per week. So in six weeks, a conventional program would involve 648 minutes of exercise. That's 42 times more than the subjects in our study. Are your results in the last six weeks 42 times better than theirs? I doubt it. Remember, these golfers were exercising in a way that did not involve stretching or moving the weight over a full range of motion. So how did this affect a full range of motion activity like a golf drive? Every one of them showed an improvement. The increase in drive distance varied from 5 to 31 yards. Keep in mind that these subjects had been golfing for up to 40 years and had handicaps as low as eleven. So getting any improvement in golfers who already play at this level is impressive. Getting it with 14 minutes of exercise spread over six weeks is truly revolutionary. The fact is every sport -- even a finesse sport like golf -- is improved by an increase in strength. Muscles are responsible for all movement in the body and stronger muscles deliver more power to every aspect of movement, irrespective of its range of motion. Since this study, I've gone on to improve this method of training. Further research showed that static hold times could be reduced to even less than what the golfers used. Workouts can be spaced further apart as a trainee gets stronger. I work with advanced trainees who train once every six weeks, yet they gain strength on every exercise each time they work out. The weights they hoist are enormous. I believe the time is coming when most people will have a better understanding of the role of proper, efficient strength training methods and frequency. For the guy who wants maximum results with minimum time invested, an ultra-brief but ultra-intense workout will be performed about as often as he gets a haircut. Anything more is just lifting weights as a busy work hobby. Train smart!

12. Measurements of their strength in twelve muscle groups were compared for a "before and after" calculation of improvement. The results of their fourteen minutes of exercise over six weeks were as follows: 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 Compare the results with a conventional training protocol. Most people do at least two exercises per muscle group, perform three sets and perhaps 12 or 15 reps per set. Allowing just five seconds per rep, that makes for at least 36 minutes of exercise per workout. This is usually done three times per week. So in six weeks, a conventional program would involve 648 minutes of exercise. That's 42 times more than the subjects in our study. Are your results in the last six weeks 42 times better than theirs? I doubt it. Remember, these golfers were exercising in a way that did not involve stretching or moving the weight over a full range of motion. So how did this affect a full range of motion activity like a golf drive? Every one of them showed an improvement. The increase in drive distance varied from 5 to 31 yards. Keep in mind that these subjects had been golfing for up to 40 years and had handicaps as low as eleven. So getting any improvement in golfers who already play at this level is impressive. Getting it with 14 minutes of exercise spread over six weeks is truly revolutionary. The fact is every sport -- even a finesse sport like golf -- is improved by an increase in strength. Muscles are responsible for all movement in the body and stronger muscles deliver more power to every aspect of movement, irrespective of its range of motion. Since this study, I've gone on to improve this method of training. Further research showed that static hold times could be reduced to even less than what the golfers used. Workouts can be spaced further apart as a trainee gets stronger. I work with advanced trainees who train once every six weeks, yet they gain strength on every exercise each time they work out. The weights they hoist are enormous. I believe the time is coming when most people will have a better understanding of the role of proper, efficient strength training methods and frequency. For the guy who wants maximum results with minimum time invested, an ultra-brief but ultra-intense workout will be performed about as often as he gets a haircut. Anything more is just lifting weights as a busy work hobby. Train smart!

13. 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

14. How is CNS Ischemia Caused? Atrial fibrillation Carotid artery disease Brain large or small artery disease

15. How is CNS Ischemia Dx’d? Careful history and physical Labs to rule out metabolic causes CT to rule out mass lesions Resolution of symptoms TIAs: most last < 30-60 minutes TIA: < 24 hrs not clinically useful

16. How Are CNS Infarcts Dx’d? 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

17. 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 isn’t the issue The key is to diagnose “cerebral infarction with transient signs”

18. 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!

19. TIA Sx and Chest Pain

20. 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

21. 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?

22. 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??

23. What Rx Must Be Provided? Antithrombotics Heparin Oral anticoagulation Antiplatelet therapy Carotid endarterectomy Risk factor management

24. Antithrombotics Useful in cardioembolic causes Long-term oral warfarin in afib Short-term heparin in afib?? LMW heparin??

25. 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

26. 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

27. Risk Factor Management HTN: BP below 140/90 DM: fasting glucose < 126 mg/dl Hyperlipidemia: LDL < 100 mg/dl Stop smoking! Exercise 30-60 min, 3x/week Avoid excessive alcohol use Weight loss: < 120% of ideal weight

28. 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!!

29. 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. 284:2901-2906

30. TIA Short-term Prognosis Acute stroke risk is correlated with 5 risk factors Age > 60, DM, Sx > 10min Weakness and speech Sx Low risk pts: less stroke risk Lower risk acutely and over time

31. Early stroke risk predicted by RF

32. How Do We Assess Risk? Lifestyle risk factors Co-morbid illnesses Vasculopathy assessment Sx duration: longer is worse Sx type: non-retinal Sx worse

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

34. Benefits of Admission Expeditious Complete evaluation likely Risk factor management easier Lifestyle modification possible Patient education more extensive Rapid assessment if CVA occurs

35. Benefits of Discharge Cost containment Patient ease and comfort Hospital infection risk Outcome has not been addressed

36. 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

37. The tPA Issue “Why not do an out-pt work-up, there’s 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

38. 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!

39. 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

40. 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

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

42. 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

43. 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

44. 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

45. 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

46. 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

47. Questions? www.FERNE.org edsloan@uic.edu 312 413 7490