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Management of E.D. Patients who Present with a Transient Ischemic Attack or Can We Safely Send TIA Patients Home From the E.D. ?? Edward P. Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL

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Presentation Transcript
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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
global objectives
Global Objectives
  • Maximize patient outcome
  • Utilize health care resources well
  • Optimize evidence-based medicine
  • Enhance ED practice
sessions objectives
Sessions Objectives
  • TIA patient cases
  • Review key concepts
  • Consider relevant questions
  • Examine treatment options
  • Develop reasonable Rx strategies
  • Answer the question
case presentation

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

case presentation8

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”

ed tia patients key concepts

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

clinical questions

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?

how do tia pts present

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!

how tia pts do not present

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!

what are tia mimics

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

how is cns ischemia caused

How is CNS Ischemia Caused?

Atrial fibrillation

Carotid artery disease

Brain large or small artery disease

how is cns ischemia dx d

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

how are cns infarcts dx d

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

cerebral infarction tias

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”

cvas and amis

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!

cns and cardiac ischemia

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

what work up must be done

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?

what work up must be done22

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??

what rx must be provided

What Rx Must Be Provided?

Antithrombotics

Heparin

Oral anticoagulation

Antiplatelet therapy

Carotid endarterectomy

Risk factor management

antithrombotics

Antithrombotics

Useful in cardioembolic causes

Long-term oral warfarin in afib

Short-term heparin in afib??

LMW heparin??

antiplatelet therapy

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

carotid endarterectomy

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

risk factor management

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

how often will cvas occur

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!!

how often will sx cvas occur

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

tia short term prognosis

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

how do we assess risk

How Do We Assess Risk?

Lifestyle risk factors

Co-morbid illnesses

Vasculopathy assessment

Sx duration: longer is worse

Sx type: non-retinal Sx worse

benefits of admission

Benefits of Admission

Expeditious

Complete evaluation likely

Risk factor management easier

Lifestyle modification possible

Patient education more extensive

Rapid assessment if CVA occurs

benefits of discharge

Benefits of Discharge

Cost containment

Patient ease and comfort

Hospital infection risk

Outcome has not been addressed

why go which route

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

the tpa issue

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

what do we tell patients

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!

what do we document

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

what do we document40

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

an answer to the question

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

some thoughts to ponder

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

more thoughts to ponder

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

conclusions

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

recommendations

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

questions
Questions?

www.FERNE.org

edsloan@uic.edu

312 413 7490