Emergency Department Management of Transient Ischemic Attack: A Survey of Emergency Physicians

• Published in: Journal of stroke and cerebrovascular diseases 2016-06, Vol.25 (6), p.1517-1523
• Main Authors: Oostema, J. Adam, MD, Brown, Michael D., MD, Reeves, Mathew, PhD
• Format: Article
• Language: English
• Subjects: ABCD2; Adult; Cardiovascular; Cerebral Angiography - methods; clinical prediction rule; Computed Tomography Angiography; Decision Support Techniques; emergency department; Emergency Medical Services - trends; Female; Health Care Surveys; Hospitalists - trends; Humans; Ischemic Attack, Transient - complications; Ischemic Attack, Transient - diagnostic imaging; Ischemic Attack, Transient - therapy; Male; Michigan; Middle Aged; Neurology; Patient Admission - trends; Platelet Aggregation Inhibitors - therapeutic use; Practice Patterns, Physicians' - trends; Risk Assessment; Risk Factors; Stroke - etiology; Stroke - prevention & control; survey; Time Factors; Transient ischemic attack (TIA); Treatment Outcome
• ISSN: 1052-3057; 1532-8511
• DOI: 10.1016/j.jstrokecerebrovasdis.2016.02.028

Background Patients are at high risk for stroke following a transient ischemic attack (TIA). The ideal setting for evaluating and treating patients with TIA has not been established, resulting in variability in emergency department (ED) TIA management. We conducted a survey to describe ED TIA management and factors that influence disposition determination for TIA patients. Methods We administered a mail survey to 480 randomly selected members of the Michigan College of Emergency Physicians. Survey questions addressed current ED TIA management, the acceptability of the ABCD2 risk-stratification tool, and disposition recommendations for a series of hypothetical TIA patients. Results A total of 188 (39%) responses were received. Head computed tomography (96.2%) and antiplatelet therapy (88.2%) were the most commonly reported ED interventions. Over 85% of respondents reported admitting most or all TIA patients. The ABCD2 score had low acceptability among emergency medicine physicians and was rarely incorporated into practice (10.7%). Respondents identified a short-term risk of stroke of less than 2% (95% confidence interval: 1.6-2.4) as an acceptable threshold for discharge; however, most respondents recommended admission even for low-risk TIA patients. Those with access to an outpatient TIA clinic were less likely to admit low-risk TIA patients; those with access to an observation unit were more likely to admit. Conclusions In this survey, ED physicians preferred hospital admission for most TIA patients, including those at low risk for stroke. The ABCD2 risk-stratification tool had low acceptability. Further research is needed to refine risk-stratification tools and define the optimal setting for TIA evaluations.