4. NICE Guidelines
• Start Aspirin 300mg (consider other modifiable
risk factors)
• Use a validated scoring system ABCD2
• 4 or more = admit
• 3 or less = home
– Specialist assessment within 1 week
– Diffusion weighted MRI within 1 week
– Carotid Doppler within 1 week
– Carotid endarterectomy within 2 weeks (if 70 – 99%
stenosis)
5. The ABCD2 Score
Predictor Points
Age > 60 1
Blood Pressure > 140/90 1
Clinical Features (max 2)
Unilateral weakness
Speech difficulty without weakness
2
1
Duration (max 2)
> 60 min
10 – 59 min
< 10 min
2
1
0
Diabetes 1
Maximum 7
6. How useful is it?
• Well used ?well validated
– Variable sensitivity
– Variable specifity
– Poor predictor of positive further diagnostic
testing
7. Why risk stratify in TIA?
• TIA carries a risk of stroke
– At 7 days 0.2 – 10%
– At 90 days 1.2 – 12%
8. What do we want?
An ED Risk stratification model that:
•Identifies those at high risk of imminent stroke
•Quickly Identifies the treatable factors that
puts them at risk
•Treat these risk factors in a timely manner
10. Monash Transient Ischemic Attack
Triggering Treatment Pathway (M3T)
• ED assessment
• Cresendo TIA or ongoing symptoms – admit
• TIA with resolved symptoms – ED Testing
– CT brain
– ECG
– Carotid USS
– Blood Tests
• Start Antiplatelet / anticoagulant (If AF), statin,
ACEi
• Discharge Home
11. M3T continued….
• ED physicians fax a referral to daily TIA clinic
• Stroke Reg and receptionist triage referrals on a daily basis
• Priority appointments for patients with ipsilateral internal
carotid stenosis > 50%
• Then CT or MRI angiography is arranged within 24 hours
• Immediate referral for surgical intervention if confirmed
stenosis > 70%
• Patients with AF also receive priority review to assess
anticoagulation
• Patients without AF or Carotid stenosis are allocated less
urgent appointments (4-6 weeks)
• Prior to this trial TIA patients were admitted to hospital
12. Results
• Primary outcome, stroke at 90 days
– 1.50% in M3T
– 4.67% in previous model
• ABCD2 score did not predict outcome in either
M3T trial or in previous model
• Significant cost reduction though reduction of
hospital admission
13. Summary
• Currently no perfect model for risk
assessment
• A well managed non-admission based TIA
model of care is likely to be safe
• This should be directed towards rapid
diagnosis of treatable pathology (AF, carotid
stenosis)
• This would likely reduce costs (as well as
reduce the patient risks of inpatient care)
14. Resources
• NICE Guideline - Stroke
https://www.nice.org.uk/guidance/cg68
• Emergency Medicine Practice 2013
http://www.ebmedicine.net/media_library/files
/0113%20TIA.pdf
Notas do Editor
Boring and knew a lot, interestng and don’t know much
Shades of grey, no one knows what exactly to do
Aim is to give people an idea in varition of practice
As consultant our job to review guidelines and improve service to improve patient care and save money!
How useful is it, well used tool but poorly validated
Variable sensitivity and specificty
Poor predictor of positive further diagnostic testing