Journal Club Recap
September 14th, 2009 at 1:36 pm by LisaLast week’s journal club topic was risk for CVA following a TIA. It has been noted that patients who present with a TIA have a 15-30% risk for stroke within the following 30 days. The ABCD and ABCD2 systems were created to risk stratify patients for either inpatient or outpatient follow up based on the factors of age, blood pressure, neurologic character of the TIA, duration of symptoms, and diabetes. The two articles discussed were:
P M Rothwell, M F Giles, E Flossmann, C E Lovelock, J N E Redgrave, C P Warlow, Z Mehta. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack.
Lancet 2005; 366: 29–36.
Thomas Zambelis, Nikolaos Zakopoulos and Demetrios Vassilopoulos Georgios Tsivgoulis, Konstantinos Spengos, Panagiota Manta, Nikolaos Karandreas. Stroke After a Transient Ischemic Attack: A Hospital-Based Case Series Study. Stroke 2006;37;2892-2897.
The Lancet article was published by the group from England who originally created the ABCD criteria. They used two cohort databases to retrospectively determine 7-day risk of stroke in a group of TIA patients. They determined that an ABCD score of five or greater vastly increased a patient’s risk of stroke within the seven days, and that these patients should be hospitalized.
The group also did a concurrent validation study. We discussed that this is unusual since a validation study is meant to prove generalizability of research, and therefore a subject population should be chosen that is different from, rather than identical to, the original subjects.
The article from Stroke was a retrospective case series. The subjects were consecutive hospital-admitted patients following episodes of TIA. The study found that the ABCD scores correlated to a 30-day risk of CVA and recommended that patients with a score of four or greater be admitted to the hospital.
Our discussion of this article brought up several points. First, the study only included admitted patients, which would have presumably excluded many TIA patients who were discharged. Second, the authors’ statistics include continuous data placed into a binary format, which was statistically significant. Third, there were many patients lost to follow up.
We then discussed how these articles relate to our practice, and how they might change our management. Points that were brought up included:
?In tertiary care centers, the admission decision ultimately rests with the neurology service.
?What level of risk are we willing to accept? Is a 2.5% 7-day risk too high for discharge?
?The work-up for stroke includes an echocardiogram, carotid Doppler ultrasound, and an MRI/MRA of the head and neck. Our patient population at Elmhurst has a low level of education and relatively poor reliability. This work up as an outpatient is complicated and has long waiting times. Often, hospital admission is the only way to guarantee that it will occur.
?An argument in favor of admission of TIA patients was that many patients live alone, or have poor understanding. It is unlikely that they would quickly return to the hospital when they developed acute symptoms of TIA/CVA. Therefore, admission greatly increased the likelihood that these patients would be candidates for thrombolysis.
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