Low positive predictive value of the ABCD<sup>2</sup> score in emergency department transient ischaemic attack diagnoses: the South Western Sydney Transient Ischaemic Attack Study

Ghia, Darshan; Thomas, Peter; Cordato, Dennis; Epstein, Danny; Beran, Roy G.; Cappelen‐Smith, Cecilia; Griffith, Neil; Hanna, Ibrahim; McDougall, Alan; Hodgkinson, S.; Worthington, John

doi:10.1111/j.1445-5994.2011.02564.x

Cited by 20 publications

(35 citation statements)

References 14 publications

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“…38 In a strategy known to improve comorbidity ascertainment in the setting of stroke 24 and other circumstances, 39 we applied a 5-year "look-back" period to capture comorbidities identified in prior hospitalizations. Our resulting comorbidity estimates are generally comparable to other studies using more direct methods to determine medical history: hypertension (59% versus 56% to 65%), 6,40,41 atrial fibrillation (21% versus 15% to 26%), 5,6,42 stroke history (11% versus 9% to 10%), 6,40,42 smoking (17% versus 20%), 40 ischemic heart disease (23% versus 15% to 26%), 6,40 carotid stenosis (6% versus 10% to 12%), 5,40 diabetes (21% versus 16%) 40,41 and TIA (8% versus 10%). 43 Only our reported prevalence of hyperlipidemia (26%) appears lower in comparison to other reports (34% to 60%).…”

Section: Discussionsupporting

confidence: 71%

“…Early stroke rates are low in Australia after a TIA (Ͻ3%), even among those treated as outpatients. 4,5,41 TIA cases that did not present to the hospital but were later admitted with stroke would not have been included. Omitting these patients would have overestimated survival; however, other researchers have excluded such cases because of difficulties in validating the TIA diagnosis.…”

Section: Discussionmentioning

confidence: 99%

“…An Australian study has shown that patients with TIA discharged from emergency have fewer stroke risk factors, shorter symptom duration, and higher early stroke risk. 41 Discharged patients probably have higher rates of misclassification than our cohort of patients with TIA, in which the diagnosis was confirmed by hospital investigation. Administrative data rely on the accuracy of physician diagnoses, which may vary according to the specialty of the treating physician and potentially introduce misclassification.…”

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confidence: 99%

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Relative Survival After Transient Ischaemic Attack

Gattellari

Goumas

Biost

et al. 2012

Stroke

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Background and Purpose-There is a lack of modern-day data quantifying the effect of transient ischemic attack (TIA) on survival, and recent data do not take into account expected survival. Methods-Data for 22 157 adults hospitalized with a TIA from July 1, 2000, to June 30, 2007, in New South Wales, Australia, were linked with registered deaths to June 30, 2009. We estimated survival relative to the age-and sex-matched general population up to 9-years after hospitalization for TIA comparing relative risk of excess death between selected subgroups. Results-At 1 year, 91.5% of hospitalized patients with TIA survived compared with 95.0% expected survival in the general population. After 5 years, observed survival was 13.2% lower than expected in relative terms. By 9 years, observed survival was 20% lower than expected. Females had higher relative survival than males (relative risk, 0.79; 95% CI, 0.69 -0.90; PϽ0.001). Increasing age was associated with an increasing risk of excess death compared with the age-matched population. Prior hospitalization for stroke (relative risk, 2.63; 95% CI, 1.98 -3.49) but not TIA (relative risk, 1.42; 95% CI, 0.86 -2.35) significantly increased the risk of excess death. Of all risk factors assessed, congestive heart failure, atrial fibrillation, and prior hospitalization for stroke most strongly impacted survival. Conclusions-This study is the first to quantify the long-term effect of hospitalized TIA on relative survival according to age, sex, and medical history. TIA reduces survival by 4% in the first year and by 20% within 9 years. TIA has a minimal effect on mortality in patients Ͻ50 years but heralds significant reduction in life expectancy in those Ͼ65 years. Key Words: follow-up Ⅲ relative survival Ⅲ transient ischaemic attack T ransient ischemic attack (TIA) is a recognized predictor of early stroke risk and its stroke outcomes have attracted intense interest. Early stroke rates vary 1,2 and recent studies report low early stroke risk with modern urgent TIA care. [3][4][5][6] In contrast to the emphasis on early stroke risk, detailed analyses of survival after TIA, and how survival varies by age, sex, and medical history have rarely been reported. Multicenter or population-based reports suggest that between 5% and 8% of patients will die within 6 months of their TIA, 7,8 and others report 5% to 15% dying by 1 year. 3,9 -11 However, the significance of these findings is uncertain. Given the advanced age at which TIA commonly occurs, it is unclear whether the observed mortality exceeds otherwise expected mortality.Calculating relative survival accounts for the "background risk" of death and identifies the excess risk of mortality above and beyond that expected from the age-and sex-matched general population. Previous population-based or multicenter studies reporting relative survival are only of historic interest with cohorts recruited from 1950 to 1988. 11-16 These studies are small-scale in terms of geographical scope and sample size (79 -330 participants), further lim...

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Section: Discussionsupporting

confidence: 71%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Relative Survival After Transient Ischaemic Attack

Gattellari

Goumas

Biost

et al. 2012

Stroke

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“…(table 1). 16,24,34,40 The proportions of patients in ABCD2 score categories ,/$4 was very consistent for each time point-about two thirds of patients were classed as ABCD2 $4 and one third as ,4. A larger proportion of patients with ABCD2 score $4 had recurrent stroke at all 3 time points than those with ABCD2 score ,4 (table 1, figure e-2, A-C): e.g., 7.2% (95% confidence interval [CI] 4.8%-10.8%) of patients with ABCD2 score $4 had recurrent stroke by 7 days compared with 2.4% (95% CI 1.1%-5.4%) of patients with ABCD2 ,4.…”

mentioning

confidence: 82%

“…All studies used a time-based definition of TIA (3 did not report the definition [15][16][17] ). 18 Five studies assessed population-based cohorts, [19][20][21][22] 4 studied hospital-based cohorts, 16,[23][24][25] 10 studied patients from emergency departments, 15,[26][27][28][29][30][31][32][33][34] and 10 studied patients from specialist stroke or neurology units. 3,9,[35][36][37][38][39][40][41][42] Timing of patient assessment after TIA varied: within 24 hours of symptom onset (7 studies), within 48 hours (4 studies), within 7 days (4 studies), "as soon as possible after the event" but did not give a time (3 studies), at median 15 days (1 study), or did not provide this information (9 studies).…”

mentioning

confidence: 99%

ABCD2 score and secondary stroke prevention

Wardlaw¹,

Brazzelli²,

Chappell³

et al. 2015

Neurology

125

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Editorial, page 304Supplemental data at Neurology.org ABCD2 score and secondary stroke prevention Meta-analysis and effect per 1,000 patients triaged ABSTRACT Objective: Patients with TIA have high risk of recurrent stroke and require rapid assessment and treatment. The ABCD2 clinical risk prediction score is recommended for patient triage by stroke risk, but its ability to stratify by known risk factors and effect on clinic workload are unknown.Methods: We performed a systematic review and meta-analysis of all studies published between January 2005 and September 2014 that reported proportions of true TIA/minor stroke or mimics, risk factors, and recurrent stroke rates, dichotomized to ABCD2 score ,/$4. We calculated the effect per 1,000 patients triaged on stroke prevention services.Results: Twenty-nine studies, 13,766 TIA patients (range 69-1,679), were relevant: 48% calculated the ABCD2 score retrospectively; few reported on the ABCD2 score's ability to identify TIA mimics or use by nonspecialists. Meta-analysis showed that ABCD2 $4 was sensitive (86.7%, 95% confidence interval [CI] 81.4%-90.7%) but not specific (35.4%, 95% CI 33.3%-37.6%) for recurrent stroke within 7 days. Additionally, 20% of patients with ABCD2 ,4 had .50% carotid stenosis or atrial fibrillation (AF); 35%-41% of TIA mimics, and 66% of true TIAs, had ABCD2 score $4. Among 1,000 patients attending stroke prevention services, including the 45% with mimics, 52% of patients would have an ABCD2 score $4. Conclusion:The ABCD2 score does not reliably discriminate those at low and high risk of early recurrent stroke, identify patients with carotid stenosis or AF needing urgent intervention, or streamline clinic workload. Stroke prevention services need adequate capacity for prompt specialist clinical assessment of all suspected TIA patients for correct patient management.

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