Managing Patients With Transient Ischemic Attack

Edlow, Jonathan A.

doi:10.1016/j.annemergmed.2017.06.026

Cited by 17 publications

(9 citation statements)

References 54 publications

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“…Regarding posterior circulation TIA, most evidence was indirect, often in studies that combined TIA and minor ischemic stroke (again, different parts of the spectrum of acute cerebrovascular disease). Patients presenting to the ED with acute neurological symptoms should undergo a careful neurological physical examination, but it is a normal examination that supports a TIA diagnosis 189–191 . In two different studies comparing emergency physician TIA diagnosis with the “criterion standard” of neurologist final diagnosis, between 36% and 44% of cases, the diagnoses were discordant 192,193 .…”

Section: Methodsmentioning

confidence: 99%

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Edlow,

Carpenter,

Akhter

et al. 2023

Academic Emergency Medicine

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This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

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Section: Methodsmentioning

confidence: 99%

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Edlow,

Carpenter,

Akhter

et al. 2023

Academic Emergency Medicine

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“…The underlying causes of delayed and incomplete TIA imaging workup after ED discharge are unclear and could include a multitude of factors, including limited access to ED and/or outpatient imaging resources, lack of provider familiarity with imaging guidelines, patients' lacking primary care physicians to assist in coordination of care, suboptimal communication of discharge instructions, and/or patient nonadherence to discharge instructions [12][13][14][15][16][17][18][19][20]. Some providers could also be discharging patients under a false sense of security after negative results on a single head CT examination, which is the most common ED neuroimaging workup in TIA and also one of the least diagnostically useful because of the limited sensitivity of CT for the detection of infarct, while omitting brain and cervical vessel imaging needed to detect vascular pathology that may have prompted the TIA episode [10,12,21].…”

Section: Discussionmentioning

confidence: 99%

Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging

Timpone

Reid

Jensen

et al. 2022

Journal of the American College of Radiology

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“…Transient ischemic attack (TIA) is transient neurological dysfunction caused by ischemia of the brain. [1] TIA is one of the most common ischemic cerebrovascular diseases. TIA affects more than 14 million people worldwide each year, and the morbidity and mortality rates are high.…”

Section: Introductionmentioning

confidence: 99%

“…TIA affects more than 14 million people worldwide each year, and the morbidity and mortality rates are high. [1–3] Moreover, the risk of stroke after TIA is very high. Therefore, TIA is an early warning signal for stroke intervention, and detection of TIA is also an important opportunity for secondary prevention of stroke.…”

Section: Introductionmentioning

confidence: 99%

Impaired heart rate recovery as a predictor for poor health-related quality in patients with transient ischemic attack

Wang

et al. 2019

Medicine

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We aimed to investigate heart rate recovery (HRR) in patients with transient ischemic attack (TIA) and the relationship between HRR and health-related quality of life (HRQOL). All available patients were enrolled during the enrollment period. A total of 120 patients with TIA and 120 healthy controls were included in this study. A treadmill stress test was performed to calculate the HRR. The HRR were calculated as follows: HRR 1, 2, 3, and 5 minutes = heart rate at peak during exercise − heart rate at 1, 2, 3, and 5 minutes at rest. All patients enrolled were asked to fill in the Short Form 36 Health Survey to calculate HRQOL. We found that the maximum heart rate of TIA patients was significantly higher than that of healthy controls (166 ± 11 vs. 162 ± 14 beats/min, P = .015). Similarly, maximum systolic blood pressure (SBP) and diastolic blood pressure (DBP) were higher in TIA group compared with healthy control group (SBP: 172 ± 15 vs. 165 ± 14 mm Hg, P < .001; DBP: 102 ± 12 vs. 93 ± 16 mm Hg, P < .001). The HRR were significantly lower in TIA group compared with control group (TIA vs. controls, HRR1: 17 ± 7 vs. 30 ± 8 beats/min, HRR2: 32 ± 11 vs. 49 ± 9 beats/min, HRR3: 43 ± 13 vs. 63 ± 12 beats/min, HRR5: 54 ± 16 vs. 73 ± 15 beats/min, all P < .001). Multivariate analysis showed that older age ( P = .03) and high BMI ( P = .04) were risk factors associated with abnormal HRR in patients with TIA. With regard to HRQOL, we found that role limitations due to physical problems, general health, vitality, and role limitations due to emotional problems were significantly lower in patients with abnormal HRR compared with patients with normal HRR. Multivariate analysis showed that older age ( P = .04) and abnormal HRR ( P = .03) were predictors for poor HRQOL in TIA patients. HRR was impaired in patients with TIA. In addition, TIA patients with abnormal HRR suffered from a significantly poorer HRQOL. Hence, given the prognostic value of HRR, patients with TIA should be monitored to prevent cardiovascular events and to improve HRQOL.

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Managing Patients With Transient Ischemic Attack

Cited by 17 publications

References 54 publications

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging

Impaired heart rate recovery as a predictor for poor health-related quality in patients with transient ischemic attack

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