Transcript Educational Objectives

Transient Ischemic Attack
Patient Update:
The Optimal Management of
Emergency Department Patients
With Suspected Cerebral Ischemia
Michael A. Ross MD FACEP
Rapid TIA Patient Evaluation in US
Emergency Departments and
Observation Units:
2008 Opportunities
Michael A. Ross MD FACEP
Rapid Evaluation of TIA in
U.S. Emergency Departments
and Observation Units
Michael A. Ross MD FACEP
Associate Professor Emergency Medicine
Medical Director, Observation Medicine
Department of Emergency Medicine
Emory University School of Medicine
Michael A. Ross MD FACEP
CME Disclosure Statement
• Research support from the Foundation
for Education and Research in
Neurologic Emergencies (FERNE) and
Emergency Medicine Foundation (EMF)
Michael A. Ross MD FACEP
Course Objectives:
1. Learn what interventions are needed for
TIA patients beyond the initial ED
evaluation.
2. Know what outcomes may be expected
from an EDOU diagnostic protocol for
TIA patients
3. Understand what resources are needed
to implement TIA protocol
Michael A. Ross MD FACEP
Case presentation
• A 58 year old female presents to the emergency
department after developing dysarthria, diploplia,
numbness, and pronounced weakness of the right face
and hand that lasted roughly 12 minutes. The patient
feels completely normal and only came in at her
families insistence.
– Review of systems - mild headache with event. No
palpitations, chest pain, or SOB.
– Past medical history - Positive for hypertension and
hyperlipidemia. No prior stroke or TIA.
– Family history positive for premature coronary
disease.
– Meds - Beta-blocker for HTN. Not on aspirin.
– Social - She does not smoke.
Michael A. Ross MD FACEP
Case presentation
• Phyisical Exam:
On examination the patient was normotensive, and
comfortable.
• HEENT exam showed no facial or oral asymmetry or
numbness. No scalp tenderness.
• CHEST exam showed no murmurs and a regular
rhythm,
• ABDOMINAL and EXTREMITY exam was normal,
• NEUROLOGICAL exam showed normal mentation, CN
II-XII normal as tested, motor / sensory exam normal,
symmetrical normal reflexes, and normal cerebellar
exam.
Michael A. Ross MD FACEP
Case presentation
• ED course:
– ECG showed a normal sinus rhythm with mild LVH.
– Non-contrast head CT scan was normal.
– Blood-work (CBC with differential, electrolytes,
BUN/Cr, and glucose) was normal. ESR was
normal.
– Monitor showed no dysrhythmias
– Normal subsequent neurological symptoms.
– The patient feels fine and is wondering if she can
go home.
What do you think?
Michael A. Ross MD FACEP
Background
•
300,000 TIAs occur annually
•
10.5% suffer a stroke within 90 days of an ED visit
•
Stroke is preceded by TIA in 15% of pts
•
Stroke is the THIRD leading cause of death
– National cost of stroke = $51 billion annually!
Michael A. Ross MD FACEP
TIA
STROKE
Michael A. Ross MD FACEP
Management of TIA:
• Areas of Certainty:
– Need for ED visit, ECG, labs, Head CT
• Areas of less certainty
– The timing of the carotid dopplers
– The need for echocardiography
• Areas of Uncertainty - Johnston SC. N Engl J Med. 2002;347:1687-92.
– “The benefit of hospitalization is unknown. . .
Observation units within the ED. . . may
provide a more cost-effective
option.”
Michael A. Ross MD FACEP
To determine if TIA patients will experience:
•shorter length of stays
•lower costs
•comparable clinical outcomes
. . . relative to traditional inpatient admission.
Michael A. Ross MD FACEP
Setting:
• William Beaumont Hospital: A high-volume
university-affiliated suburban teaching hospital
– Emergency department
• 2005 ED census = 115,894
– ED observation unit = 21 beds
• Emergency physician - “admitting” physician for all
patients
Michael A. Ross MD FACEP
Patient population:
• Presented to the ED with symptoms of TIA
• ED evaluation:
– History and physical
– ECG, monitor, HCT
– Appropriate labs
– Diagnosis of TIA established
• Decision to admit or observe
• SCREENING AND RANDOMIZATION
Michael A. Ross MD FACEP
Methods:
ADP Exclusion criteria
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Persistent acute neurological deficits
Crescendo TIAs
Positive HCT
Known embolic source (including a. fib)
Known carotid stenosis (>50%)
Non-focal symptoms
Hypertensive encephalopathy / emergency
Prior stroke with large remaining deficit
Severe dementia or nursing home patient
Social issues making ED discharge / follow up unlikely
History of IV drug use
Michael A. Ross MD FACEP
Methods:
ADP Interventions
• TIA Protocol Development process:
– Consensus group:
• Emergency medicine, Neurology, Vascular Surgery,
Cardiology, Radiology, Internal Medicine.
– Protocol development:
• Literature search, consensus protocol, pre-study
pilot testing phase (>1year), study phase.
• BOTH study groups had orders for the same four
components
Michael A. Ross MD FACEP
Accelerated Diagnostic Protocol (ADP) in an
ED Observation Unit (EDOU)
Ross MA et al. Ann Emerg Med 2007;50(2):109-119.
Michael A. Ross MD FACEP
Methods:
ADP Disposition criteria
• Home
– No recurrent deficits, negative workup
– Appropriate antiplatelet therapy and follow-up
• Inpatient admission from EDOU
– Recurrent symptoms or neuro deficit
– Surgical carotid stenosis (ie >50%)
– Embolic source requiring treatment
(anticoagulation)
– Unable to safely discharge patient
Michael A. Ross MD FACEP
Medical management
Antiplatelet Therapy
• Useful in non-cardioembolic causes
–Aspirin 50-325 mg/day
–Clopidogrel or ticlopidine
–Aspirin plus dipyridamole
•Latter two if ASA intolerant or if TIA while on ASA
Michael A. Ross MD FACEP
Medical management
Risk Factor Management
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•
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•
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HTN: BP below 140/90
DM: fasting glucose < 126 mg/dl
Hyperlipidemia: LDL < 100 mg/dl
Stop smoking!
Exercise 30-60 min, 3x/week
Avoid excessive alcohol use
Weight loss: < 120% of ideal weight
Michael A. Ross MD FACEP
Results
Michael A. Ross MD FACEP
Results:
Performance of clinical testing
Inpatient
(n=74)
TIA-ADP
(n=75)
67
(90.5%)
25.2 hr
(17.3 – 37.1)
73
(97.3%)
13.0 hr
(8.4 – 18.0)
54
(73%)
43.0 hr
(23.8 – 63.8)
73
(97.3%)
19.1 hr
(16.7 – 22.5)
Carotid imaging
Number completed (n, %)
Time to completion
Echocardiography
Number completed (n, %)
Time to completion
Michael A. Ross MD FACEP
Results:
Length of Stay
Median
Inpatient
= 61.2 hr
ADP
= 25.6 hr
Difference = 29.8 hr
(Hodges-Lehmann, p<0.001)
ADP sub-groups:
ADP - home = 24.2 hr
ADP - admit= 100.5 hr
Michael A. Ross MD FACEP
Results:
90-Day Clinical Outcomes
90 Day Outcomes
Related return visits
Clinical Outcomes
Index visit CVA
Subsequent CVA (90 day)
Total 90 day CVA
Related Major event or MACE
Inpatient
Total
n=74
9 (12%)
TIA-ADP
Total
n=75
9 (12%)
5
2
7
(9%)
4
7
3
10
(13%)
4
Michael A. Ross MD FACEP
Outcomes of Index Visit Clinical Testing:
ADP in EDOU versus Inpatient Admission
Ross MA et al. Ann Emerg Med 2007;50(2):109-119.
Michael A. Ross MD FACEP
90 Day Clinical Outcomes:
ADP in EDOU versus Inpatient Admission
• 11% incidence of stroke at 90 days
– 3% after discharge
Ross MA et al. Ann Emerg Med 2007;50(2):109-119.
Michael A. Ross MD FACEP
Results:
90 - day Costs
Median:
Inpatient
ADP
= $1548
= $890
Difference = $540
(Hodges-Lehmann, p<0.001)
ADP sub-groups:
ADP - home = $844
ADP - admit= $2,737
Michael A. Ross MD FACEP
Study conclusion:
Compared to inpatient admission, the ED
TIA diagnostic protocol was:
• More efficient
• Less costly
• With comparable (or better) outcomes
Michael A. Ross MD FACEP
Unanswered questions:
1. With newer TIA risk scores and imaging, what is the
optimal ADP for 2009?
2. Will an ADP for TIA follow the Chest Pain experience
and show:
– Improved patient satisfaction ?
– Improved quality of life?
– Improved hospital resource availability?
3. Do findings from the EXPRESS and SOS-TIA studies
apply to the ADP?
–
Lower rates of stroke compared with traditional care
Michael A. Ross MD FACEP
Unanswered
questions:
Subsequent stroke rate for
patients with TIA vs small stroke
4. Can an ADP be
used for patients with
a very small clinical
stroke (ie NIHSS<2)?
Comparable 90 day risk
Lancet Neurol 2006; 5: 323–31
Michael A. Ross MD FACEP
Hospital Resources
Needed for the TIA ADP
1.
Rapid Treatment Unit / Area for Patients
–
2.
Carotid imaging availability
–
–
3.
MRI/MRA or CTA – Nice if you have them
Doppler – Adequate as an alternative
Echocardiography for selected patients
–
4.
Appropriate staffing, ECG monitoring
Timing and need for echo remains unclear
Neurology consultation availability
Michael A. Ross MD FACEP
Pros
Imaging
modality
Carotid artery
doppler and Bmode
ultrasound
CTA of head
/neck
MRI / MRA of
head/neck
Cons
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Present screening standard
Lowest cost
No radiation / contrast
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Need an ACR or ICAVL accredited lab
Timeliness of availability
No associated brain imaging
Clarity of report information
Does not identify carotid dissection
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May be coupled with initial HCT
Potential 24/7 availability
Fast
Accurate vascular imaging
Imaging of both head and neck
vessels
May provide perfusion information
May be coupled with brain MRI
(superior brain imaging)
May be done if doppler / CTA is not
available or contraindicated (ie CRF)
Imaging of both head and neck
vessels
May provide perfusion information
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Higher cost
Contrast / renal failure issues
Much more radiation
Limited evidence to support as an alternative
to doppler
More “back-end” reformatting work involved
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Higher cost
Longer imaging acquisition time
Patient tolerance - metal implants /
claustrophobia
Timeliness of availability
Minor contrast / renal failure issues (may be
done without if needed)
Michael A. Ross MD FACEP
National Feasibility
• National feasibility of ADP:
– 18% of EDs have an EDOU
– 220 JCAHO stroke centers
– 380 SCPC accredited CPCs
• Learning from these models Hospitals with ADP resources may have:
– More inpatient beds
– More competitive market
– Higher volume
– More likely to be urban
Michael A. Ross MD FACEP
Economic Implications – U.S.
Health Care Costs
• National health care costs
– “Hospital Care” accounts for the largest
portion of US health care (30%)
– Potential savings:
• If only 18% used ADP = $29 million
• If all used ADP = $161 million
– Medicare is now paying hospitals for the
observation of ALL conditions (including
TIA) with APC 8003
• Effective January
Michael A. Ross MD FACEP
CLINICAL CASE - OUTCOME
• The patient was started on aspirin and admitted to the ED observation
unit.
• While in the unit she had a 2-D echo with bubble contrast, that was
normal. She had no arrhythmia detected on cardiac monitoring and no
subsequent neurological deficits.
• However, carotid dopplers were abnormal. She showed 30-50% stenosis
of the right internal carotid artery, and a severe flow limiting >70%
stenosis of the left carotid artery at the origin of the internal carotid
artery.
• She was admitted to the hospital for endarterectomy. Five days following
ED arrival, and following inpatient pre-operative clearance, she
underwent successful endarterectomy.
• On one month follow-up she was asymptomatic and her carotids were
doing well.
Michael A. Ross MD FACEP
Conclusions
• TIAs are ominous
– Justifies acute interventions, including hospitalization
– Opportunity to prevent injury
• “TIAs” are heterogeneous in origin
– Management should be individualized
– Prognostic scores and newer imaging may help
• Secondary prevention is critical
Michael A. Ross MD FACEP
Questions??
www.ferne.org
<[email protected]>
ferne_clindec_2008_tia_ross_observation_extended_062508_final
Michael A. Ross MD FACEP