TIA Hotline (ASPIRE Project) and TIA Management Thomas Jeerakathil BSc, MD, MSc, FRCP(C) February 23rd, 2009 Telehealth Presentation.

TIA Hotline (ASPIRE Project) and TIA

ManagementThomas Jeerakathil BSc, MD, MSc, FRCP(C)

February 23rd, 2009Telehealth Presentation

Objectives•What is a TIA and what isn’t?

•How can we differentiate high risk from low risk TIAs? What are the data?

•How urgently should TIA patients receive diagnosis, assessment, investigation and management?

•How to facilitate rapid assessment of TIA? The ASPIRE Project and the TIA Hotline.

Patient 1

•Jerome is a 85 year old male with HT, CHF, hyperlipidemia.

•Complains of three spells in the previous four days that have been referred as TIAs

•Spells involve loss of consciousness

•Are these TIAs?

Diagnosing ‘spells’

•Phenomenology: before, during, after the event

•Was the event witnessed? What did witnesses observe?

•What is the setting? (vascular risk factors, elderly, young without risk factors)

Patient 1•Upon rising from seated to standing

patient develops a sense of dizziness and unsteadiness and feels very light-headed

•Then experiences blurring of the vision starting peripherally and loses consciousness

Patient 1•Upon rising from seated to standing

patient develops a sense of dizziness and unsteadiness and feels very light-headed

•Then experiences blurring of the vision starting peripherally and loses consciousness

•Syncope

Top 6 symptoms likely to be a TIA-1•Sudden onset, lasting minutes to hours, resolves

•6. Vertigo only if present with brainstem symtoms

•5. Hemibody numbness

•4. Double vision, crossed numbness or weakness, slurred speech, ataxia of gait

Top 6 symptoms likely to be a TIA - 2

•3. Speech disturbance for a defined period of time (definite dysarthria, muteness or marked word finding difficulty, paraphasic speech)

•2. Monocular or hemifield visual loss (not blurring of entire visual field)

•1. Hemibody weakness

Top 7 symptoms unlikely to be a TIA

•7. Postural dizziness alone

•6. Tingling of all 4 extremities

•5. Syncopal events

•4. Momentary word finding trouble that is not new

•3. Positional and recurrent numbness of one limb

•2. Scintillating or flashing visual disturbances

Symptoms unlikely to be a TIA - 2

•1. Almost anything with hyperventilation or chest pain (but make sure it isn’t cardiac!)

How do we identify high risk TIA?

Coutts et al. Annals of Neurology 2005

90 Day Prognosis after ED Dx of TIA

•180 / 1707 (10.5%) patients had stroke– 91 occurred in first 2 days

– Age > 60, DM, Sx > 10 min, weakness, speech

•428 (25.1%) had some adverse event– More than half occurred in first 4 days

Johnston SC, JAMA 2000;284:2901-2906

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Independent risk factors for stroke following Independent risk factors for stroke following suspected TIA include:suspected TIA include:Age > 60 yearsAge > 60 yearsDiabetes mellitusDiabetes mellitusMotor weaknessMotor weaknessSpeech impairmentSpeech impairmentSymptom duration > 10 minutesSymptom duration > 10 minutes

Independent Risk Factors for Independent Risk Factors for Stroke Following TIAStroke Following TIA

Johnston et al. JAMA 2000;284:2901-6.

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ABCD rule for stratifying risk after TIA – assign points

•Age > 60 = 1

•BP during event > 140 systolic or > 90 diastolic = 1

•Clinical features: unilateral weakness = 2; speech disturbance without weakness =1; other = 0

•Duration of symptoms (minutes): >= 60 = 2; 10-59 =1 ; < 10 = 0

•Rothwell, Lancet 2005; 366: 29–36

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ABCD 2 Score

Diabetes added and scores 1 extra point

Predictive Value of the ABCD2 progostic score

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Alberta TIA StudyAlberta TIA Study Identified all ED diagnoses of stroke across Identified all ED diagnoses of stroke across

Alberta for 1 fiscal year using admin dataAlberta for 1 fiscal year using admin data 2285 TIAs2285 TIAs 2 day stroke rate 1.4% (readmissions)2 day stroke rate 1.4% (readmissions) 7 day stroke rate 6.7%7 day stroke rate 6.7% 30 day stroke rate 9.5%30 day stroke rate 9.5% 1 year stroke rate 15%; stroke or death 21%1 year stroke rate 15%; stroke or death 21% ASPIRE Consensus meeting Aug 2008;ASPIRE Consensus meeting Aug 2008; Data for ABCD symptoms/scores applied to Data for ABCD symptoms/scores applied to

Alberta populationAlberta population

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ABCDABCD

ABCD 2005; 3 groupsABCD 2005; 3 groupsDerivation (prob and def TIA) (n=209) – 18 Derivation (prob and def TIA) (n=209) – 18

strokesstrokesValidation cohort (prob and def TIA) (n=190) – Validation cohort (prob and def TIA) (n=190) –

20 strokes20 strokesReferal population for validation cohort (all Referal population for validation cohort (all

referrals) (n=378) – 20 strokes referrals) (n=378) – 20 strokes

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ABCD2ABCD2 ABCD2 2007ABCD2 2007 Evaluated ABCD and California rule each in Evaluated ABCD and California rule each in

6 different populations6 different populations Created a combined ABCD2 scoreCreated a combined ABCD2 score 6 study groups6 study groups

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Symptoms – ABCD2Symptoms – ABCD2 6 study groups; 4809 patients; 442 strokes6 study groups; 4809 patients; 442 strokes Derivation cohortsDerivation cohorts

California ED – 1707California ED – 1707Oxford popln based – 209Oxford popln based – 209

Validation cohortsValidation cohortsCalifornia ED2 – 1069California ED2 – 1069California clinic – 962California clinic – 962Oxford popln based -547Oxford popln based -547Oxford clinic 315Oxford clinic 315

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Prognostic scores for screening: Prognostic scores for screening: caution advisedcaution advised

Highest scores

medium scores

lowest scores

= recurrent stroke

Most events actually occur in those of medium risk! So be careful of too high a cutoff.

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Impression:Impression:

•Either ABCD2 >=4 OR Speech or motor symptoms can identify high risk symptoms

•They have similar sensitivity (88-100%) and specificity (31-52%) to identify high risk stroke patients

•ASPIRE Consensus group choose these cutoffs for TIA Triaging within Alberta

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How urgently should high risk How urgently should high risk TIA patients be assessed?TIA patients be assessed?Does it make a difference?Does it make a difference?

Express Study

Express Study

ASPIRE TIA Triaging Consensus

•Urgent triage and assessment of TIA province-wide deserves evaluation within Alberta

•TIA Triaging algorithm created at Aug 2008 meeting

•Facilitate urgent access using a TIA Hotline

•Backing of the APSS and the Educational Strategy of the APSS

•Pocket cards have been produced

Hotline process•North - every TIA hotline call will

result in contact with a Telestroke Neurologist

•South - TIAs will be screened by operator using risk algorithm;

•High or medium risk or if refering physician requests it still - Stroke Neurologist

•Low risk and if no specific request - fax referral in to clinic

ASPIRE Data

•The TIA Hotline and TIA Triaging Strategy overlap with APSS Educational Strategy as well as Pillar 1 - quality improvement

•Data will be tracked by TIA Hotlines (SARC in the south and the CCL/UCL in the north)

•Stroke Prevention Clinic referral forms will be faxed to a central number to track all TIAs that come to referral across the province

ASPIRE Outcomes•Rate of recurrent stroke determined

by presentations to emergency departments and admissions to hospital will be tracked using administrative data

•Two years ‘pre’ compared to two years ‘post’ implementation

•Is the TIA Hotline/Triaging strategy effective? Is it worth the cost and effort?

•Ongoing feedback and refinement

TIA Hotline ‘go live’ dates

•North including Red Deer (1-888-282-4825)

•Goes live March 16, 2009

•South excluding Red Deer (1-800-661-1700)

•Goes live March 16th, 2009

THANK YOU!