ASM3: In patients with a suspected TIA/minor stroke does early versus late expert assessment reduce mortality and morbidity?

ReferenceStudy type Evidence levelNumber of patientsPatient characteristicsInterventionComparisonLength of follow- upOutcome measuresSource of funding
Rothwell PM, Giles MF, Chandratheva A et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007; 370(9596):1432–1442. Ref ID 5025Prospective cohort study 2++ single centre UKN=1278Patients with suspected TIA or stroke

Phase I (N=634) : Age < 80 yrs 60%, 47% male, TIA 37%, hypertension 58%, prior antiplatelet 46%, prior statin 20%

Phase 2 (N=644) : age < 80 yrs 58%, 46% male, TIA 39%, hypertension 59%, prior antiplatelet 44%, prior statin 28%

Patients referred to EXPRESS clinic: Phase 1 (N=310) Age > 80 yrs 67%, 45% male, TIA 50%, hypertension 54%, prior antiplatelet 45%, prior statin 20%

Phase 2 (N=281) : Age > 80 yrs 67%, 47% male, TIA 57%, hypertension 59%, prior antiplatelet 39%, prior statin 32%

The groups were well matched at baseline except for prior statin use.
Phase 1

N=634

Presented with TIA N=233

Presented with stroke N=401

Outpatient care N=323

Referred to: EXPRESS clinic N=310 Other clinic N=13

Hospital- based care N=285: Discharged from A&E N=33 Inpatient care N=252

Not referred to secondary care N=26

Primary- care physicians referred, by fax, any patient they suspected had had a TIA or stroke but whom they did not consider required immediate hospital admission, to a daily TIA and minor stroke clinic.

The study team contacted the patient at home to arrange a clinic appointment as soon as possible. The patient was seen in a daily (weekdays only) hospital outpatient clinic or at home, and brain imaging (usually CT) and ECG were obtained on the same day or shortly thereafter. Carotid ultrasound (all patients) and transthoraic or transoesophageal echocardiography (when indicated) were arranged during the following week.

A report of the initial clinical assessment, with the treatment recommendations, was faxed to the primary- care physician after the clinic (usually within 24 hrs) but no treatment was given at the study clinic and no prescription was issued.

Treatment by the primary- care physician included aspirin or clopidogrel when indicated, simvastin, perindropril and/or indapamide and anticoagulation as required
Phase 2

N=644

Presented with TIA N=252

Presented with stroke N=392

Outpatient care N=297

Referred to: EXPRESS clinic N=281 Other clinic N=16

Hospital -based care N=322: Discharged from A&E N=54 Inpatient care N=268

Not referred to secondary care N=25

Clinic at which no appointment was necessary and at which treatment was initiated immediately if the diagnosis was confirmed. Who should be referred to the clinic was no changed from phase 1.

Primary- care physicians were requested to send all patients directly to the study clinic each weekday afternoon immediately after they presented to medical attention.

Patients were assessed as for phase 1, but all patients considered to have had a TIA or stroke were given aspirin 300mg to take in the clinic, together with a prescription for a 4- week supply of any other study medication. A loading dose of clopidogrel 300 mg was given in all cases where aspirin was initiated.

A CT scan obtained to excluded ICH when indicate d

A report of the assessment, investigations and treatment was faxed to the primary- care physician as soon as possible after the clinic (usually within 24 hrs).
90 daysStrokeMedical Research Council Dunhill Medical Trust Stroke Association BUPA Foundation National Institute for Health Research Thames Valley Primary Care Research Partnership
Effect
Phase 1 vs. Phase 2
After blinded independent adjudication, 90 follow-up events were classified as first recurrent strokes within 90 days of first medical attention. The risk of stroke within 90-days of first presentation with TIA was significantly higher in phase 1 than it was in phase 2 (29/233 (12.4%) vs 11/252 (4.4%); p<0.0015). A similar finding was reported for the risk of recurrent stroke in patients presenting with stroke for phase 1 compared with phase 2 (34/401 (8.5%) vs 16.393 (4.1%); p=0.0077).

In patients referred to the study clinic, the risk of stroke during the 90 days after presentation was significantly lower in phase 2 than phase 1 (6/281 (2.1%) vs 32/310 (10.3%); p=0.0001). The overall risk of non-stroke, myocardial infarction, or death at 90 days was significantly lower in phase 2 than phase 1 (10/281 (3.6%) vs 37/310 (11.9%); p=0.0002).

There was no statistical difference in the delay from the presenting event to seeking medical attention in patients subsequently referred to the study clinic between the two study phases (NS).

There was a significantly longer delay in seeking medical attention in primary care to assessment in clinic in phase 1 compared with phase 2 (median 3 (IQR 2 to 5) vs less than 1 (0 to 3); p<0.0001). A significantly higher proportion of patients were seen within six hrs or less from first call to medical attention to assessment in the study clinic in phase 2 than in phase 1 (29% vs 1.7%; p<0.0001). Consequently, they were fewer recurrent strokes after presentation to primary care but before assessment in clinic in phase 2 (3/281) than in phase 1 (11/310; p=−0.048).

Median time from seeking medical attention to first prescription of one or the other treatments recommended in the faxed letter from the study clinic to primary care was significantly longer in phase 1 than in phase 2 (20 (8 to 53) vs 1 (0 to 3) days; p<0.0001).

At one month a statistically higher proportion of patients referred to the study clinic in phase two compared with phase one were prescribed antiplatelet agents or anticoagulant therapy, aspirin and a 30-day course of clopidogrel, one or more blood pressure lowering drugs or were referred to carotid surgery within seven days or less or 30 days or less

The 90-days of risk of recurrent stroke in referrals to the study clinic was significantly greater in phase 1 than in phase 2 for:
  • Patients presenting with TIA (16/156 vs 1/160)
  • Patients presenting with stroke (16/154 vs 5/121)
  • Men (16/141 vs 2/132)
  • Women (16/169 vs 4/149)
  • All ages
Early treatment (phase 2) did not increase the 30-day risk of bleeding events requiring medical attention. No symptomatic intracerebral or other intracerebral haemorrhages were identified in either phase of the study and there was no symptomatic haemorrhagic transformation of infaction.
Lavallee PC, Meseguer E, Abboud H et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurology. 2007; 6(11):953–960. Ref ID 5024Observational study 3 single centre FranceN=1085Patients with sudden retinal or cerebral focal symptoms judged to be related to ischaemia and with a full recover y

Patient population:

TIA, no new lesion (N=535) :
Mean age 66 yrs, 55% male, hypertension 52%, weakness 35%, previous antiplatelet 23%

TIA, new lesion (N=108) :
Mean age 66 yrs, 61% male, hypertension 64%, weakness 57%, previous antiplatelet 31%

Minor stroke (N=58): Mean age 68 yrs, 48% male, hypertension 54%, weakness 57%, previous antiplatelet 24%
SOS-TIA

TIA clinic open 24 hrs a day, 7 days a week and contactable via a toll-free telephone number

Between 0900 and 1700 h the centre was staffed by a stroke- prevention nurse. Out of hours the calls were transferred to a senior vascular neurologist.

Patients were admitted to the clinic is they had focal signs of brain or retinal dysfunction presumed to be related to ischemia and had made a full recovery

Clinical assessment occurred within 4 hrs of admission. Tests include brain imaging, carotid imaging, ECG, transthoracic echocardiography and transoesophageal echocardiography when indicated and blood samples

Patients were discharged after the assessment. The family doctor received a copy of the discharge summary.

In all patients anti-thrombotic therapy was started immediately (aspirin). Medication to lower lipids or BP was also started or modified if possible.

Patients with AF received subcutaneous heparin in addition to oral anticoagulation until INR was 2.
Risk of stroke according to ABCD2One yearRisk of stroke, myocardial infarction and vascular deathNone reported
Effect
Mean number of patients seen each month 30.

87% patients were seen by a neurologist within 24 hrs of the telephone call and 53% were seen within 24 hrs of symptom onset.

*Recurrent stroke
For patients seen within 24 hrs of symptom onset (N=552), the 90-day stroke rate was 1.63% (95%CI 0.85 to 3.12), where as the risk expected from the ABCD2 scores was 6.49%. For all patients 13/1052 stroke occurred (% risk of stroke 1.24 (95CI 0.72 to 1.21 compared with 5.96% expected risk based on ABCD2). For TIA patients with no new lesion (N=524) there were seven stroke (1.34% (0.64 to 2.78) vs 6.13%). For TIA patients with a new lesion five stroke occurred (4.76% (2.01 to 11.06) vs 7.76%).

From: Evidence Tables

Cover of Stroke
Stroke: National Clinical Guideline for Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA).
NICE Clinical Guidelines, No. 68.
National Collaborating Centre for Chronic Conditions (UK).
Copyright © 2008, Royal College of Physicians of London.

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