title: Can lower risk patients presenting with transient ischaemic attack be safely managed as outpatients?
abstract: This study aimed to examine outcome in low risk transient ischaemic attack (TIA) patients presenting to emergency departments (ED) in a regional Australian setting discharged on antiplatelet therapy with expedited neurology review. All patients presenting to Gosford or Wyong Hospital ED with TIA, for whom faxed referrals to the neurology department were received between October 2008 and July 2010, were included in this prospective cohort study. Classification of low risk was based on an age, blood pressure, clinical features, duration of symptoms and diabetes (ABCD2) score <4 and the absence of high risk features, including known carotid disease, crescendo TIA, or atrial fibrillation. Patients with ABCD2 scores > or =4 or with high risk features were discussed with the neurologist on call (a decision regarding discharge or admission was then made at the neurologist's discretion). Patients were investigated with a brain CT scan and/or CT angiography, routine pathology, and an electrocardiogram. All discharged patients were commenced on antiplatelet therapy and asked to follow up with their local medical officer within 7 days. The patients were contacted by the neurology department to arrange follow-up. Our primary outcome was the number of subsequent strokes occurring within 90 days. Of 200 discharged patients for whom referrals were received, three patients had a stroke within 90 days. None of these would have been prevented through hospitalisation. In conclusion, medical assessment, expedited investigation with immediate commencement of secondary prevention and outpatient neurology review may be a reasonable alternative to admission for low risk patients presenting to the ED with TIA.
authors.affiliation: Department of Neurology, Royal North Shore Hospital, Pacific Hwy, St Leonards, NSW 2065, Australia. Electronic address: daynagriffiths@yahoo.ca.
authors.forename: D
authors.initials: D
authors.lastname: Griffiths
authors.affiliation: Department of Neurology, Gosford Hospital, Gosford, NSW, Australia.
authors.forename: J
authors.initials: J
authors.lastname: Sturm
authors.affiliation: Department of Neurology, Gosford Hospital, Gosford, NSW, Australia.
authors.forename: R
authors.initials: R
authors.lastname: Heard
authors.affiliation: Department of Neurology, Gosford Hospital, Gosford, NSW, Australia.
authors.forename: E
authors.initials: E
authors.lastname: Reyneke
authors.affiliation: Department of Neurology, Gosford Hospital, Gosford, NSW, Australia.
authors.forename: S
authors.initials: S
authors.lastname: Whyte
authors.affiliation: Department of Neurology, Gosford Hospital, Gosford, NSW, Australia.
authors.forename: T
authors.initials: T
authors.lastname: Clarke
authors.affiliation: Department of Neurology, Gosford Hospital, Gosford, NSW, Australia.
authors.forename: W
authors.initials: W
authors.lastname: O'Brien
authors.affiliation: Department of Neurology, Gosford Hospital, Gosford, NSW, Australia.
authors.forename: D
authors.initials: D
authors.lastname: Crimmins
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D015331:Cohort Studies; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D010045:Outpatients; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000517:prevention & control
chemical_list: D010975:Platelet Aggregation Inhibitors
keywords: Ischemic attack; Regional health planning; Secondary prevention; Transient