title: Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic.
abstract: OBJECTIVE
  1) To evaluate whether transient ischemic attack (TIA) management in emergency departments (EDs) of the Nova Scotia Capital District Health Authority followed Canadian Best Practice Recommendations, and 2) to assess the impact of being followed up in a dedicated outpatient neurovascular clinic.
  
  
  METHODS
  Retrospective chart review of all patients discharged from EDs in our district from January 1, 2011 to December 31, 2012 with a diagnosis of TIA. Cox proportional hazards models, Kaplan-Meier survival curve, and propensity matched analyses were used to evaluate 90-day mortality and readmission.
  
  
  RESULTS
  Of the 686 patients seen in the ED for TIA, 88.3% received computed tomography (CT) scanning, 86.3% received an electrocardiogram (ECG), 35% received vascular imaging within 24 hours of triage, 36% were seen in a neurovascular clinic, and 4.2% experienced stroke, myocardial infarction, or vascular death within 90 days. Rates of antithrombotic use were increased in patients seen in a neurovascular clinic compared to those who were not (94% v. 86.3%, p<0.0001). After adjustment for age, sex, vascular disease risk factors, and stroke symptoms, the risk of readmission for stroke, myocardial infarction, or vascular death was lower for those seen in a neurovascular clinic compared to those who were not (adjusted hazard ratio 0.28; 95% confidence interval 0.08-0.99, p=0.048).
  
  
  CONCLUSIONS
  The majority of patients in our study were treated with antithrombotic agents in the ED and investigated with CT and ECG within 24 hours; however, vascular imaging and neurovascular clinic follow-up were underutilized. For those with neurovascular clinic follow-up, there was an association with reduced risk of subsequent stroke, myocardial infarction, or vascular death.
authors.affiliation: *Faculty of Medicine,Queen Elizabeth II Health Sciences Centre,Dalhousie University,Halifax,NS.
authors.forename: Gregory W
authors.initials: GW
authors.lastname: Hosier
authors.affiliation: †Division of Neurology,Queen Elizabeth II Health Sciences Centre,Dalhousie University,Halifax,NS.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Phillips
authors.affiliation: ‡Research Methods Unit,Queen Elizabeth II Health Sciences Centre,Dalhousie University,Halifax,NS.
authors.forename: Steve P
authors.initials: SP
authors.lastname: Doucette
authors.affiliation: §Department of Emergency Medicine,Queen Elizabeth II Health Sciences Centre,Dalhousie University,Halifax,NS.
authors.forename: Kirk D
authors.initials: KD
authors.lastname: Magee
authors.affiliation: †Division of Neurology,Queen Elizabeth II Health Sciences Centre,Dalhousie University,Halifax,NS.
authors.forename: Gordon J
authors.initials: GJ
authors.lastname: Gubitz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000379:methods; D000554:Ambulatory Care Facilities; D000925:Anticoagulants / Q000627:therapeutic use; D002561:Cerebrovascular Disorders / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D015331:Cohort Studies; D018450:Disease Progression; D004636:Emergency Service, Hospital; D016894:Endarterectomy, Carotid / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002546:Ischemic Attack, Transient / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009674:Nova Scotia; D057216:Propensity Score; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants
keywords: TIA; emergency department; neurovascular clinic; stroke management; stroke prevention clinic; transient ischemic attack