1. Michael A. Ross MD FACEP Transient Ischemic Attack Patient Update: The Optimal Management of Emergency Department Patients With Suspected Cerebral Ischemia

2. Michael A. Ross MD FACEP Rapid TIA Patient Evaluation in US Emergency Departments and Observation Units: 2008 Opportunities

3. 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

4. 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)

5. 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

6. 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.

7. 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.

8. 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?

9. 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!

10. Michael A. Ross MD FACEP TIA STROKE

11. 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.”

12. 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.

13. 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

14. 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

15. Michael A. Ross MD FACEP Methods: ADP Exclusion criteria 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

16. Michael A. Ross MD FACEP 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 Methods: ADP Interventions

17. 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.

18. 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

19. Michael A. Ross MD FACEP Medical management 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

20. Michael A. Ross MD FACEP Medical management Medical management Risk Factor Management 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

21. Michael A. Ross MD FACEP Results

22. Results: Performance of clinical testing

23. 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

24. Michael A. Ross MD FACEP Results: 90-Day Clinical Outcomes

25. 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.

26. Michael A. Ross MD FACEP 90 Day Clinical Outcomes: ADP in EDOU versus Inpatient Admission Ross MA et al. Ann Emerg Med 2007;50(2):109-119. 11% incidence of stroke at 90 days –3% after discharge

27. Michael A. Ross MD FACEP Results: 90 - day Costs Median: Inpatient = $1548 ADP = $890 Difference= $540 (Hodges-Lehmann, p<0.001) ADP sub-groups: ADP - home= $844 ADP - admit= $2,737

28. 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

29. 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

30. Michael A. Ross MD FACEP Unanswered questions: Unanswered questions: 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 Subsequent stroke rate for patients with TIA vs small stroke

31. Michael A. Ross MD FACEP Hospital Resources Needed for the TIA ADP 1.Rapid Treatment Unit / Area for Patients –Appropriate staffing, ECG monitoring 2.Carotid imaging availability –MRI/MRA or CTA – Nice if you have them –Doppler – Adequate as an alternative 3.Echocardiography for selected patients –Timing and need for echo remains unclear 4.Neurology consultation availability

32. Michael A. Ross MD FACEP Imaging modality ProsCons Carotid artery doppler and B- mode ultrasound  Present screening standard  Lowest cost  No radiation / contrast  Need an ACR or ICAVL accredited lab  Timeliness of availability  No associated brain imaging  Clarity of report information  Does not identify carotid dissection CTA of head /neck  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  Higher cost  Contrast / renal failure issues  Much more radiation  Limited evidence to support as an alternative to doppler  More “back-end” reformatting work involved MRI / MRA of head/neck  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  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)

33. 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

34. 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

35. 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.

36. 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

37. Michael A. Ross MD FACEP Questions?? www.ferne.org Questions?? www.ferne.org www.ferne.org ferne_clindec_2008_tia_ross_observation_extended_062508_final