ACEP: Diagnose, treat TIAs more rapidly
ACEP: Diagnose, treat TIAs more rapidly
Authors suggest change to TIA definition
Citing a growing body of evidence showing that patients who have had a transient ischemic attack (TIA) are at a significant risk of having a stroke within 48 hours, authors of a four-article supplement in the latest edition of the Annals of Emergency Medicine have underscored the need to diagnose and treat TIA much more quickly than previously believed.1-4
"There are about 700,000 to 800,000 strokes a year in America, and it is a leading cause of disability," notes Andy Jagoda, MD, FACEP, editor of the supplement. Jagoda is professor and vice chair of emergency medicine at Mount Sinai School of Medicine and medical director of the ED at Mount Sinai Medical Center, both in New York City. In patients who have a TIA, 10% are going to have a stroke within three months, and 5% are going to have one within 48 hours of the TIA, she says. "Therefore, when presented with patient who has a TIA, there is an urgency — no, an emergency — to initiate an evaluation to find the reversible causes of their TIA and prevention strategies before there is a recurrent event or stroke," Jagoda says.
Mark Melrose, DO, FACEP, director of the ED at Mountainside Hospital in Montclair, NJ, agrees. "The incidence of stroke is so great in the weeks and months following a TIA that it's important for the medical professional to know how to go about evaluating and treating patients with TIA," he says.
Accordingly, the authors recommend that the definition of a TIA be changed from an event that lasts less than 24 hours to an event lasting less than one hour. They argue that symptoms lasting less than one hour still can indicate brain injury and a heightened risk of further neurological or cardiovascular events going forward. "The definition really has to change because our ability to detect permanent damage has become better," notes Melrose. "If symptoms last up to 24 hours, they might not show on a CAT scan, but now we have more advanced technology like the MRI." If symptoms resolve in less than an hour, he notes, even an MRI probably would not help, "but if they last over an hour, chances are good."
Jagoda adds, "The MRI's definition is much more sensitive in picking up subtle abnormalities, and this will end up pushing our radiology and neurology colleagues to work with us on protocols for facilitated MRI." (For more specifics on treating TIAs, see the stories below.)
References
- Cucchiare B, Ross M. Transient ischemic attack: risk stratification and treatment. Ann Emerg Med 2008; 52:S27-S39.
- Jagoda A, Chan Y-F Y. Transient ischemic attack overview: defining the challenges for improving outcomes. Ann Emerg Med 2008; 52:S3-S6.
- Lewandowski C, Rao CPV, Silver B. Transient ischemic attack: definitions and clinical presentations. Ann Emerg Med 2008; 52:S7-S16.
- Messe SR, Jauch EC. Transient ischemic attack: diagnostic evaluation. Ann Emerg Med 2008; 52:S17-S26.
Sources
For more information on diagnosing and treating transient ischemic attacks, contact:
- Andy Jagoda, MD, FACEP, Professor, Vice Chair of Emergency Medicine, Mount Sinai School of Medicine, ED Medical Director, Mount Sinai Medical Center, New York City. Phone: (212) 241-2987.
- Mark Melrose, DO, FACEP, ED Director, Mountainside Hospital, Montclair, NJ. Phone: (917) 887-99864.
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