Can we manage TIA patients safely in outpatient clinics?

Can lower risk patients presenting with transient ischemic attack be safely managed as outpatients? This is a question we need to answer during these days, where one would like to avoid hospitalization expenditure

A paper published by an Australian author said 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 Emergency Department with TIA.

Stroke is second only to ischemic heart disease as a leading cause of disease burden in Australia. Stroke places considerable strain on the public health system in Australia (length of stay averages 8 days and outcomes range from returning home to nursing home placement to death). There is a paucity of data regarding the best approach to care provision following a transient ischemic attack (TIA) in the Australian setting. The risk of stroke following a TIA is as high as 5–10% in the first 7 days depending on the population and clinical setting examined, with the lowest risks observed in the context of emergent management. Higher rates have been reported among high risk populations in the absence of protocol driven initiation of secondary prevention.

TIA represent a window of opportunity for effective secondary stroke prevention.7 Review in a daily (as opposed to weekly) TIA  clinic with no appointment necessary and immediate commencement of therapy has demonstrated an 80% reduction in risk of recurrent cerebrovascular accident within 90 days (10.3% versus 2.1%) in the EXPRESS study with demonstrated cost-savings in terms of bed days, acute costs, and 6 month disability.8 Risk reduction with early intervention is also supported by results of the SOSTIA study and other approaches, all of which involve immediate commencement of anti platelet therapy.

External validation studies have yielded inconsistent results with regard to predictability of the age, blood pressure, clinical features, duration of symptoms and diabetes (ABCD2) score at determining risk of stroke recurrence, thus, its clinical utility remains unclear. Two recent large population based studies have again raised questions about the clinical utility of the ABCD2 score. It is likely that the optimal approach to risk stratification incorporates the results of diffusion-weighted imaging (as examined by the more recently devised ABCD2–I and ABCD3–I scores) and early carotid imaging (as assessed by the ABCD3–I score), although prompt cerebral MRI may not be possible in many practice settings.

Stroke is a major cause for loss of life, limbs and speech in India, with the Indian Council of Medical Research estimating that in 2004, there were 9.3 lakh cases of stroke and 6.4 lakh deaths due to stroke in India, most of the people being less than 45 years old. Experts say that if deaths as well as disability are counted together, then India lost 63 lakh of disability-adjusted life years in 2004.WHO estimates suggest that by 2050, 80% stroke cases in the world would occur in low and middle income countries mainly India and China. Those with high blood pressure, diabetes, high blood fat (cholesterol) are specially at risk. The most important of these risk factors is high BP. In India, more than 16% of people above 20 years of age suffer from high BP. Fifty per cent of those with high BP are not even aware of it. Of those who are aware, only 50% take measures to control it, and of those who take these measures, only 50% are adequately controlled. "Thus, only 12.5% of patients with high BP are adequately controlled".  In the absence of high risk factors (low risk patients) one may consider the outpatient clinic protocol based therapies in India also!!