October 30, 2008 (Chicago, Illinois) — Patients who presented to the emergency department with a transient ischemic attack (TIA) had a series of risk factors, which resulted in the death of 15.6% of the patients during a 2-year period.

The study was presented here at the American College of Emergency Physicians (ACEP) 2008 Scientific Assembly.

Lead study researcher M. Fernanda Bellolio, MD, senior research fellow and instructor, Department of Emergency Medicine, Mayo Clinic College of Medicine in Rochester, Minnesota, told Medscape Emergency Medicine: “The older a person is the more TIA incidents a person may have. TIA’s, which are similar to a stroke, are very common. Usually, TIA’s last less than 24 hours and some people ignore their symptoms.”

Dr. Bellolio emphasized that common warning symptoms such as numbness, weakness, visual changes, a facial drop or slurred speech should indicate that an emergency department visit should occur immediately.

This study focused on a total of 340 patients visiting the emergency department with a diagnosis of TIA during a 3-year study period (2001-2004). Data collected for this study included demographic information, laboratory data, past stroke history, TIA history, diabetes mellitus, hypertension, and atrial fibrillation. The objective was to evaluate the risk for death and the factors associated with mortality in patients seen in the emergency department with a diagnosis of TIA.

Every patient was treated and evaluated with a standardized approach. Those patients considered a high risk for a stroke were admitted to the hospital. Other patients were sent home. However, the hospital followed up on these patients with a neurologist within a 48-hour period. The goal was to start secondary preventions early to decrease the risk for stroke.

The study gave Bellolio and her colleagues critical information about TIA patients. “The mean age ± standard deviation of the 340 patients was 72.4 ± 13.8 [years], and 169 were females (49.7%). There were 57 (16.7% patients with past history of stroke, 59 (17.3%) with TIA, 47 (13.8%) with atrial fibrillation, 62 (18.2%) with diabetes mellitus and 208 (61.2%) with hypertension.”

When patients presented higher risk factors in the emergency department, they significantly related to a higher mortality in the univariate analysis. Although the study adjusted for age and sex, these variables were associated with higher mortality (all P < .0001).

“There were 53 deaths (15.6% of the cohort) in the first two years,” said Dr. Bellolio. “There were 93 deaths during the 3 years of follow-up (27.4% of the cohort). The median time to death was 654 days (IQR [interquartile range]: 287 – 1134). Patients have a higher risk of death with lower hemoglobin levels, higher creatinine, higher glucose at presentation, a history of atrial fibrillation and the presence of diabetes. These were independent predictors of mortality.”

David Nestler, MD, attending physician, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, who was not a participant in this study, told Medscape Emergency Medicine, “TIA is a common emergency room presentation and emergency room physicians struggle with risk stratifying these patients. This study contributes to helping emergency room physicians identify patients who have a higher risk for bad outcomes.”

Brian O’Neil, MD, course director for the ACEP Research Forum and associate chair of the Department of Emergency Medicine, at Wayne State University School of Medicine in Detroit, Michigan, told Medscape Emergency Medicine, “Although this study is not especially large with only 340 patients, it is a nice study because it is a longitudinal study. Most of the studies we looked at previously were 9 months to 1 year. This study is reconfirming previous known predictors such as high glucose level history and atrial fibrillation, which all predict a worse outcome.”

The study was internally funded by the Mayo Foundation for Education and Research. Dr. Nester is also funded for his study by the Mayo Foundation for Education and Research.

American College of Emergency Physicians (ACEP) 2008 Scientific Assembly: Abstract 390. Presented October 28, 2008.
Pearls for Practice

* Among patients who presented to the emergency department with a TIA, 15.6% died within 2 years and 27.4% died within 3 years. The median time to death was 654 days.
* Independent predictors of mortality were age, sex, lower hemoglobin levels, higher creatinine levels, higher glucose levels at presentation, history of atrial fibrillation, and the presence of diabetes.


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