Clinical diagnosis of TIA or minor stroke and prognosis in patients with neurological symptoms: A rapid access clinic cohort.

Catriona Graham,Simon Hart,Peter Sandercock,Aidan Hutchison,Fergus Doubal,Martin Dennis,Andrew Farrall,Cathie Sudlow,William Whiteley,David Bailey,Joanna Wardlaw

doi:10.1371/journal.pone.0210452

Abstract

BackgroundThe long-term risk of stroke or myocardial infarction (MI) in patients with minor neurological symptoms who are not clinically diagnosed with transient ischaemic attack (TIA) or minor stroke is uncertain.MethodsWe used data from a rapid access clinic for patients with suspected TIA or minor stroke and follow-up from four overlapping data sources for a diagnosis of ischaemic or haemorrhagic stroke, MI, major haemorrhage and death. We identified patients with and without a clinical diagnosis of TIA or minor stroke. We estimated hazard ratios of stroke, MI, major haemorrhage and death in early and late time periods.Results5,997 patients were seen from 2005–2013, who were diagnosed with TIA or minor stroke (n = 3604, 60%) or with other diagnoses (n = 2392, 40%). By 5 years the proportion of patients who had a subsequent ischaemic stroke or MI, in patients with a clinical diagnosis of minor stroke or TIA was 19% [95% confidence interval (CI): 17–20%], and in patients with other diagnoses was 10% (95%CI: 8–15%). Patients with clinical diagnosis of TIA or minor stroke had three times the hazard of stroke or MI compared to patients with other diagnoses [hazard ratio (HR)2.83 95%CI:2.13–3.76, adjusted age and sex] by 90 days post-event; however from 90 days to end of follow up, this difference was attenuated (HR 1.52, 95%CI:1.25–1.86). Older patients and those who had a history of vascular disease had a high risk of stroke or MI, whether or not they were diagnosed with minor stroke or TIA.ConclusionsCareful attention to vascular risk factors in patients presenting with transient or minor neurological symptoms not thought to be due to stroke or TIA is justified, particularly those who are older or have a history of vascular disease.

Highlights

National guidelines recommend rapid clinical assessment for patients with suspected stroke or transient ischaemic attack (TIA) in hospital-based clinics or emergency departments[1,2] in order to prevent vascular events, stroke
Careful attention to vascular risk factors in patients presenting with transient or minor neurological symptoms not thought to be due to stroke or TIA is justified, those who are older or have a history of vascular disease
We looked for significant linear multiplicative interactions of diagnosis with age, sex, clinical experience of the examining clinician, atrial fibrillation (AF), prior vascular diseases, the chief presenting complaint and delay from clinical event to assessment, to determine whether a clinical diagnosis was more or less useful in different types of patients

Summary

Methods

We used data from a rapid access clinic for patients with suspected TIA or minor stroke and follow-up from four overlapping data sources for a diagnosis of ischaemic or haemorrhagic stroke, MI, major haemorrhage and death. We identified patients with and without a clinical diagnosis of TIA or minor stroke. We estimated hazard ratios of stroke, MI, major haemorrhage and death in early and late time periods

Results

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