Transient Ischemic Attack Admissions Research Articles

Changes in stroke and TIA admissions during the COVID-19 pandemic: A meta-analysis.

To perform a meta-analysis on how the admissions of stroke and transient ischemic attack (TIA) changed during the Corona Virus infection-19 (COVID-19) pandemic and evaluate if the effect was depending on stroke severity. Observational cohort studies comparing the number of stroke and/or TIA admissions during a period of the pandemic compared to a period before the pandemic were identified in PubMed and Embase. After excluding studies with overlapping populations and studies without satisfactory case ascertainment, data was extracted and meta-analyzed. A total of 59 studies were included. During the pandemic, there was a decrease in admissions of ischemic stroke (admission rate ratio (ARR) = 0.77, 95% confidence interval (CI): 0.72, 0.82), intracerebral hemorrhage (ARR = 0.79, 95% CI: 0.70, 0.90) and TIA (ARR = 0.66, 95% CI: 0.58, 0.75). Albeit admission rates of both mild (ARR = 0.61, 95% CI: 0.49, 0.77) and severe (ARR = 0.82, 95% CI = 0.71, 0.95) strokes decreased, milder strokes decreased more (proportion ratio (PR) = 0.76, 95% CI: 0.65, 0.89). Potential causes for the admission reduction could be strict prioritizations within the health care, patients' fear of acquiring COVID-19, or decreased access to health care due to lockdowns. During the COVID-19 pandemic, there was a reduction in admissions of stroke and TIA, possibly caused by reluctance to seek medical care.

Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks

It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed. To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to. This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified. For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics. Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients. Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients. This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.

Clinical Characteristics, Management, and In-Hospital Outcomes in Patients With Stroke or Transient Ischemic Attack in China

Stroke represents a significant burden on the health care system of China. The Chinese Stroke Center Alliance was launched in 2015 to monitor and improve care quality and outcomes for patients with acute stroke and transient ischemic attack (TIA). To evaluate the clinical characteristics, management, and in-hospital clinical outcomes and complications among patients with stroke or TIA in China. This quality improvement study assessed stroke or TIA admissions to 1476 participating hospitals in the Chinese Stroke Center Alliance between August 1, 2015, and July 31, 2019. Stroke types and calendar year. Eleven guideline-based admission or discharge management measures and 2 summary measures: an all-or-none binary outcome and a composite score (range, 0 [nonadherence] to 1 [perfect adherence]) for adherence to evidence-based stroke and TIA care and in-hospital clinical outcomes, including death or discharge against medical advice (DAMA), major adverse cardiovascular events (MACEs), including ischemic stroke, hemorrhagic stroke, TIA, or myocardial infarction; and in-hospital complications. Of 1 006 798 patients with stroke or TIA (mean [SD] age, 65.7 [12.2] years; 383 500 [38.1%] female), 838 229 (83.3%) had an ischemic stroke, 64 929 (6.4%) had TIA, 85 705 (8.5%) had intracerebral hemorrhage (ICH), and 11 241 (1.1%) had subarachnoid hemorrhage (SAH). Management measures varied by cerebrovascular event type, with the mean (SD) composite score ranging from 0.57 (0.31) in SAH to 0.83 (0.24) in TIA. Poor outcomes and complications were highest among patients with SAH (21.9%; 95% CI, 21.0%-22.8% in-hospital death or DAMA; 9.6%; 95% CI, 9.1%-10.2% MACEs; and 31.4%; 95% CI, 30.6%-32.3% in-hospital complications) and patients with ICH (17.2%; 95% CI, 16.9%-17.5% in-hospital death or DAMA; 9.3%; 95% CI, 9.1%-9.5% MACEs; and 31.3%; 95% CI, 31.0%-31.6% in-hospital complications), followed by patients with ischemic stroke (6.1%; 95% CI, 6.0%-6.1% in-hospital death or DAMA; 6.3%; 95% CI, 6.3%-6.4% MACEs; and 12.8%; 95% CI, 12.7%-12.9% in-hospital complications), and lowest in patients with TIA (5.0%; 95% CI, 4.8%-5.2% in-hospital death or DAMA; 2.4%; 95% CI, 2.3%-2.5% MACEs; and 0.8%; 95% CI, 0.7%-0.8% in-hospital complications). Temporal improvements in management measures were observed from 2015 to 2019, especially in administration of intravenous recombinant tissue plasminogen activator (+60.3% relatively; 95% CI, 52.9%-70.5%), dysphagia screening (+14.7% relatively; 95% CI, 14.0%-15.6%), and use of anticoagulants for atrial fibrillation (+31.4% relatively; 95% CI, 25.7%-37.3%). Temporal improvements in in-hospital death or DAMA (-9.7% relatively; 95% CI, -9.6% to -8.5%) and complications (-27.1% relatively; 95% CI, -28.6% to -25.3) were also observed. In this quality improvement study, performance measure adherence and poor outcomes and complications varied by cerebrovascular event type; although there were substantial improvements over time, these results suggest that support for the use of evidence-based practices is needed.

Guideline-directed low-density lipoprotein management in high-risk ischemic stroke or transient ischemic attack admissions in China from 2015 to 2019.

BackgroundLowering low-density lipoprotein cholesterol (LDL-C) is crucial for secondary stroke prevention in stroke patients with preexisting cardiovascular diseases (CVD) or cerebrovascular diseases (CeVD). However, data on attainment of guideline-recommended LDL-C levels are lacking.MethodsWe analyzed data from the Chinese Stroke Center Alliance (CSCA) program for patients with ischemic stroke and transient ischemic attack (TIA) hospitalized between August 2015 and July 2019. Participants were classified into different disease groups according to preexisting CeVD (stroke/TIA) or CVD [coronary heart disease (CHD) or myocardial infarction (MI)].ResultsOf 858,509 patients presenting with an acute stroke/TIA, 251,176 (29.3%) had a preexisting CeVD, 44,158 (5.1%) had preexisting CVD, 33,070 (3.9%) had concomitant preexisting CeVD and CVD, and 530,105 (61.7%) had no documented history of CeVD/CVD. Overall, only 397,596 (46.3%) met the target for LDL-C <2.6 mmol/L, 128,177 (14.9%) for LDL-C <1.8 mmol/L and 55,275 (6.4%) for LDL-C <1.4 mmol/L, and patients with concomitant CeVD and CVD had higher attainment rates than other disease groups (P<0.001). Despite improvements over time in the proportion of patients who attain LDL-C targets (P for trend <0.05), it remains suboptimal. Younger age, women, having a history of hypertension or dyslipidemia, current smoking or drinking, and being admitted to hospitals located in eastern China were associated with lower odds of meeting the LDL-C goals.ConclusionsOverall attainment of guideline LDL-C targets in a population of stroke/TIA patients is low and indicates the need for better management of dyslipidemia, particularly for high-risk stroke patients with pre-existing CeVD or CVD.

Risk of Ischemic Stroke after an Inpatient Hospitalization for Transient Ischemic Attack in the United States

Introduction: A diagnosis of transient ischemic attack (TIA) must be followed by prompt investigation and rapid initiation of measures to prevent stroke. Prior studies evaluating the risk of stroke after TIA were conducted in the emergency room or clinic settings. Experience of patients admitted to the hospital after a TIA is not well known. We sought to assess the early risk of ischemic stroke after inpatient hospitalization for TIA. Methods: We used the 2010–2015 Nationwide Readmissions Database to identify all hospitalizations with the primary discharge diagnosis of TIA and investigated the incidence of ischemic stroke readmissions within 90 days of discharge from the index hospitalization. Results: Of 639,569 index TIA admissions discharged alive (mean ± SD age 70.4 ± 14.4 years, 58.7% female), 9,131 (1.4%) were readmitted due to ischemic stroke within 90 days. Male sex, head/neck vessel atherosclerosis, hypertension, diabetes, atrial flutter/fibrillation, previous history of TIA/stroke, illicit drug use, and higher Charlson Comorbidity Index score were independently associated with readmissions due to ischemic stroke. Ischemic stroke readmissions were associated with excess mortality, discharge disposition other than to home, and elevated cost. Conclusions: Patients hospitalized for TIA have a lower risk of ischemic stroke compared to that reported in the studies based on the emergency room and/or outpatient clinic evaluation. Among these patients, those with cardiovascular comorbidities remain at a higher risk of readmission due to ischemic stroke despite undergoing an inpatient evaluation and should therefore be the target for future preventive strategies.

High ABCD2 Scores and In-Hospital Interventions following Transient Ischemic Attack

Background and Purpose: Following transient ischemic attack (TIA), there is increased risk for ischemic stroke. The American Heart Association recommends admission of patients with ABCD² scores ≥3 for observation, rapid performance of diagnostic tests, and potential acute intervention. We aimed to determine if there is a relationship between ABCD² scores, in-hospital ischemic events, and in-hospital treatments after TIA admission. Methods: We reviewed consecutive patients admitted between 2006 and 2011 following a TIA, defined as transient focal neurological symptoms attributed to a specific vascular distribution and lasting <24 h. Three interventions were prespecified: anticoagulation for atrial fibrillation, carotid or intracranial revascularization, and intravenous or intra-arterial reperfusion therapies. We compared rates of in-hospital recurrent TIA or ischemic stroke and the receipt of interventions among patients with low (<3) versus high (≥3) ABCD² scores. Results: Of 249 patients, 11 patients (4.4%) had recurrent TIAs or strokes during their stay (8 TIAs, 3 strokes). All 11 had ABCD² scores ≥3, and no neurological events occurred in patients with lower scores (5.1 vs. 0%; p = 0.37). Twelve patients (4.8%) underwent revascularization for large artery stenosis, 16 (6.4%) were started on anticoagulants, and no patient received intravenous or intra-arterial reperfusion therapy. The ABCD² score was not associated with anticoagulation (p = 0.59) or revascularization (p = 0.20). Conclusions: Higher ABCD² scores may predict early ischemic events after TIA but do not predict the need for intervention. Outpatient evaluation for those with scores <3 would potentially have delayed revascularization or anticoagulant treatment in nearly one-fifth of ‘low-risk' patients.

Shifting Trend of Transient Ischemic Attack Admission and Prognosis in Canada.

Stroke is often preceded by transient symptoms. Although global stroke rates have been shown to be declining, previous studies have reported inconsistent temporal trends of transient ischemic attacks (TIA). The objective of the current study is to report the temporal trends of TIA admissions and outcomes in Canada over the last 11 years. We conducted a complete population cohort study using a national administrative database to study the temporal trend of age- and sex-adjusted TIA admission rates in Canada from 2003 to 2013. We also determined the rates of TIA and stroke diagnoses in the emergency department in the province of Ontario during the same period. We used multivariable analyses to study discharge location after acute hospitalization as well as 90-day stroke and/or TIA readmission rates. Of 425,799 admissions to an acute care hospital for all stroke and TIA, 71,443 (16.8%) were TIA. The age- and sex-standardized rates of TIA admission decreased significantly during the study period from 30.0 to 20.6 per 100,000 (p<0.0001). In Ontario, decreasing TIA admissions is mirrored by decreasing rates of TIA directly discharged from the emergency department (55.1 to 46.8 per 100,000, p = 0.002). The odds of 90-day readmission rates for stroke or TIA are also decreasing (adjusted odds ratio, 0.97; 95% confidence interval, 0.96-0.99). We show that TIA admission rates have declined in the past 11 years in Canada, reflecting improved vascular risk reduction and stroke care. Future studies to confirm our findings on improved stroke or TIA recurrence rates are necessary.

Abstract W P220: Use Of A Prehospital Stroke Scale Increases Accuracy Of Emergency Medical Services Stroke Recognition

Background: Prehospital activation of in-hospital stroke response depends on accurate Emergency Medical Services (EMS) provider stroke recognition. While screening tools such as the Cincinnati Prehospital Stroke Scale (CPSS) have been validated, their real world impact is less clear. We determined the accuracy of prehospital stroke recognition and its relationship to CPSS documentation in a cohort of EMS transported suspect and confirmed stroke patients. Methods: We identified a prospective cohort of all suspected or confirmed ischemic stroke or transient ischemic attack (TIA) patients transported by EMS to a large primary stroke center. Data on prehospital and hospital care were abstracted from medical records. The sensitivity and positive predictive value (PPV) of EMS stroke recognition were calculated using the final hospital discharge diagnosis of ischemic stroke or TIA as the gold standard. We compared the sensitivity and PPV of EMS recognition among cases with and without a documented CPSS using chi square tests. We performed multivariable logistic regression analysis to determine the independent relationship between CPSS use and the odds of EMS stroke recognition among confirmed stroke and TIA cases. Results: Over a 12 month period, 434 EMS transported patients met inclusion criteria. The median age was 78 and 60% were female. EMS transported 371 (85.5%) patients as suspect strokes and documented a CPSS in 343 (79.0%). A total of 246 cases (56.7%) were confirmed ischemic strokes (n=186) or TIA (n=60). The sensitivity of EMS stroke recognition was 74.4% (95% CI 68.9 to 79.8) and PPV was 49.3% (95% CI 44.2 to 54.4). Sensitivity was higher among cases with CPSS documentation than without (85.9% vs. 25.5% p&lt;0.0001) as was the PPV (54.3% vs. 21.4%, p&lt;0.0001). After adjustment for age, sex, stroke severity, dispatch reason, and time from symptom onset, CPSS use was associated with substantially higher odds of EMS stroke recognition (OR 19.04, 95% CI: 7.95 to 45.59). Conclusion: EMS providers recognized three quarters of all stroke or TIA admissions, while EMS suspicion of stroke was correct only half of the time. Documentation of a CPSS was associated with substantially higher EMS stroke recognition.

Time Trends in Transient Ischemic Attack Admission from the Emergency Department (P5.115)

Time Trends in Transient Ischemic Attack Admission from the Emergency Department (P5.115)

Abstract T P189: Time Trends in Transient Ischemic Attack Admission From the Emergency Department

Background: Prior studies suggest transient ischemic attack (TIA) admission from the Emergency Department (ED) increased over time. We investigated how TIA admission trends may have changed with publication of TIA risk stratification rules involving the ABCD /ABCD2 scores. Methods: We used ED data on TIA from the National Hospital Ambulatory Medical Care Survey. We defined three time periods to account for the initial publication by Johnston et al., highlighting the risk of ischemic stroke following TIA (2000) and related reports on the ABCD (2005) and ABCD2 (2007) scores. We defined 2005 through 2007 as a washout period to allow for any practice change that occurred with the evolution of ABCD/ABCD2 scores. Admission trends were stratified across younger (18-64y) and older (65y+) patients. Results: There were 327,339 TIA visits yearly from 1994 to 2010 in adults 18+ years. We compared three distinct time periods (1994-1999; 2001-2004 and 2008-2010 to reflect the timing of publications above. We observed interaction between time and age with regard to TIA admission (Figure). TIA patients 18-64y showed a decreasing admission trend overall (p = 0.047). Patients 65y+ showed a similar decreasing trend up to 2005-2007, but after 2007 had a marked increase in TIA admissions (p = 0.021). A comparison of stroke admissions during the same time period did not show an increasing trend in the 65+ group. Conclusion: Contrary to prior reports, TIA admissions decreased over time among persons 18-64y. Among older persons 65+, there was a sharp increase in TIA admission after 2007 that was not due to an increase in admissions for stroke or stroke-related diagnosis. The increase in TIA admissions could be related to new tools for the risk-stratification of TIA patients, but a large percentage of TIA patients are discharged from the ED. More research is needed to ensure that all high risk TIA patients receive a rapid evaluation.

Prehospital Triage to Primary Stroke Centers and Rate of Stroke Thrombolysis

Implementation of prehospital stroke triage is a public policy intervention that can have an immediate impact on acute stroke care in a region. OBJECTIVE To evaluate the impact that a citywide policy recommending prehospital triage of patients with suspected stroke to the nearest primary stroke center had on intravenous tissue plasminogen activator (tPA) use in Chicago, Illinois. Retrospective multicenter cohort study from September 1, 2010, to August 31, 2011 (6 months before and after intervention that began March 1, 2011). Ten primary stroke center hospitals in Chicago. All admitted patients with stroke and transient ischemic attack. INTERVENTION Prehospital triage policy of patients with stroke to primary stroke centers. Intravenous tPA use (measured as a fraction of patients with ischemic strokes arriving through the emergency department). RESULTS There were 1075 stroke and transient ischemic attack admissions in the pretriage period and 1172 in the posttriage period. Patient demographic characteristics including age, sex, and risk factors were similar between the 2 periods (mean age, 65 years; 53% female). Compared with the pretriage period, use of emergency medical services increased from 30.2% to 38.1% (P < .001) and emergency medical services prenotification increased from 65.5% to 76.5% (P = .001) after implementation. Rates of intravenous tPA use were 3.8% and 10.1% (P < .001) and onset-to-treatment times decreased from 171.7 to 145.7 minutes (P = .03) in the pretriage and posttriage periods, respectively. Stroke unit admission, symptomatic intracranial hemorrhage rates, and in-hospital mortality were not significantly different between periods. Adjusting for mode of arrival, prehospital notification, and onset-to-arrival time, the posttriage period was independently associated with increased tPA use for patients with ischemic stroke presenting through the emergency department (adjusted odds ratio = 2.21; 95% CI, 1.34-3.64). Implementation of a prehospital stroke triage policy in Chicago resulted in significant improvements in emergency medical services use and prenotification and more than doubled intravenous tPA use at primary stroke centers.

Quantifying the Contribution of Risk Factors for Ischemic Stroke in Patients with a History of TIA

Background. Patients with a history of transient ischemic attack (TIA) are known to be at higher risk for a stroke. We sought to investigate predictors of individual risk for an ischemic stroke within 30 days of a TIA. Methods and Results. A retrospective analysis of 57,585 TIA admissions was collected from 155 United States hospitals. Data describing each admission included demographic and clinical data, and information about the admitting hospital. Cerebrovascular disease was the primary readmission reason (19% of readmissions) in the TIA patient population. The prevalence of 30-day ischemic stroke readmissions was 11 per 1,000 TIA admissions; however, 53% of stroke readmissions occurred within one week. Hierarchal regression models suggested that peripheral vascular disease and hypertensive chronic kidney disease were significant individual stroke risk factors, whereas history of myocardial infarction, essential hypertension, and diabetes mellitus was not associated with significant stroke risk. Certified stroke centers were not associated with significantly lower stroke readmission rates. Conclusions. The results suggest that cardiovascular comorbidities confer the most significant risk for an ischemic stroke within 30 days of a TIA. Interestingly, certified stroke centers do not appear to be associated with significantly lower stroke-readmission rates, highlighting the challenges managing this patient population.

Neurointerventional Procedural Volume per Hospital in United States

Availability of neurointerventional procedures is recommended as a necessary component of a comprehensive stroke center by various regulatory guidelines that also emphasize adequate procedural volumes. We studied the volumes of neurointerventional procedures performed in various hospitals across the United States with subsequent comparisons with rates of minimum procedural volumes recommended by various professional bodies or used in clinical trials to ensure adequate operator experience. We reviewed the Nationwide Inpatient Sample database in the United States for the years 2005 to 2008. Using International Classification of Disease-Clinical Modification, 9th revision, and Medicare severity diagnosis-related group codes, we identified among hospitals that admit stroke patients those that met the minimum criteria for overall and individual procedural volumes specified in various guidelines. We then compared the characteristics between the high-volume hospitals that performed at least 100 cervicocerebral angiograms and met ≥1 other procedural criterion (n=79) and low-volume hospitals (n=958). Proportions of hospitals that met individual procedural volume criteria over the 4-year period according to procedure were: cervicocerebral angiography (7.0%-7.8%); endovascular acute ischemic stroke treatments (0.4%-2.6%); carotid angioplasty/stent placement (3.0%-5.3%); intracranial angioplasty/stent placement (0.3%-1.3%); and aneurysm embolization (1.3%-2.6%). There were significant trends for increasing numbers of all the endovascular procedures except intracranial angioplasty/stent placement over the course of 4 years. The high-volume hospitals were more likely to be urban teaching hospitals (70.9% versus 13.1%; P<0.001), had larger bed size (79.7% versus 26.9%; P<0.001), and had significantly higher rates of hemorrhagic stroke admissions and lower rates of transient ischemic attack admissions. Urban teaching location/status (OR, 8.92; CI, 4.3-18.2; P<0.001) and large bed size (OR, 4.40; CI, 2.0-9.5; P<0.001) remained as independent predictors of a high-volume hospital when adjusted for age, gender, risk factors, and stroke subtype. There are very few hospitals in the United States that meet all the neurointerventional procedural volume criteria for all endovascular procedures recommended to ensure adequate operator experience. Our results support the creation of specialized regional centers for ensuring adequate procedural volume within treating hospitals.

Characteristics, Performance Measures, and In-Hospital Outcomes of the First One Million Stroke and Transient Ischemic Attack Admissions in Get With The Guidelines-Stroke

Stroke results in substantial death and disability. To address this burden, Get With The Guideline (GWTG)-Stroke was developed to facilitate the measurement, tracking, and improvement in quality of care and outcomes for acute stroke and transient ischemic attack (TIA) patients in the United States. We analyzed the characteristics, performance measures, and in-hospital outcomes in the first 1 000 000 acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and TIA admissions from 1392 hospitals that participated in the GWTG-Stroke Program 2003 to 2009. Patients were 53.5% women, 73.3% white, and with mean age of 70.1+/-14.9 years. There were 601 599 (60.2%) ischemic strokes, 108 671 (10.9%) intracerebral hemorrhages, 34 945 (3.5%) subarachnoid hemorrhages, 26 977 (2.7%) strokes not classified, and 227 788 (22.8%) TIAs. Performance measures showed small to moderate differences by cerebrovascular event type. In-hospital mortality rate was highest among intracerebral hemorrhage (25.0%) and subarachnoid hemorrhage (20.4%), and intermediate in ischemic stroke (5.5%) patients and lowest among TIA patients (0.3%). Significant improvements over time from 2003 to 2009 in quality of care were observed: all-or-none measure, 44.0% versus 84.3% (+40.3%, P<0.0001). After adjustment for patient and hospital variables, the cumulative adjusted odds ratio for the all-or-none measure over the 6 years was 9.4 (95% confidence interval, 8.3 to 10.6, P<0.0001). Temporal improvements in length of stay and risk-adjusted in-hospital mortality rate (for ischemic stroke and TIA) were also observed. With more than 1 million patients enrolled, GWTG-Stroke represents an integrated stroke and TIA registry that supports national surveillance, innovative research, and sustained quality improvement efforts facilitating evidence-based stroke/TIA care.

Characteristics, Performance Measures, and In-Hospital Outcomes of the First One Million Stroke and Transient Ischemic Attack Admissions in Get With The Guidelines-Stroke

Characteristics, Performance Measures, and In-Hospital Outcomes of the First One Million Stroke and Transient Ischemic Attack Admissions in Get With The Guidelines-Stroke

Frequency and Determinants of Lipid Testing in Ischemic Stroke and Transient Ischemic Attack

National guidelines recommend lipid testing for all patients with ischemic stroke and transient ischemic attack. This study examined the frequency and predictors for in-hospital low-density lipoprotein testing using data from a nationwide stroke registry. Between 2003 and 2008, Get With The Guideline-Stroke (GWTG-Stroke) hospitals (n=981) contributed 479 284 consecutive ischemic stroke or transient ischemic attack admissions. Logistic regression models were used to determine patient and hospital characteristics associated with lipid testing. Frequency of LDL measurement increased from 54.3% in 2003 to 81.9% in 2008 (P<0.001), the adjusted OR for LDL measurement was 1.23 per additional calendar year (95% CI, 1.18 to 1.29; P<0.001). The frequency of LDL measurement also increased with longer hospital program participation; the adjusted OR was 1.17 per additional year of GWTG-Stroke participation (95% CI, 1.12 to 1.23; P<0.001). LDL measurement was lower in women, nonsmokers, those with atrial fibrillation, those with a history of stroke or transient ischemic attack, and in those with transient ischemic attack (versus ischemic stroke; all P<0.001). LDL >or=100 mg/dL was seen in 52.1% of those tested, including in 35.5% of patients already prescribed lipid-lowering therapy before admission. Rates of LDL measurement in hospitalized patients with ischemic stroke and transient ischemic attack have improved dramatically in this large quality improvement program, although disparities in testing still exist. Testing frequently revealed an LDL level that could prompt a change in clinical management.

Diffusion-Weighted Imaging Showing ‘Pearls’ Predicts Large-Vessel Disease as Stroke Etiology

Background: The patterns on diffusion-weighted (DWI) MRI may be predictive of stroke etiology. In this retrospective study, we assessed whether DWI bright lesions termed ‘pearls’ predicted the presence of large-vessel arterial stenosis as the etiology of stroke. Methods: All stroke and transient ischemic attack admissions to an academic hospital over a 2-year period were reviewed. Patients without DWI, with hemorrhagic strokes or with nonvascular disease were excluded. Two vascular neurologists reviewed medical records and classified the probable stroke etiology by modified TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Another investigator, blinded to the clinical diagnoses, reviewed MRI images only. A ‘pearl’ was defined as a DWI bright lesion 20 mm or less in diameter. A ’string of pearls’ was defined as 3 or more pearls in a line found unilaterally in the anterior circulation. ‘Scattered pearls’ were classified as 3 or more pearls distributed such that no single line could connect them, also found unilaterally in the anterior circulation. Results: Fifty-six percent of the patients with either ‘pearls’ sign were classified as TOAST 1 or 2, with this classification only found in 33% of the patients with other DWI patterns (p = 0.0009). If either ‘pearl’ sign was seen on MRI, a patient was 2.65 times (95% CI = 1.32–5.32) more likely to have either extracranial or intracranial large-vessel stenosis. Conclusions: The presence of either ‘string of pearls’ or ‘scattered pearls’ on MRI was associated with an independently determined mechanism of intracranial or extracranial arterial stenosis. In patients with acute stroke distributions consistent with either of these patterns, additional vascular imaging should be considered.

Elderly Women Have Lower Rates of Stroke, Cardiovascular Events, and Mortality After Hospitalization for Transient Ischemic Attack

Patients with transient ischemic attack (TIA) are at increased risk for stroke, cardiovascular events, and death, yet little is known about whether these risks differ for men and women. We determined whether there are sex-based differences in these outcomes 30 days and 1 year after TIA using a national sample of elderly patients. Rates of 30-day and 1-year hospitalization for TIA (International Classification of Diseases, 9th Revision Code 435), stroke (International Classification of Diseases, 9th Revision Codes 433, 434, and 436), coronary artery disease (International Classification of Diseases, 9th Revision Codes 410 to 414), all-cause readmission, and mortality were determined for fee-for-service Medicare patients >or=65 years of age discharged with a TIA in 2002. Cox proportional hazards models and random-effects logistic models compared outcomes with risk adjustment for demographics, medical history, comorbidities, and prior hospitalizations. The study included 122063 TIA hospitalizations (mean age, 79.0+/-7.6 years; 62% women; 86% white). Men were younger but had higher rates of cardiac comorbidities than women. Women had lower unadjusted rates of stroke, coronary artery disease, and mortality at 30 days and 1 year after TIA admission. These relationships persisted in risk-adjusted analyses at 30 days for stroke (hazard ratio, 0.70; 95% CI, 0.64 to 0.77), coronary artery disease (hazard ratio, 0.86; 0.74 to 1.00), and mortality (odds ratio, 0.74; 0.68 to 0.82) as well as at 1 year for stroke (hazard ratio, 0.85; 0.81 to 0.89), coronary artery disease (hazard ratio, 0.81; 0.77 to 0.86), and mortality (odds ratio, 0.78; 0.75 to 0.81). These data suggest that women have a better prognosis than men within the first year after hospital discharge for a TIA. Additional research is needed to identify factors that may explain these sex-related differences in outcomes.

Correction

HomeStrokeVol. 36, No. 8Correction Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection Originally published1 Aug 2005https://doi.org/10.1161/01.STR.0000178108.54612.9eStroke. 2005;36:1820This article corrects the followingAcute Stroke Care in the USIn the article by Arora et al1, “Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry,” which appeared in the June 2005 issue of the Stroke, the first author listed in the footnote listing participants in the Paul Coverdell Prototype Registries Writing Group should have been Mathew J. Reeves, so that the listing would be Mathew J. Reeves, Shalini Arora, Joseph P. Broderick, Michael Frankel, John P. Heinrich, Susan Hickenbottom, Herbert Karp, Kenneth A. LaBresh, Ann Malarcher, George Mensah, Charles J. Moomaw, Lee Schwamm, and Paul Weiss. The authors apologize for this error.When citing this article, please use the following: Reeves MJ, Arora S, Broderick JP, Frankel M, Heinrich JP, Hickenbottom S, Karp H, LaBresh KA, Malarcher A, Mensah G, Moomaw CJ, Schwamm L, Weiss P; Paul Coverdell Prototype Registries Writing Group. Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry. Stroke. 2005;36:1232–1240. Previous Back to top Next FiguresReferencesRelatedDetailsCited ByFonarow G, Reeves M, Smith E, Saver J, Zhao X, Olson D, Hernandez A, Peterson E and Schwamm L (2010) Characteristics, Performance Measures, and In-Hospital Outcomes of the First One Million Stroke and Transient Ischemic Attack Admissions in Get With The Guidelines-Stroke, Circulation: Cardiovascular Quality and Outcomes, 3:3, (291-302), Online publication date: 1-May-2010.Reeves M, Fonarow G, Zhao X, Smith E and Schwamm L (2009) Quality of Care in Women With Ischemic Stroke in the GWTG Program, Stroke, 40:4, (1127-1133), Online publication date: 1-Apr-2009.Related articlesAcute Stroke Care in the USStroke. 2005;36:1232-1240 August 2005Vol 36, Issue 8 Advertisement Article InformationMetrics https://doi.org/10.1161/01.STR.0000178108.54612.9e Originally publishedAugust 1, 2005 PDF download Advertisement