Diagnosis and management of transient ischemic attacks in primary care: a systematic review
Priyanka Bose 1 , Andrew Wilson 1 , Amit Mistri 1
+ Author Affiliations
- Author Affiliations
1 University of Leicester, Health Sciences Centre for Medicine, Leicester, UK
Correspondence to: Priyanka Bose, University of Leicester, Health Sciences Centre for Medicine (Floor 3, Room 3.06), 15 Lancaster Road, Leicester LE1 7HA 0116 252 5449, UK. Email: pb274@le.ac.uk
Journal of Primary Health Care 9(2) 114-130 https://doi.org/10.1071/HC17003
Published: 30 June 2017
Journal Compilation © Royal New Zealand College of General Practitioners 2017.
This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Abstract
INTRODUCTION: Many patients who suffer a transient ischaemic attack (TIA) present to their general practitioner (GP). Early identification and treatment reduces the risk of subsequent stroke, disability and mortality.
AIM: To review the accuracy of TIA diagnosis in primary care, immediate management and interventions to assist GPs with the condition.
METHODS: This study included the search of Medline, Embase, Web of Science and Scopus databases (1995–2015). Relevant titles and abstracts were obtained using structured criteria (diagnosis, immediate management or intervention of TIAs in primary care), with full review and data extraction for eligible publications.
RESULTS: Most studies found limitations in GPs’ knowledge and ability to diagnose TIAs to varying extent over time and between countries. GPs tended to over-interpret non-specific symptoms (e.g. isolated vertigo) when considering a TIA diagnosis. Reported referral behaviour varied between countries, with some favouring admission and others preferring outpatient management. Consistent under-referral and under-use of effective medication was reported. However, GPs may refer some patients to exclude rather than confirm a final diagnosis. This, alongside evidence of under-referral, suggests the need for education and decision support tools to enhance referral patterns. Intervention studies suggested that electronic decision support may increase referrals and timely management.
CONCLUSION: This review revealed deficiencies in knowledge and clinical practice, and identified potential avenues to addressing these. Issues for future research were also identified.
KEYWORDS: TIA; diagnosis; management; primary care; systematic review
References
[1] World Health Organization. UNAIDS. Prevention of cardiovascular disease. Geneva: World Health Organization; 2007.[2] Bos MJ, Van-Rijn MJE, Witteman JCM, et al. Incidence and prognosis of transient neurological attacks. JAMA. 2007; 298 2877–85.
| Incidence and prognosis of transient neurological attacks.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD1cXmvFOq&md5=7d71311037e269cc7304f50800a46971CAS |
[3] Intercollegiate Stroke Working Party. National clinical guideline for stroke 2012. [cited 2016 November 15]. Available from: http://bsnr.org.uk/wp-content/uploads/2014/05/national-clinical-guidelines-for-stroke-fourth-edition.pdf
[4] Sempere AP, Duarte J, Cabezas C, et al. Incidence of transient ischemic attacks and minor ischemic strokes in Segovia, Spain. Stroke. 1996; 27 667–71.
| Incidence of transient ischemic attacks and minor ischemic strokes in Segovia, Spain.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK287ot1CjtA%3D%3D&md5=caf618d4a7dd8770cf3239bd671cb300CAS |
[5] Edlow JA, Kim S, Pelletier AJ, et al. National study on emergency department visits for transient ischemic attack, 1992–2001. Acad Emerg Med. 2006; 13 666–72.
[6] Barber PA, Krishnamurthi R, Parag V, et al. Incidence of transient ischemic attack in Auckland, New Zealand, in 2011 to 2012. Stroke. 2016; 47 2183–8.
| Incidence of transient ischemic attack in Auckland, New Zealand, in 2011 to 2012.Crossref | GoogleScholarGoogle Scholar |
[7] Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007; 370 1432–42.
| Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison.Crossref | GoogleScholarGoogle Scholar |
[8] Lavallée PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007; 6 953–60.
| A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects.Crossref | GoogleScholarGoogle Scholar |
[9] Gommans J, Barber P, Fink J. New Zealand guideline for the assessment and management of people with recent transient ischaemic attack. Wellington: Stroke Foundation of New Zealand; 2008.
[10] European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee Guidelines for management of ischaemic stroke and transient ischaemic attack Cerebrovasc Dis. 2008; 25 457–507.
| Guidelines for management of ischaemic stroke and transient ischaemic attackCrossref | GoogleScholarGoogle Scholar |
[11] Prevention S. Italian guidelines for stroke prevention and management: syntheses and recommendations. Milan, Italy: Stroke Prevention and Educational Awareness Diffusion; 2003; 38.
[12] National Collaborating Centre for Chronic Conditions (Great Britain), Royal College of Physicians of London. Stroke: national clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). City: Royal College of Physicians; 2008 [cited 2017 March 1]. Available from: https://www.nice.org.uk/guidance/cg68/resources/surveillance-report-2017-stroke-and-transient-ischaemic-attack-in-over-16s-diagnosis-and-initial-management-2008-nice-guideline-cg68-4358987103/chapter/Surveillance-decision
[13] Suljic E, Mehicevic A, Gavranovic A. Stroke emergency medical care: initial assessment, risk factors, triage and hospitalization outcome. Mater Sociomed. 2013; 25 83
| Stroke emergency medical care: initial assessment, risk factors, triage and hospitalization outcome.Crossref | GoogleScholarGoogle Scholar |
[14] Noureddine A, Ghandehari K, Taghi Shakeri M. Differentiation of true transient ischemic attack versus transient ischemic attack mimics. Iran J Neurol. 2014; 13 127–30.
[15] Senes S, Penm E. Medicines for cardiovascular health: are they used appropriately? Canberra: Australian Institute of Health and Welfare; 2007.
[16] Hong JB, Kerse N, Scahill S, et al. Use of aspirin and statins for cardiovascular risk reduction in New Zealand: the residential care story. J Prim Health Care. 2009; 1 184–9.
[17] Kern R, Nagayama M, Toyoda K, et al. Comparison of the European and Japanese guidelines for the management of ischemic stroke. Cerebrovasc Dis. 2013; 35 402–18.
| Comparison of the European and Japanese guidelines for the management of ischemic stroke.Crossref | GoogleScholarGoogle Scholar |
[18] Pluye P, Robert E, Cargo M, et al. Proposal: a mixed methods appraisal tool for systematic mixed studies reviews. Montréal: McGill University 2011; 2 1–8.
[19] Jagadesham VP, Aparajita R, Gough MJ. Can the UK guidelines for stroke be effective? Attitudes to the symptoms of a transient ischaemic attack among the general public and doctors. Clin Med. 2008; 8 366–70.
| Can the UK guidelines for stroke be effective? Attitudes to the symptoms of a transient ischaemic attack among the general public and doctors.Crossref | GoogleScholarGoogle Scholar |
[20] Purroy F, Cruz E, Galindo O, et al. Survey of the knowledge and management of transient ischemic attacks among primary care physicians and nurses. Neurologia. 2011; 26 200–7.
| Survey of the knowledge and management of transient ischemic attacks among primary care physicians and nurses.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC38vntVOltQ%3D%3D&md5=b26f1aa88222a287efab2040339d1375CAS |
[21] Ismail MA, Negm ME. A study of knowledge of TIA’s in primary care practice in Ismailia governorate, Egypt. Egypt J Neurol Psychiat Neurosurg. 2013; 50 5–12.
[22] Nguyen-Huynh MN, Fayad P, Gorelick PB, et al. Knowledge and management of transient ischemic attacks among US primary care physicians. Neurology. 2003; 61 1455–6.
| Knowledge and management of transient ischemic attacks among US primary care physicians.Crossref | GoogleScholarGoogle Scholar |
[23] Middleton S, Sharpe D, Harris J, et al. Case scenarios to assess Australian general practitioners’ understanding of stroke diagnosis, management, and prevention. Stroke. 2003; 34 2681–6.
| Case scenarios to assess Australian general practitioners’ understanding of stroke diagnosis, management, and prevention.Crossref | GoogleScholarGoogle Scholar |
[24] Leung ES, Hamilton-Bruce MA, Price C, et al. Transient ischaemic attack (TIA) knowledge in general practice: a cross-sectional study of Western Adelaide general practitioners. BMC Res Notes. 2012; 5 278
| Transient ischaemic attack (TIA) knowledge in general practice: a cross-sectional study of Western Adelaide general practitioners.Crossref | GoogleScholarGoogle Scholar |
[25] Ranta A, Cariga P. Who should manage transient ischemic attacks? A comparison between stroke experts, generalists, and electronic decision support. N Z Med J. 2013; 126 25–31.
[26] Tomasik T, Windak A, Margas G, et al. Transient ischaemic attacks: desired diagnosis and management by Polish primary care physicians. Fam Pract. 2003; 20 464–8.
| Transient ischaemic attacks: desired diagnosis and management by Polish primary care physicians.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3szntlGrsQ%3D%3D&md5=3e62efdc806a0747cc4f2e5ce07e0b11CAS |
[27] Gibbs RGJ, Newson R, Lawrenson R, et al. Diagnosis and initial management of stroke and transient ischemic attack across UK health regions from 1992 to 1996: experience of a national primary care database. Stroke. 2001; 32 1085–90.
| Diagnosis and initial management of stroke and transient ischemic attack across UK health regions from 1992 to 1996: experience of a national primary care database.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3MvpsFymug%3D%3D&md5=dfe67da364b92826d25f4c6fcde4bdc3CAS |
[28] Clarey J, Lasserson D, Levi C, et al. Absolute cardiovascular risk and GP decision making in TIA and minor stroke. Fam Pract. 2014; 31 664–9.
| Absolute cardiovascular risk and GP decision making in TIA and minor stroke.Crossref | GoogleScholarGoogle Scholar |
[29] Magin P, Lasserson D, Parsons M, et al. Referral and triage of patients with transient ischemic attacks to an acute access clinic: risk stratification in an Australian setting. Int J Stroke. 2013; 8 81–9.
| Referral and triage of patients with transient ischemic attacks to an acute access clinic: risk stratification in an Australian setting.Crossref | GoogleScholarGoogle Scholar |
[30] McNeill A. How accurate are primary care referral letters for presumed acute stroke? Scott Med J. 2008; 53 11–2.
| How accurate are primary care referral letters for presumed acute stroke?Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1cjotlyisw%3D%3D&md5=0337e7c4a9ebabb293e6395735c01429CAS |
[31] Dawson J, Lamb KE, Quinn TJ, et al. A recognition tool for transient ischaemic attack. QJM. 2009; 102 43–9.
| A recognition tool for transient ischaemic attack.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1M%2FhvVCquw%3D%3D&md5=aada1d38285e09bb7107986a5b3822f0CAS |
[32] Lasserson DS, Mant D, Richard Hobbs FD, Rothwell PM. Validation of a TIA recognition tool in primary and secondary care: implications for generalizability. Int J Stroke. 2015; 10 692–6.
| Validation of a TIA recognition tool in primary and secondary care: implications for generalizability.Crossref | GoogleScholarGoogle Scholar |
[33] Roebers S, Wagner M, Ritter M, et al. Attitudes and current practice of primary care physicians in acute stroke management. Stroke. 2007; 38 1298–303.
| Attitudes and current practice of primary care physicians in acute stroke management.Crossref | GoogleScholarGoogle Scholar |
[34] Mead GE, Murray H, McCollum CN, et al. How do general practitioners manage patients at risk from stroke? Br J Clin Pract. 1996; 50 426–30.
| 1:STN:280:DyaK2s7ptFOluw%3D%3D&md5=9371d6f4d5f08f94cd3a3061a41afad5CAS |
[35] Wiszniewska M, Swiderski W, Wlodek A, et al. How do general practitioners proceed on initial contact with patients after cerebrovascular ischemia? Neurol Neurochir Pol. 2000; 34 1119–27.
| 1:STN:280:DC%2BD3MzlsFertw%3D%3D&md5=9f20359e95129c46fd032ab7b668bca0CAS |
[36] Otten A, Niño YB, Limburg M, et al. Management of transient ischemic attacks by the general practitioner. Cerebrovasc Dis. 1995; 5 358–61.
| Management of transient ischemic attacks by the general practitioner.Crossref | GoogleScholarGoogle Scholar |
[37] Goldstein LB, Bian J, Samsa G, et al. New transient ischemic attack and stroke: outpatient management by primary care physicians. Arch Intern Med. 2000; 160 2941–6.
| New transient ischemic attack and stroke: outpatient management by primary care physicians.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3crgt1Wksw%3D%3D&md5=cafe383035e8cf58333938de0dd0a90cCAS |
[38] Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007; 369 283–92.
| Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack.Crossref | GoogleScholarGoogle Scholar |
[39] Edwards D, Cohn SR, Mavaddat N, et al. Varying uses of the ABCD2 scoring system in primary and secondary care: a qualitative study. BMJ Open. 2012; 2 e001501
| Varying uses of the ABCD2 scoring system in primary and secondary care: a qualitative study.Crossref | GoogleScholarGoogle Scholar |
[40] Jäkel A, Plested M, Chapman A, et al. Management of patients with transient ischemic attack: insight from real-life clinical practice in Europe and the United States. Curr Med Res Opin. 2012; 28 429–37.
| Management of patients with transient ischemic attack: insight from real-life clinical practice in Europe and the United States.Crossref | GoogleScholarGoogle Scholar |
[41] Wright J, Harrison S, McGeorge M, et al. Improving the management and referral of patients with transient ischaemic attacks: a change strategy for a health community. Qual Saf Health Care. 2006; 15 9–12.
| Improving the management and referral of patients with transient ischaemic attacks: a change strategy for a health community.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD28%2FntV2ksw%3D%3D&md5=5b76fb61268a2ec73d60ac888c6f724bCAS |
[42] Wright J, Bibby J, Eastham J, et al. Multifaceted implementation of stroke prevention guidelines in primary care: cluster-randomised evaluation of clinical and cost effectiveness. Qual Saf Health Care. 2007; 16 51–9.
| Multifaceted implementation of stroke prevention guidelines in primary care: cluster-randomised evaluation of clinical and cost effectiveness.Crossref | GoogleScholarGoogle Scholar |
[43] Lavin TL, Ranta A. Transient ischaemic attack/stroke electronic decision support: a 14-month safety audit. J Stroke Cerebrovasc Dis. 2014; 23 267–70.
| Transient ischaemic attack/stroke electronic decision support: a 14-month safety audit.Crossref | GoogleScholarGoogle Scholar |
[44] Ranta A, Yang C, Funnell M, et al. Utility of a primary care based transient ischaemic attack electronic decision support tool: a prospective sequential comparison. BMC Fam Pract. 2014; 15 86
| Utility of a primary care based transient ischaemic attack electronic decision support tool: a prospective sequential comparison.Crossref | GoogleScholarGoogle Scholar |
[45] Ranta A, Dovey S, Weatherall M, et al. Cluster randomized controlled trial of TIA electronic decision support in primary care. Neurology. 2015; 84 1545–51.
| Cluster randomized controlled trial of TIA electronic decision support in primary care.Crossref | GoogleScholarGoogle Scholar |
[46] Kraaijeveld CL, van Gijn J, Schouten HJ, et al. Interobserver agreement for the diagnosis of transient ischemic attacks. Stroke. 1984; 15 723–5.
| Interobserver agreement for the diagnosis of transient ischemic attacks.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaL2c3nsFersw%3D%3D&md5=b26f736f3a24bbaada262aa43a9d1ae8CAS |
[47] McAvoy BR, Kaner EF. General practice postal surveys: a questionnaire too far? BMJ. 1996; 313 732
| General practice postal surveys: a questionnaire too far?Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK28vhs1Kmsw%3D%3D&md5=fa64a1fe4d290082af04d2433c9e25e3CAS |
[48] Dutta D. Diagnosis of TIA (DOT) score–design and validation of a new clinical diagnostic tool for transient ischaemic attack. BMC Neurol. 2016; 16 20
| Diagnosis of TIA (DOT) score–design and validation of a new clinical diagnostic tool for transient ischaemic attack.Crossref | GoogleScholarGoogle Scholar |
