Ep 117 TIA Update – Risk Stratification, Workup and Dual Antiplatelet Therapy

This is Part 1 of EM Cases two part podcast on TIA and Stroke with Walter Himmel and David Dushenski - TIA Update - Risk Stratification, Workup and Dual Antiplatelet Therapy. Much has changed in recent years when it comes to TIA risk stratification, workup and antiplatelet therapy. In this podcast we use the overarching theme of timing to elucidate how to distinguish true TIA from the common TIA mimics, the importance of timing in the workup of TIA, why the duration of therapy with dual antiplatelet therapy and timing of starting anticoagulation in patient with atrial fibrillation, contributes to the difference between preventing catastrophic strokes and causing intracranial hemorrhage. Remember that stroke is a leading cause of adult disability and is the third leading cause of death in Canada. It's time we paid more attention to TIA... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Shaun Mehta & Alex Hart, edited by Anton Helman November, 2018 Cite this podcast as: Helman, A, Himmel, W, Dushenski, D. TIA Update - Risk Stratification, Workup and Dual Antiplatelet Therapy. Emergency Medicine Cases. November, 2018. https://emergencymedicinecases.com/tia-update/. Accessed [date] Go to part 2 of this 2-part podcast on TIA/stroke TIA Mimics The ED misdiagnosis rate of TIA has been reported to be between 5% and 31%, which can lead to needless workups, iatrogenic complications and morbidity. The three mimics that are often not obvious on history and physical are migraines, seizures and psychiatric disorders. Distinguishing these from TIA is mostly in the timing of symptom onset, associated symptoms and presence of "positive" vs "negative" symptoms. It is important to consider a few of the less common underlying causes of TIA in the ED as these have time-sensitive workups and therapies. TIA Important Causes and Common Mimics An observational study from 2014 shows that memory loss, headache, and blurred vision were associated with mimics, while unilateral weakness was associated with true TIA. Clinical Pearl: The “TIA AND” presentation. TIA symptoms AND neck pain – think neck dissection. TIA symptoms AND fever or new heart murmur – think endocarditis. TIA risk stratification - the death of the ABCD2 score The importance of risk stratification for TIA lies in the questions: what’s the chance that a TIA patient you see in the ED will have a stroke in the next 2 days? 90 days? And can we identify the patients who are eligible for a carotid endarterectomy fast enough to prevent that stroke? There exists an alarming 12-20% 90 day stroke risk in those presenting with high risk TIA symptoms. Half of these patient suffer from a stroke in the first 48hrs. A 2016 NEJM study fortunately found that this high risk can be reduced to less than 4% with rapid follow-up and aggressive secondary prevention. Based on these findings, it is good practice for high risk TIA patients to be worked up in the first 48 hours. So which patients who present with TIA symptoms are high risk? While the CHADS2VASC helps identify AFib patients at risk for future embolic event, The ABCD2 score has been the most ubiquitously used risk stratifying tool in ED since its inception. The elements of the ABCD2 include: * Age over 60 * Initial BP over 140/90 * Clinical features of unilateral weakness and speech impairment * Duration of symptoms * History of D More recent studies by Stead and Ghia have failed to valid...