Risk of subsequent stroke among patients who were evaluated in a clinic for transient ischemic attack (TIA) was similar to that in patients admitted to hospitals, whereas patients who received treatment in EDs without further follow-up were at higher risk, according to a systematic review and meta-analysis.
Researchers searched the peer-reviewed literature through October 2020 for studies evaluating the occurrence of ischemic stroke after TIA or minor ischemic stroke and assessed risk among patients who received care at TIA or neurology clinics, inpatient units, EDs, and unspecified or multiple settings at 2, 7, 30, and 90 days. The analysis included 226,683 patients from 71 articles published between 1981 and 2018. The results were published Jan. 5 by JAMA Network Open.
Overall, 5,636 patients (50.8% men) received care at TIA clinics, 130,139 (38.4% men) received care as inpatients, 3,605 (52.4%) received care at EDs, and 87,303 (49.8% men) received care at an unspecified setting. Among the patients who were treated at a TIA clinic, risk of subsequent stroke following a TIA or minor ischemic stroke was 0.3% (95% CI, 0.0% to 1.2%) within 2 days, 1.0% (95% CI, 0.3% to 2.0%) within 7 days, 1.3% (95% CI, 0.4% to 2.6%) within 30 days, and 2.1% (95% CI, 1.4% to 2.8%) within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was 0.5% (95% CI, 0.1% to 1.1%) within 2 days, 1.2% (95% CI, 0.4% to 2.2%) within 7 days, 1.6% (95% CI, 0.6% to 3.1%) within 30 days, and 2.8% (95% CI, 2.1% to 3.5%) within 90 days. The risk of stroke did not differ significantly among patients treated at TIA clinics versus while hospitalized. For patients treated at EDs, the risk was 1.9% (95% CI, 1.2% to 2.7%) within 2 days, 3.4% (95% CI, 2.3% to 4.7%) within 7 days, 3.5% (95% CI, 1.5% to 6.3%) within 30 days, and 3.5% (95% CI, 2.5% to 4.5%) within 90 days.
The researchers concluded that rapid management at TIA clinics was not inferior to inpatient care but that patients treated at and discharged from the ED without follow-up care had an increased risk of subsequent stroke.
“Although several studies have found TIA clinics could substantially reduce the cost of care, evaluation of the cost-effectiveness of TIA clinics remains limited in the literature,” they wrote. “Beyond clinical management, the benefits of TIA clinics could also include a more accurate diagnosis for patients with suspected TIA compared with inpatient and ED settings, fast-track access to specialists, and appropriate patient education and follow-up, which could depend on the infrastructure and resources of the existing health service system.”