Patients who have experienced a transient ischemic attack or minor stroke may be safely and feasibly managed with an outpatient approach, according to a new study, but one expert said the outcomes were not “pristine.”
Bernard Chang, MD, PhD, the vice chair of research and an assistant professor of emergency medicine, led a group of emergency physicians and stroke neurologists at Columbia University Medical Center in New York City to study stroke outpatient management. Dr. Chang, also a psychologist interested in the relationship between emergency department crowding and post-traumatic stress disorder among stroke and acute coronary syndrome patients, said research suggests that being exposed for an extended period of time to “the chaotic, loud environment of a typical emergency department can produce PTSD in a significant percentage of these patients. We are looking for ways to reduce the exposure to that type of environment in order to improve psychiatric outcomes.”
Using a literature review they published last year pointing to the safety of managing this stroke population as outpatients (J Emerg Med. 2018;54:636; http://bit.ly/2mqIqu3), the Columbia group developed a 24-hour rapid follow-up clinic jointly managed by emergency medicine and neurology. Dr. Chang said RAVEN (Rapid Access Vascular Evaluation-Neurology) is among the first outpatient, integrated, rapid-access stroke clinics in the United States.
After an evaluation by an emergency physician and a neurology resident, patients are screened into the RAVEN clinic based on criteria including a score of 5 or less on the NIH stroke scale, a head CT with no evidence of hemorrhage, no ED treatment with thrombolysis, no fluctuating symptoms or recurrent symptoms within the past month, an ECG showing no new-onset atrial fibrillation or cardiac ischemia, and the ability to follow up within 24 hours. (Ann Emerg Med. 2019 Jul 17. doi: 10.1016/j.annemergmed.2019.05.025 [Epub ahead of print]; complete criteria can be found in the article.)
Patients who qualify are seen at the RAVEN clinic within 24 hours of ED discharge to be evaluated by a vascular neurologist and receive same-day, outpatient vascular imaging with carotid duplex and transcranial Doppler. Patients are also referred for magnetic resonance imaging, an echocardiogram, and outpatient Holter monitoring at the discretion of the neurologist. Blood pressure, antithrombotic, and statin medications are optimized as indicated, and patients receive counseling on lifestyle modifications, including smoking cessation and risk-factor control.
“We tried to be conservative in how we stratified our population,” Dr. Chang said. “We would ultimately hope that patients with TIA or minor stroke could be risk-stratified by an emergency physician and not require a neurology consult, but we wanted to put the training wheels on. Similarly, some evidence suggests that the follow-up consultation does not need to be within 24 hours, but again, we wanted to be cautious for our first iteration.”
The researchers screened 253 patients for RAVEN discharge between December 2016 and June 2018, with 162 individuals enrolled. Seventeen of those were lost to follow-up (10.5%) at 90 days, leaving 145. Twenty-eight of those (19.3%) presented to an ED again or were admitted to the hospital within 90 days; six (3.7%) had recurrent TIA symptoms; and one (0.7%) had a recurrent stroke. Two individuals (1.4%) died, one of metastatic cancer and the other of respiratory failure and congestive heart failure.
Nine of the remaining 19 readmissions were for cardiac reasons (syncope, heart failure exacerbation, hypertension, and elective valve repair), seven for potential neurologic complaints (lip tingling, dizziness, and vertigo), all of whom were evaluated and discharged from the ED without admission; and three for miscellaneous complaints (chemotherapy, urologic condition, and alcohol intoxication). None of the readmissions was judged to be preventable according to missed secondary prevention treatment or related to the index transient ischemic attack and minor stroke score.
“We think these outcomes are very encouraging so far in terms of safety,” Dr. Chang said. “Our initial and 90-day safety outcomes were similar to those of several large published trials involving similar populations of patients.” He noted that the POINT trial (platelet-oriented inhibition in new TIA and minor ischemic stroke), which studied more than 4500 patients with TIA and minor stroke, had percentages of stroke recurrence (6.3%) and 90-day death from any cause (0.5%) in its control arm similar to or higher than the RAVEN outcomes. (Int J Stroke. 2013 Aug;8(6):479; http://bit.ly/2kUAPmS.)
Concerns about Safety
But Benton Hunter, MD, an associate professor of clinical emergency medicine at Indiana University School of Medicine, questioned the outcomes of the study and the need for the RAVEN model in an opinion article for NEJM Journal Watch. (July 26, 2019; http://bit.ly/2mqaL3C [subscription required].)
“Their 90-day outcomes were not terrible, but they weren't so pristine that it screams that this is clearly safe either,” he said. “It's difficult to say much about safety without a comparison group. Also, if you have 17 patients lost to follow-up from an initial cohort of 160, if even a few of those patients didn't do well, that could easily bump the recurrent stroke or TIA rate up to a range more like seven to eight percent, where people would say that doesn't look safe. When you combine an event rate that most people would say is acceptable but not exceptional, and 10 percent are lost to follow-up, that prompts concerns about safety.”
The RAVEN model, he said, also seems primarily suited for academic centers. “These are the types of centers where you can typically get same-day advanced imaging anyway. If the patient is already seeing a neurologist in the ED and getting a head CT, why not do the CT angiogram and MRI that same day and potentially discharge the patient within 24 hours in most cases, without having to set up an entirely new clinic? I'm not convinced I see the need for this type of model.”
Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.