Accuracy of telephone triage in patients suspected of transient ischaemic attack or stroke: a cross-sectional study.

BACKGROUND: The Netherlands Triage Standard (NTS) is a widely used decision support tool for telephone triage at Dutch out-of-hours primary care services (OHS-PC), which, however, has never been validated against clinical outcomes. We aimed to determine the accuracy of the NTS urgency allocation for patients with neurological symptoms suggestive of a transient ischaemic attack (TIA) or stroke, with the clinical outcomes TIA, stroke, and other (neurologic) life-threatening events (LTEs) as the reference. METHOD: A cross-sectional study of telephone triage recordings of patients with neurological symptoms calling the OHS-PC between 2014 and 2016.The allocated NTS urgencies were derived from the electronic medical records of the OHS-PC. The clinical outcomes were retrieved from the electronic medical records of the patients' own general practitioners. The accuracy of a high NTS urgency allocation (medical help within 3 h) was calculated in terms of sensitivity, specificity, positive and negative predictive values (PPV and NPV) with the clinical outcomes TIA/stroke/other LTEs as the reference. RESULTS: Of 1269 patients, 635 (50.0%) received the diagnosis TIA/stroke (34.2% TIA/minor stroke, 15.8% major ischaemic or haemorrhagic stroke), and 4.8% other LTEs. For TIA/stroke/other LTEs, the sensitivity and specificity of the NTS urgency allocation were 0.72 (95%CI 0.68-0.75) and 0.48 (95%CI 0.43-0.52), and the PPV and NPV were 0.62 (95%CI 0.60-0.64) and 0.58 (95%CI 0.54-0.62). CONCLUSIONS: The NTS decision support tool used in Dutch OHS-PC performed poor to moderately regarding safety (sensitivity) and efficiency (specificity) in allocating adequate urgencies to patients with and without TIA/stroke/other LTEs. TRIAL REGISTRATION: The Netherlands National Trial Register, identification number NTR7331 /Trial NL7134 .

Diagnostic Accuracy of the Explicit Diagnostic Criteria for Transient Ischemic Attack: A Validation Study.

Background and Purpose- The clinical diagnosis of a transient ischemic attack (TIA) can be difficult. Evidence-based criteria hardly exist. We evaluated if the recently proposed Explicit Diagnostic Criteria for TIA (EDCT), an easy to perform clinical tool focusing on type, duration, and mode of onset of clinical features, would facilitate the clinical diagnosis of TIA. Methods- We used data from patients suspected of a TIA by a general practitioner and referred to a TIA service in the region of Utrecht, the Netherlands, who participated in the MIND-TIA (Markers in the Diagnosis of TIA) study. Information about the clinical features was collected with a standardized questionnaire within 72 hours after onset. A panel of 3 experienced neurologists ultimately determined the definite diagnosis based on all available diagnostic information including a 6-month follow-up period. Two researchers scored the EDCT. Sensitivity, specificity, and predictive values of the EDCT were assessed using the panel diagnosis as reference. A secondary analysis was performed with modified subcriteria of the EDCT. Results- Of the 206 patients, 126 (61%) had a TIA (n=104) or minor stroke (n=22), and 80 (39%) an alternative diagnosis. Most common alternative diagnoses were migraine with aura (n=24; 30.0%), stress related or somatoform symptoms (n=16; 20.0%), and syncope (n=9; 11.3%). The original EDCT had a sensitivity of 98.4% (95% CI, 94.4-99.8) and a specificity of 61.3% (49.7-71.9). Negative and positive predictive values were 96.1% (86.0-99.0) and 80.0% (75.2-84.1), respectively. The modified EDCT showed a higher specificity of 73.8% (62.7-83.0) with the same sensitivity and a similar negative predictive value of 96.7%, but a higher positive predictive value of 85.5% (80.3-89.5). Conclusions- The EDCT has excellent sensitivity and negative predictive value and could be a valuable diagnostic tool for the diagnosis of TIA.

Candidate Biomarkers for the Diagnosis of Transient Ischemic Attack: A Systematic Review.

BACKGROUND AND PURPOSE: A rapid serum biomarker that confirms or rules out a transient ischemic attack (TIA) would be of great value in clinical practice. We aimed to systematically review current evidence for the diagnostic accuracy of blood biomarkers in the early diagnosis of TIA. METHODS: This is a systematic review with quality appraisal of individual studies using the QUADAS-2 tool. MEDLINE and EMBASE databases were searched up to May 1, 2017, to select primary diagnostic accuracy studies evaluating potential biomarkers in blood for the diagnosis of TIA or ischemic stroke. RESULTS: Of 4,215 studies retrieved, 78 met our eligibility criteria. Forty-five studies restricted their population to ischemic stroke patients, 32 included both TIA and ischemic stroke patients, and only one study was restricted to TIA patients. In total 62/78 (79.5%) studies had a case-control design comparing TIA or stroke patients with healthy subjects. Overall, 125 single biomarkers and 5 biomarker panels were studied, with a median number of participants per study of 92.0 (interquartile range 44.8-144.5), varying from 8 to 915. Sufficient information to extract 2 × 2 tables was available for 35 (44.9%) articles, and for 60 (48.0 %) biomarkers. Several markers, such as NR2A/B (antibodies), Parkinson 7, nucleoside diphosphate kinase A, ubiquitin fusion degradation protein-1, and heart-type fatty acid binding protein, have shown moderate to high diagnostic accuracy in multiple studies. CONCLUSIONS: Although the methodological quality of studies evaluating biomarkers of brain ischemia was poor, several biomarkers have shown the potential to detect transient brain ischemia in an early phase. Diagnostic accuracy studies in suspected cases of TIA are needed to determine their true clinical value.

Determinants of Patient Delay in Transient Ischemic Attack.

INTRODUCTION: Early diagnosis and stroke preventive treatment in patients with transient ischemic attack (TIA) are crucial, but hampered by delayed reporting of symptoms. Previous studies on causes of patient delay provided inconsistent results. We aimed to assess determinants of patient delay among patients with symptoms suggestive of TIA. METHODS: We interviewed participants referred by their general practitioner to an outpatient TIA clinic within 72 h from symptom onset. We determined (i) the exact time from symptom onset to the first contact with a medical service (patient delay); (ii) demographic and clinical characteristics; (iii) patient's initial perception, and reaction to symptoms; and (iv) patient's knowledge about TIA. We used multivariable linear regression to identify determinants of patient delay. RESULTS: We interviewed 202 suspected TIA patients (mean age 67.7 (SD 13.7) years, 111 (55.0%) male), of whom 123 (60.9%) received a definite diagnosis of TIA or minor stroke. Median patient delay was 1.5 (interquartile range 0.4-14.6) hours. Of all patients, 119 (58.9%) considered a TIA (or stroke) as the cause of their symptoms. Among them, 30 (25.2%) thought it was a medical emergency, while of the 83 not considering TIA as the cause of symptoms 38 (45.8%) thought of a medical emergency. Independently related to increased delay were (i) symptom onset out of hours, (ii) absence of dysarthria, (iii) being unaware that TIA requires urgent treatment, (iv) not considering the event an emergency, and (v) knowledge of TIA symptoms. Results for patients with a definite diagnosis of TIA/minor stroke were similar to those with alternative diagnoses. CONCLUSION: Patients still tend to wait till office hours to report TIA symptoms. Speech difficulties, and specifically dysarthria, are related to shorter delay. To reduce patient delay, awareness of TIA symptoms should increase and more importantly lay people should be educated to consider a TIA an emergency.

Delay in patients suspected of transient ischaemic attack: a cross-sectional study.

OBJECTIVES: Suspected transient ischaemic attack (TIA) necessitates an urgent neurological consultation and a rapid start of antiplatelet therapy to reduce the risk of early ischaemic stroke following a TIA. Guidelines for general practitioners (GPs) emphasise the urgency to install preventive treatment as soon as possible. We aimed to give a contemporary overview of both patient and physician delay. METHODS: A survey at two rapid-access TIA outpatient clinics in Utrecht, the Netherlands. All patients suspected of TIA were interviewed to assess time delay to diagnosis and treatment, including the time from symptom onset to (1) the first contact with a medical service (patient delay), (2) consultation of the GP and (3) assessment at the TIA outpatient clinic. We used the diagnosis of the consulting neurologist as reference. RESULTS: Of 93 included patients, 43 (46.2%) received a definite, 13 (14.0%) a probable, 11 (11.8%) a possible and 26 (28.0%) no diagnosis of TIA. The median time from symptom onset to the visit to the TIA service was 114.5 (IQR 44.0-316.6) hours. Median patient delay was 17.5 (IQR 0.8-66.4) hours, with a delay of more than 24 hours in 36 (38.7%) patients. The GP was first contacted in 76 (81.7%) patients, and median time from first contact with the GP practice to the actual GP consultation was 2.8 (0.5-18.5) hours. Median time from GP consultation to TIA service visit was 40.8 (IQR 23.1-140.7) hours. Of the 62 patients naïve to antithrombotic medication who consulted their GP, 27 (43.5%) received antiplatelet therapy. CONCLUSIONS: There is substantial patient and physician delay in the process of getting a confirmed TIA diagnosis, resulting in suboptimal prevention of an early ischaemic stroke.

Patient delay in TIA: a systematic review.

BACKGROUND: Patients who suffer a transient ischemic attack (TIA) have a high short-term risk of developing ischemic stroke, notably within the first 48 h. Timely diagnosis and urgent preventive treatment substantially reduce this risk. We conducted a systemic review to quantify patient delay in patients with (suspected) TIA, and assess determinants related to such delay. METHODS: A systematic review using MEDLINE and EMBASE databases up to March 2017 to identify studies reporting the time from onset of TIA symptoms to seeking medical help. RESULTS: We identified nine studies providing data on patient delay, published between 2006 and 2016, with 7/9 studies originating from the United Kingdom (UK). In total 1103 time-defined TIA patients (no remaining symptoms > 24 h), and 896 patients with a minor stroke (i.e., mild remaining symptoms > 24 h) were included (49.1% men, mean age 72.2 years). Patient's delay of more than 24 h was reported in 33.1-44.4% of TIA patients, with comparable proportions for minor stroke patients. Delays were on average shorter in patients interviewed at the emergency department than among patients seen at TIA outpatient clinics. Univariably associated with a shorter delay were (1) a longer duration of symptoms, (2) motor symptoms, (3) a higher ABCD2 score, and (4) correct patient's recognition as possible ischemic cerebrovascular event. CONCLUSIONS: More than a third of patients experiencing a TIA delays medical attention for more than a day, thus critically extending the initiation of stroke preventive treatment. There still seems to be insufficient awareness among lay people that symptoms suggestive of TIA should be considered as an emergency. Additional data and multivariable analyses are needed to define main determinants of patient delay.

Serum biomarkers for the early diagnosis of TIA: The MIND-TIA study protocol.

BACKGROUND: A Transient Ischaemic Attack (TIA) bears a high risk of a subsequent ischaemic stroke. Adequate diagnosis of a TIA should be followed immediately by the start of appropriate preventive therapy, including antiplatelets. The diagnosis of a TIA based on symptoms and signs only is notoriously difficult and biomarkers of brain ischaemia might improve the recognition, and target management and prognosis of TIA patients. Our aim is to quantify the added diagnostic value of serum biomarkers of brain ischaemia in patients suspected of TIA. STUDY DESIGN: a cross-sectional diagnostic accuracy study with an additional six month follow-up period. STUDY POPULATION: 350 patients suspected of TIA in the primary care setting. Patients suspected of a TIA will be recruited by at least 200 general practitioners (GPs) in the catchment area of seven TIA outpatient clinics willing to participate in the study. In all patients a blood sample will be drawn as soon as possible after the patient has contacted the GP, but at least within 72 h after onset of symptoms. Participants will be referred by the GP to the regional TIA outpatient clinic for additional investigations, including brain imaging. The 'definite' diagnosis (reference standard) will be made by a panel consisting of three experienced neurologists who will use all available diagnostic information and the clinical information obtained during the outpatient clinic assessment, and a six month follow-up period. The diagnostic accuracy, and value in addition to signs and symptoms of candidate serum biomarkers will be assessed in terms of discrimination with C statistics, and calibration with plots. We aim to include 350 suspected cases, with 250 patients with indeed definite TIA (or minor stroke) according to the panel. DISCUSSION: We hope to find novel biomarkers that will enable a rapid and accurate diagnosis of TIA. This would largely improve the management and prognosis of such patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01954329.