A rapid outpatient strategy is safe and feasible for management of transient ischemic attack (TIA) and minor stroke evaluated in the emergency department. This strategy has the potential to improve ED throughput, reduce inpatient hospitalizations, and lead to reductions in secondary hospital-associated adverse outcomes and health care–associated costs, according to study results published in Annals of Emergency Medicine.
The American College of Emergency Physicians and the American Heart Association/American Stroke Association recommend rapid diagnostic evaluation of patients with TIA and minor stroke to initiate secondary stroke prevention and identify those who may need rapid intervention. While the majority of patients with TIA or minor stroke evaluated in the emergency departments in the United States are admitted, some studies report that expedited outpatient evaluation can be safe and cost-effective.
Researchers created the first outpatient integrated treatment strategy for the management of TIA and minor stroke, called the Rapid Access Vascular Evaluation–Neurology (RAVEN), intended to offer a safe alternative management strategy to inpatient admission. The study describes the feasibility and safety of this treatment strategy, including diagnosis and care at initial evaluation and 90-day outcomes.
From December 2016 through June 2018, patients treated in the emergency department who had a possible nondisabling TIA or minor stroke were screened for potential RAVEN discharge from the emergency department. All relevant cases were evaluated at the RAVEN clinic within 24 hours by a vascular neurologist, and outpatient vascular imaging with carotid duplex and transcranial Doppler imaging were conducted that same day, in addition to referral for magnetic resonance imaging.
Researchers recorded the rate of participant follow-up to the RAVEN clinic, along with adverse events, including 90-day recurrent TIA or stroke, death, or revisit to the hospital.
Of the 253 patients screened for possible RAVEN discharge, 162 were enrolled for discharge to the RAVEN clinic. Most patients (154, 95.1%) appeared as scheduled and were followed in the RAVEN clinic the next day. Of the 154 individuals who followed up in the RAVEN clinic, 101 (66%) were found to have a final diagnosis of TIA (42 patients) or minor stroke (59 patients).
Among patients treated in the RAVEN clinic, 2 (1.3%) required hospitalization (one for worsening symptoms and one for intracranial arterial stenosis caused by zoster). Outcomes at day 90 were assessed for the 101 RAVEN patients with a final diagnosis of TIA or minor stroke. Of these, 18 patients (19.1%) were readmitted or returned to the emergency department, 6 patients (5.9%) had new TIA or stroke, and 9 patients (8.9%) were lost to follow-up. Noindividuals with TIA and minor stroke died, and none received thrombolytics or thrombectomy.
Limitations of this study, according to the researchers, included having a single-site cohort study at an institute with a comprehensive stroke center and retrospective chart review design. The potential adverse events that were not accounted for as a result of patients lost to follow-up and a lack of a comparator group may have further limited findings.
“Our study has demonstrated that a rapid outpatient follow-up strategy for the management of TIA and minor stroke may be a safe and feasible strategy in the acute care setting,” concluded the researchers. They also note that an integration of this strategy with modern platforms for patient care (eg, telemedicine) has the potential to provide a “comprehensive treatment program for transient ischemic attack and minor stroke, avoiding potential inpatient admissions and allowing greater access to specialized neurologic care in diverse clinical settings.”
Chang BP, Rostanski S, Willey J, et al. Safety and feasibility of a rapid outpatient management strategy for transient ischemic attack and minor stroke: The Rapid Access Vascular Evaluation-Neurology (RAVEN) approach (published online July 17, 2019). Ann Emerg Med. doi:10.1016/j.annemergmed.2019.05.025