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How to run a TIA Clinic

How to run a TIA Clinic. Inter-Professional Learning Seminar 30 th November 2005. Dr Pauline Morrow. Associate Specialist in Medicine for the Elderly Delancey Hospital. Incidence of stroke and TIA. 125,000 strokes / year in UK For East Gloucestershire population of 245,0000 expect:

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How to run a TIA Clinic

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  1. How to run a TIA Clinic Inter-Professional Learning Seminar 30th November 2005

  2. Dr Pauline Morrow Associate Specialist in Medicine for the Elderly Delancey Hospital

  3. Incidence of stroke and TIA • 125,000 strokes / year in UK • For East Gloucestershire population of 245,0000 expect: • 588 strokes / year (33% secondary events) • 123 TIAs / year • For the average GP expect: • 2–5 strokes / year • 20-40 TIA and stroke survivors

  4. Secondary events after TIA • 44% have a major vascular event over the next 10 years (e.g. stroke, MI, vascular death). • At 3 months after a TIA: • 10.5% will have a stroke. • 2.6% will be hospitalised with other cardiovascular events. • 2.6% will have died.

  5. Myocardial infarction and stroke • A Cardiac infarction is a heart attack. • A Cerebral infarction is a brain attack. • TIAs and minor strokes are medical emergencies!

  6. Refer urgentlyRefer directly

  7. The TIA dream team (in clinic) • Physicians. • Vascular technologists. • Vascular surgeons. • Specialist nurse. • Receptionist. • Nursing auxiliary / clinic assistant. • Medical and surgical secretaries.

  8. Radiologists. Radiographers. Cardiac technicians. Phlebotomists. Pharmacists. Anaesthetists. Clinical Psychologists. The pain management team. General Practitioners. District Nurses. Practice counsellors. Health visitors. Social workers. The TIA dream team (the wider team)

  9. Purpose of TIA clinic • Rapid diagnosis • Rapid lifestyle advice • Rapid secondary prophylaxis • Rapid brain imaging • Rapid carotid artery imaging • Rapid surgical referral • Rapid surgical assessment • Rapid carotid endarterectomy

  10. Where and how…? • Weekly on Wednesday mornings. • Prestbury Clinic, CGH. • 1 hour consultation with Associate Specialist. • Carotid duplex scanning. • New consultation with vascular surgeon if indicated. • Blood tests, ECG, CXR. • (Lifestyle advice). • Initiation of medical treatment.

  11. Current limitations to service • Only a single doctor available. • No specialist nurse. • No nursing auxiliary. • Numbers seen therefore limited. • Many patients necessarily diverted to alternative clinics. • duplex scanning on a different day. • delayed access to surgical opinion.

  12. Where actually seen

  13. Then what? • CT brain scan if indicated. • Carotid surgery if indicated. • Echocardiogram if indicated. • Ongoing treatment of risk factors. • Reinforcement of lifestyle advice. • Entry to community and hospital stroke registers. • Review currently in Stroke Clinic at 3 months (but delegate to primary care in future?). • ???Possibility of nurse led service in future.

  14. Purpose 1: Diagnosis Is this a TIA or something else?

  15. Symptoms likely to be TIA (1) • Carotid Distribution • Unilateral motor / sensory defects • Dysphasia • Amaurosis fugax • Homonymous hemianopia • Combinations of the above

  16. Symptoms likely to be TIA (2) • Vertebrobasilar Distribution • Motor or sensory deficits affecting any combination of limbs • Ataxia • Homonymous hemianopia • Bilateral visual loss • The following in combination with the above or each other but NOT in isolation • Vertigo, diplopia, dysphagia, dysarthria • Combinations of the above.

  17. Symptoms not acceptable as TIA (1) • Loss of consciousness • Falls • Confusion • Generalised weakness • Dizziness • Incontinence • Amnesia (including TGA)

  18. Symptoms not acceptable as TIA (2) • Any of the following in isolation: • Vertigo • Diplopia • Dysphagia • Dysarthria

  19. ABCD score for TIA Please tick if applicable: Age ≥ 60 □ (1) Systolic BP>140 and / or Diastolic BP ≥ 90 □(1) Unilateral weakness □(2) Speech disturbance without weakness □(1) Duration of symptoms: < 10 minutes □ (0) 10 – 59 minutes □ (1) ≥ 60 minute □ (2) Total ABCD score: The ABCD score assesses the one week risk of stroke after TIA. If score is 5 or 6 please telephone a consultant geriatrician to discuss urgent management.

  20. One or more of: (Tick) Dysphasia  Mono-ocular visual loss  Unilateral weakness  Unilateral sensory disturbance  Needs carotid duplex Fax to Dr Pauline Morrow (East Glos) on 08454 222092 or to Sr Mary Kandiah (West Glos) on 08454 228539. Hard copy to Dr Pauline Morrow, Delancey Hospital or Sr Mary Kandiah, ARU, GRH. Please start patient on Aspirin 300 mg daily or Clopidogrel 75 mg daily if sensitive to Aspirin.

  21. Fax to Dr Pauline Morrow (East Glos) on 08454 222092 or to Sr Mary Kandiah (West Glos) on 08454 228539. Hard copy to Dr Pauline Morrow, Delancey Hospital or Sr Mary Kandiah, ARU, GRH. Please start patient on Aspirin 300 mg daily or Clopidogrel 75 mg daily if sensitive to Aspirin. One or more of: (Tick) Bilateral simultaneous  visual loss. Bilateral simultaneous  weakness. Bilateral simultaneous  Sensory disturbance. Crossed sensory/motor  loss. Brain stem TIA Possible One or more of: (Tick) Dysarthria  Ataxia  Dysphagia  Diplopia  Vertigo  Two or more symptoms Posterior TIA possible

  22. Please remember…After a suspected TIA or stroke patients are not permitted to drive for at least one month.(DVLA At a glance guidelines on fitness to drive)

  23. One or more of: (Tick) Dysarthria  □ Ataxia □ Dysphagia □ Diplopia □ Vertigo □ Consider referral to Consultant Physician or Geriatrician, CGH, GRH or other hospital. Single symptom TIA unlikely

  24. One or more of: (Tick) Loss of consciousness □ Light-headedness / faintness / dizziness □ Total body weakness or fatigue □ Drop attacks □ Amnesia □ Consider referral to Syncope Clinic or Consultant Physician or Geriatrican, CGH, GRH or other hospital. NOT TIA

  25. Differential Diagnoses – London audit • Cerebrovascular diagnoses • Cerebral infarction 42% • Cerebral haemorrhage 3% • Subarachnoid haemorrhage <1% • Cerebral TIA 16% • Amaurosis fugax 4%

  26. Differential Diagnoses – London audit • Non-cerebrovascular diagnoses • Migraine 13% • Benign positional vertigo 5% • “Functional” symptoms 4% • Asymptomatic carotid stenosis 3% • Sickle cell disease 3% • Syncope / arrhythmia 2% • Epilepsy 2%

  27. Purpose 2: Rapid lifestyle advice What can the patient do to stop it happening again?

  28. Lifestyle advice • Ideal role for Stroke Specialist Nurse • Smoking cessation • Weight reduction • Salt reduction • Regular exercise • Moderation of alcohol intake.

  29. Purpose 3: Rapid secondary prophylaxis How can we stop this happening again?

  30. Dr Robert Welding Consultant General and Geriatric Medicine Cheltenham General Hospital

  31. Secondary prophylaxis • Antiplatelets • Antihypertensives • Statins • Anticoagulants for AF

  32. Antiplatelet therapy • For every 1000 TIA pts treated with aspirin: • 25 fewer strokes, 15 fewer deaths after 3 yrs • Aspirin 300mg for two weeks • Aspirin plus dipyridamole MR (more effective than either alone) • Aspirin 75mg • Clopidogrel (for those truly aspirin intolerant) • (do NOT use clopidogrel and aspirin together)

  33. Antihypertensives • Lowering BP even in normotensive pts reduces stroke risk, but not all cause mortality • Aim as low as possible as long as BP>115/75 • ACEI and thiazides better than b blockers

  34. Antihypertensives (BHS target: BP<140/85 if non-diabetic, <130/80 if diabetic) • Ramipril - HOPE • Perindopril plus indapamide - PROGRESS • Thiazide diuretics • Angiotensin-II receptor antagonists • Calcium channel blockers • (Betablockers) • (Alphablockers)

  35. Statins • Simvastatin most studied. • 40 mg at night reduced secondary vascular event rate by 25 – 30% (Heart Protection Study). • Evidence exists for patients aged below 80. • Effect takes 4 years. • Benefit regardless of “normal” cholesterol (provided > 3.5). • (No benefit in haemorrhagic stroke)

  36. Atrial Fibrillation NICE 2006 • Control rhythm if symptomatic AF, younger pts, CCF, lone AF, AF due to corrected precipitant • Otherwise rate control with b blockers, verapamil or diltiazem rather than digoxin

  37. Atrial FibrillationNICE 2006 • TIA pts are high risk group: Warfarin • Aspirin 300mg per day if cannot manage Warfarin • In AF 2.4 events per 100py if on warfarin • In AF 4.5 events per 100py if on aspirin • Risk similar for all types of AF

  38. Purpose 4: Rapid brain imaging Is this really a stroke and, if so, what type is it?

  39. Brain imaging • Required only for completed stroke. • (DWI MRI scan for recurrent TIAs?) • Recommended within 24 hours for inpatients. • Diagnostic window to distinguish infarct from bleed is 10 – 14 days. • Recommended pre-operatively for those to undergo carotid artery surgery to exclude stroke mimics. • The reality is a 6 week wait for outpatient CT scans.

  40. Purpose 5: Rapid carotid artery imaging Does this patient have significant carotid artery stenosis?

  41. Julia Minor Vascular Technologist Cheltenham General Hospital

  42. Purpose 6: Urgent surgical referral Is this patient’s carotid artery operable?

  43. Purpose 7: Rapid surgical opinion Is this patient likely to benefit from surgical intervention?

  44. Purpose 8: Rapid carotid endarterectory Can I intervene surgically to stop this patient having another stroke?

  45. How to run a TIA clinic Any questions…?

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