TWO ACES: Transient Ischemic Attack Work-Up as Outpatient Assessment of Clinical Evaluation and Safety

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Background and Purpose—To evaluate a novel emergency department-based TIA triage system.Methods—We developed an approach to TIA triage and management based on risk assessment using the ABCD2 score in combination with early cervical and intracranial vessel imaging. It was anticipated that this triage system would avoid hospitalization for the majority of TIA patients and result in a low rate of recurrent stroke. We hypothesized that the subsequent stroke rate among consecutively encountered patients managed with this approach would be lower than predicted based on their ABCD2 scores.Results—From June 2007 to December 2009, 224 consecutive patients evaluated in the Stanford emergency department for a possible TIA were enrolled in the study. One hundred fifty-seven were discharged to complete their evaluation at the outpatient TIA clinic; 67 patients were hospitalized. One hundred sixteen patients had a final diagnosis of TIA/minor stroke or possible TIA. The stroke rates at 7, 30, and 90 days were 0.6% (0.1%–3.5%) for patients referred to the TIA clinic and 1.5% (0.3%–8.0%) for the hospitalized patients. Combining both groups, the overall stroke rate was 0.9% (0.3%–3.2%), which is significantly less than expected based on ABCD2 scores (P=0.034 at 7 days and P=0.001 at 90 days).Conclusions—This emergency department-based inpatient versus outpatient TIA triage system led to a low rate of hospitalization (30%). Recurrent stroke rates were low for both the hospitalized and outpatient subgroups.

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