Patients at high risk for having a stroke are being undertreated in Ontario

Patients who have suffered a common warning sign of an impending stroke, called a transient ischemic attack (TIA), are not receiving the care they need to reduce their risk of actually having a stroke, a new study from the Institute for Clinical Evaluative Sciences (ICES) has found.

Researchers examined the management and outcomes of 371 TIA patients who came to the emergency department (ED) of four regional hospital stroke centers throughout Ontario in 2000.

Results:

• Three-quarters of TIA patients were discharged from the ED.
• One in 20 TIA patients discharged from the ED had a stroke within 30 days. There was a 9% risk of stroke or death within 30 days for patients with a TIA involving a speech disturbance, and a 12% risk of stroke or death within 30 days for TIAs involving a motor deficit. Half of the strokes occurred within the first 2 days after the warning TIA.
• Diagnostic investigations were underutilized: within 30 days, only 58% of TIA patients had obtained a computed tomography (CT) brain scan, and less than half had received carotid Doppler ultrasound studies.
• Over one-third of TIA patients were not given prescriptions for antithrombotic stroke prevention medication at discharge.
• TIA patients were also less likely than stroke patients to have in-hospital consultations with a specialist.

Implications:

“These findings confirm that patients who are diagnosed with a TIA, or ‘mini-stroke’, have a high immediate and short-term risk of stroke,” said lead author and ICES research fellow Dr. David Gladstone. “Our results highlight the need to approach TIAs with the same sense of urgency and seriousness as we do for patients with stroke.”

“Patients must be aware of the symptoms of a TIA – such as sudden paralysis, sudden loss of speech, or sudden loss of vision – and the need to seek medical attention immediately, even if the symptoms are brief and clear completely.”

After a TIA, diagnostic tests such as brain scans and blood flow studies are important to determine the underlying cause of the symptoms and to get the patient the most appropriate preventative treatment. Dr. Gladstone points out that a large proportion of TIA patients do not receive the recommended diagnostic investigations in a timely fashion on an outpatient basis, and “while effective stroke prevention treatments exist, they are being underutilized.”

However, Dr. Gladstone and his fellow co-authors note that important measures are being taken to optimize stroke care throughout the province, such as the Ontario Co-ordinated Stroke Strategy, which has been establishing stroke prevention clinics and regional stroke centres to improve the situation, as well as public education initiatives, by the Heart and Stroke Foundation of Ontario.

"We are so pleased that, as part of the Ontario Co-ordinated Stroke Strategy, there are secondary prevention clinics that can do a more adequate job on following up on TIAs," says Mary Lewis, Heart and Stroke Foundation of Ontario. "These clinics are just one of the important outcomes of our initiative to track this information in order to provide better care for stroke patients across the province."

The study, “Management and outcomes of transient ischemic attacks in Ontario”, is in the Mar. 30, 2004 issue of the Canadian Medical Association Journal (CMAJ).

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners and practitioners to make decisions about care delivery and to develop policy.

FOR FURTHER INFORMATION, PLEASE CONTACT:

• Julie Argles
• Media Relations Officer, ICES
• (416) 480-4055 ext. 3602 or cell (416) 432-8143