Management of Transient Ischemic Attack (TIA)

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1
Management of Transient Ischemic Attack (TIA)
Initial Assessment / Triage
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Use National Institutes of Health (NIH) Stroke
Scale to assess patient for signs/ symptoms of
stroke.
Rapidly assess from initial time of symptom onset
(last know well time (LKW)) per patient and/or
family.
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ABCD Score for TIA.
Making the Diagnosis
Emergency Department
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If symptoms have resolved, consult Neurology for
TIA evaluation.
Call Stroke Level 1 only if symptoms are present
and LKW < 8 hours.
Call Stroke Level 2 for symptom onset between
8-12 hours from LKW.
Refer to NIH Stroke Scale.
o Document in all patients.
Inpatient
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Consult Stroke Team.
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Inpatient Admission
The decision to admit is at the discretion of the
Neurovascular attending. Patients who should be admitted
to inpatient floors include:
• Patients with > 1 symptomatic episode in a
24-hour period.
• Patients presenting with crescendo symptoms.
• New onset atrial fibrillation with TIA symptoms.
• Patients with TIA symptoms and > 70% stenosis
of a carotid artery.
Patient Care in CDU
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TIA Evaluation – For All Patients
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Imaging:
o Head CT- initial evaluation.
o MRI brain scan without contrast.
o MRA or CTA of brain and neck.
o Carotid Doppler if MRA and CTA are not
possible.
Glucose (HbA1c).
CBC with platelet count.
Electrolytes, BUN, creatinine.
PT / INR, aPTT.
Lipid profile.
LFT.
EKG.
Echocardiography.
Continuous cardiac monitoring.
Obtain repeat head CT scan or MRI brain scan for
patients with neurologic deterioration.
NOTE: If return of symptoms or clinical deterioration,
CALL STROKE ALERT IMMEDIATELY.
Determining Hospital Admission
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Antihypertensive medication:
o Withhold antihypertensive agents unless
SBP > 220 mmHg or DBP > 120 mmHg.
o When treatment is indicated, lower BP
cautiously.
o Aim for a 10-15% reduction in BP.
Provide continuous cardiac monitoring for at least
24-48 hours after TIA to detect possible cardiac
complications.
Treat hypoglycemia (< 70 mg /dL).
o See OSUWMC Diabetes: Hypoglycemia
Treatment in Non-Pregnant Adults
guideline.
Treat hyperglycemia (> 140 mg /dL).
General Interdisciplinary Care of the Patient
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Avoid use of indwelling catheters, if possible, to
reduce risk of UTI.
Complete NIH Stroke Scale every 4 hours or as
ordered.
Provide stroke education.
Provide tobacco cessation information.
Initiate early rehabilitation.
Discharge Planning
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Observation/CDU
It is reasonable to hospitalize patients with TIA in the
CDU, if they present within 72-hours of the event and
meet the following criteria:
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• ABCD score of > 3.
For Inpatient Management of TIA.
Consult Stroke Team.
Immediate Care of the Patient
Confirming the Diagnosis
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2
ABCD score of 0-2 and uncertainty that
diagnostic workup can be completed within 2 days
as an outpatient.
2
ABCD score of 0-2 and other evidence that
indicates the patient’s event was caused by focal
ischemia.
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Follow-up to be scheduled prior to discharge
with appointment made within 14 days of
discharge date, at the discretion of the
Neurovascular Stroke Attending.
Involve patient’s family/caregiver in assessment of
post discharge needs, decision making, and
treatment planning.
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Complete at discharge:
o Modified Rankin Scale.
o NIH Stroke Scale.
Multidisciplinary Focus
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Provide education for patient’s family/caregivers
about stroke (pathology, prevention,
signs/symptoms, and actions to take), follow-up
appointments/therapy, treatment plan, and how to
access community resources.
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Case Manager
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Consider availability of support services and
desires of the patient’s family/caregiver.
Provide information about discharge plans and
post-discharge management to primary care
physicians and community services.
Associated Order Sets
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ED: CDU/OBS TIA (transient ischemic attack)
[2359]
ED: Ischemic Stroke – Confirmed no TPA [2993]
ED: Ischemic Stroke – Confirmed (TPA) [2931]
ED: Stroke Alert [2265]
NV1: Admission Stroke – no TPA [2240]
NV1: Admission Stroke – with TPA [2148]
NV1: Stroke Bundle with and without TPA [4389]
References
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Adams, RJ, et al. (2008). Update to the AHA/ASA
Recommendations for the Prevention of Stroke in
Patients with Stroke and Transient Ischemic
Attack. Stroke, 39(5):1647-52.
Easton, JD, et al. (2009). Definition and
Evaluation of Transient Ischemic Attack: A
Scientific Statement for Healthcare Professionals
from the American Heart Association/American
Stroke Association; Council on Cardiovascular
Surgery and Anesthesia; Stroke, 40: 2276-2293.
Furie, KL, et al. (2011). American Heart
Association/ American Stroke Association
Guideline. Guidelines for the Prevention of Stroke
in Patients with Stroke or Transient Ischemic
Attack (TIA). Stroke, 42: 227-276.
James PA, et al. (2014). Evidence-Based
Guideline for the Management of High Blood
Pressure in Adults: Report from the Panel
Members Appointed to the Eighth Joint National
Committee (JNC 8). JAMA, 311(5):507-520.
Jaunch, EC, et al. (2013). Guidelines for the Early
Management of Patients with Acute Ischemic
Stroke: A Guideline for Healthcare Professionals
from the American Heart Association/American
Stroke Association. Stroke, 44: 870-947.
Stone NJ, et al. (2013). 2013 ACC/AHA Guideline
on the Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults: A
Report of the American College of
Cardiology/American Heart Association Task
Force on Practice Guidelines. Circulation. doi:
10.1161/01.cir.0000437738.63853.7a
Summers, D, et al. (2009). Comprehensive
Overview of Nursing and Interdisciplinary Care of
the Acute Ischemic Stroke Patient: A Scientific
Statement from the American Heart Association.
Stroke, 40; 2911-2944.
Wintermark M, et al. (2013). Imaging
Recommendations for Acute Stroke and
Transient Ischemic Attack Patients: A Joint
Statement by the American Society of
Neuroradiology, the American College of
Radiology and the Society of
NeuroInterventional Surgery. J Am Coll Radiol,
10: 828-832.
Inpatient Quality Measures
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Venous thromboembolism (VTE) prophylaxis
Discharged on antithrombotic therapy
Anticoagulation therapy for atrial fibrillation/ flutter
Antithrombotic therapy by end of hospital day 2
Dysphagia screening
Stroke education
Tobacco cessation information
Assessed for rehabilitation
Guideline Authors
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Noah Grose, RN, BSN, ACNP-BC
Andrew King, MD
Ciaran Powers, MD, PhD
Jennifer Severing, PharmD, BCPS
Michelle Graf, PT
Kelsey Kauffman, PharmD
Sarah Adriance, PharmD, BCPS
Xuan Nguyen, MD, PhD
Peg Baylin, PharmD
Sharon Hammond-Heaton MA, BSN, RN, EMT-P
Andrew Slivka, MD
Guideline Approved
August 31, 2016. Second Edition.
Disclaimer: Clinical practice guidelines and algorithms at The
Ohio State University Wexner Medical Center (OSUWMC) are
standards that are intended to provide general guidance to
clinicians. Patient choice and clinician judgment must remain
central to the selection of diagnostic tests and therapy.
OSUWMC’s guidelines and algorithms are reviewed periodically
for consistency with new evidence; however, new developments
may not be represented.
Copyright © 2016. The Ohio State University Wexner Medical
Center. All rights reserved. No part of this document may be
reproduced, displayed, modified, or distributed in any form
without the express written permission of The Ohio State
University Wexner Medical Center.
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Table 1: Management of Risk Factors Associated with Stroke or TIA
Hypertension
• Individualize BP targets and drug therapy.
• If appropriate, consider:
o Benefit has been associated with average reduction of 10/5 mmHg.
o Normal BP levels have been defined as:
 ≤ 60 years of age: 140/90mmHg.
 > 60 years of age: < 150/90mmHg.
o Drug regimen of diuretics or the combination of diuretics and an ACEI.
Diabetes
• Hemoglobin A1c goal no higher than 7%.
• Glucose control near-normoglycemic levels.
Hypercholesterolemia
• High- or moderate- intensity statin therapy should be initiated on all patients regardless of
LDL (in the absence of contraindications).
Note: See ACC/AHA guideline for recommendations on the treatment of blood cholesterol to
reduce atherosclerotic cardiovascular risk.
Tobacco
• Advise patients who have smoked in the last year to discontinue cigarette smoking.
• Consider tobacco cessation information.
Alcohol Consumption
• Advise heavy drinkers to eliminate or reduce consumption of alcohol.
• Light to moderate levels of no ≤ 2 drinks for men and ≤ 1 drink per day for non-pregnant
women acceptable.
Obesity
• BMI goal of 18.5 to 24.9 kg/m .
• Waist circumference of < 35 in. for women and < 40 in. for men.
Physical Activity
• Advise at least 30 min. of moderate-intensity physical activity most days.
• Advise supervised therapeutic exercise regimen for those with disability after stroke.
2
Table 2: Noncardioembolic Stroke or TIA
Noncardioembolic
Stroke or TIA
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Acceptable options for initial therapy:
o Aspirin and extended-release dipyridamole (Aggrenox®).
 May be more effective than aspirin alone.
o Aspirin 81-325 mg daily
o Clopidogrel (Plavix®) 75 mg daily.
 Consider in patients with aspirin allergy.
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Table 3: Treatment Recommendations for Patients with Stoke Caused by Large Artery
Atherosclerosis
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Carotid Endarterectomy (CEA)
o Recommended for patients with recent TIA or ischemic stroke within the last 6
months and severe stenosis (70% to 99%) and perioperative morbidity and mortality
of < 6%.
o Consider for moderate stenosis (50% to 69%), depending on risk factors and
symptoms; not recommended for < 50% stenosis.
o When CEA is indicated, surgery within 2 weeks of TIA or stroke is suggested rather
than delaying surgery.
o Measure carotid stenosis using North American Symptomatic Carotid
Endarterectomy Trial (NASCET) criteria.
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Carotid Artery Balloon Angioplasty and Stenting (CAS)
o Consider in patients with severe stenosis, and CEA contraindicated and periprocedural morbidity and mortality 4-6%.
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Extracranial-Intracranial (EC/IC) Bypass Surgery
o Not routinely recommended.
Intracranial Arterial
Disease
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Endovascular Treatment
o Recommendation limited to lesion refractory to medical therapy.
Extracranial
Vertebrobasilar
Disease
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Endovascular Treatment
o Consider endovascular treatment when symptoms persist despite medical
therapies.
Extracranial Carotid
Disease
Table 4: Treatment Recommendations for Patients with Cardioembolic Stroke
Note: TIA or ischemic stroke patients with cardiac disease are generally treated with anticoagulant drugs.
Atrial Fibrillation
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Alternatives to warfarin in patients with nonvalvular AFib include:
o Dabigatran (Pradaxa®)*150mg Q12H
o Rivaroxaban (Xarelto®)* 20mg Q24H
o Apixiban (Eliquis®)* 5mg Q12H
o Edoxaban (Lixiana®)* 60mg Q24H
 Not part of OSUW MC formulary.
Warfarin.
o Target INR: 2.5 (range 2-3)
Aspirin 325 mg/day if unable to take oral anticoagulants.
*Note: Dosing may require adjustment for renal dysfunction.
Acute MI and Left
Ventricular Thrombus
• Oral anticoagulation (target INR 2-3) for 3-12 months and enteric-coated aspirin up to
162 mg/day.
Dilated
Cardiomyopathy
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Warfarin (target INR: 2-3) or antiplatelet therapy.
Valvular Heart
Disease
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Rheumatic Mitral Valve Disease
o Warfarin.
 Target INR: 2.5 (range 2-3).
o Add aspirin 81 mg per day if recurrent embolism on warfarin.
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Mitral Valve Prolapse (MVP)
o Long-term antiplatelet therapy.
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Mitral Annular Calcification (MAC)
o Antiplatelet or warfarin therapy may be considered for mitral regurgitation resulting
with MAC without atrial fibrillation.
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Aortic Valve Disease
o Antiplatelet therapy without atrial fibrillation.
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Prosthetic Heart Valves
o See Anticoagulation Recommendations Post-Valve Replacement.
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