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Outpatient management of new TIA or minor stroke could be improved

About 750,000 Americans have strokes each year, and many die or are disabled as a result. Patients who have suffered a recent transient ischemic attack (TIA or mini stroke) are at highest risk of stroke soon after the TIA. Thus, even in those not admitted to a hospital, a rapid and complete diagnostic evaluation is warranted.

Yet in a recent study, one-third (32 percent) of patients with a first TIA or stroke initially evaluated in the office by their primary care physician (PCP) were not hospitalized and had no further diagnostic evaluations over the next 30 days. The study was carried out by the Stroke Prevention Patient Outcomes Research Team (PORT) and supported by the Agency for Healthcare Research and Quality (PORT contract 290-91-0028). In fact, diagnostic studies necessary for rational therapeutic decisions, for example, brain imaging and vascular imaging, frequently were not performed.

Some PCPs also appeared to underuse anticoagulants to prevent stroke in patients who had atrial fibrillation and additional cardioembolic risk factors, notes PORT principal investigator David B. Matchar, M.D., of Duke University. The researchers retrospectively audited medical records from 27 primary care practices of 95 patients with a first-ever TIA and 81 patients with a first stroke.

Only 6 percent of these patients were admitted to a hospital for further diagnostic testing and management on the day of their initial office evaluation (2 percent of TIA patients and 10 percent of stroke patients). An additional 3 percent of patients were admitted to a hospital during the subsequent 30 days. PCPs ordered a brain computerized tomography scan or magnetic resonance imaging on the day of the initial visit in only 30 percent of patients (23 percent TIA, 37 percent stroke), regardless of whether the patient was referred to a specialist. They obtained carotid ultrasound studies in 28 percent, electrocardiograms in 19 percent, and echocardiograms in 16 percent of patients. Fewer than half of patients with a prior history of atrial fibrillation were anticoagulated. Larry B. Goldstein, M.D., the study's lead author, cautions that the patients in this study represent a biased sample of stroke patients, many of whom were evaluated primarily in hospital settings, and the data used for the study were limited to those documented in the patients' records.

See "New transient ischemic attack and stroke: Outpatient management by primary care physicians," by Dr. Goldstein, John Bian, M.S., Gregory P. Samsa, Ph.D., and others, in the October 23, 2000 Archives of Internal Medicine 160, pp. 2941-2946.

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