ACEP News - June 2008 - (Page 7)

JUNE 2008 • ACEP NEWS NEUROLOGY 7 New Score Determines Stroke Risk Soon After TIA BY GREG MUIRHEAD Else vier Global Medical Ne ws WA I K O L O A , H AWA I I — A new scoring system works well in assessing the 2day risk of stroke for a patient who has had a transient ischemic attack—but can it really determine which patients should be sent home? There’s been a need to be able to assess the risk of a stroke soon after a patient has a transient ischemic attack (TIA), because the risk may be quite high, explained Dr. Diane M. Birnbaumer, professor of medicine at the University of California, Los Angeles. One of the first efforts to address that need was a retrospective study that sought high-risk factors for the occurrence of a stroke after a TIA ( JAMA 2000;284:29016), Dr. Birnbaumer said at a symposium on emergency medicine sponsored by Stanford (Calif.) University. That study included 1,707 TIA patients enrolled in an HMO. The investigators found an overall risk of 10.5% for patients to have a stroke within 90 days of a TIA, but half of those strokes occurred within just 2 days. That meant 1 in 20 TIA patients was going to have a stroke within 48 hours. The researchers then tried to find the risk factors that would help identify that one patient who was likely to have a stroke in 2 days, Dr. Birnbaumer said. The factors they identified were age older than 60 years, diabetes, TIA symptoms lasting longer than 10 minutes, weakness, and speech impairment. The greater the number of factors found in a post-TIA patient, the greater that patient’s risk of having a stroke. Having all of the risk factors meant a one-in-three risk of having a stroke in 90 days; having none of these factors meant there was virtually no risk of stroke within 90 days. The problem with those findings, Dr. Birnbaumer said, was that “I don’t want to know the 90-day risk; I want to know the 2-day risk.” Also, the data were retrospectively tested, not prospectively validated. In a later study of 209 people, researchers used the high-risk criteria from the earlier study, modified them, and then set up a 6-point system called the “ABCD score” to better assess the risk for stroke (Lancet 2005;366:29-36). The ABCD score was determined by the following: Age. At least 60 years = 1 point. Blood pressure. Systolic BP greater than 140 and/or diastolic BP greater than or equal to 90 = 1 point. Clinical features. Unilateral weakness = 2 points; speech disturbance without weakness = 1 point; any other neurologic finding = 0 points. Duration of symptoms. At least 60 minutes = 2 points; 10-59 minutes = 1 point; less than 10 minutes = 0 points. “It’s actually a pretty easy scale to use,” Dr. Birnbaumer said, and the study’s investigators prospectively validated it with 375 new patients. Using the ABCD point system, the researchers determined the risk of stroke within 7 days after TIA. A score of 4 points was associated with a 1.1% risk. For 5 points, the risk was 12.1%; and for 6 points, the risk was 31.4%. A more recent study used a somewhat different point system called “ABCD2” to assess the 2-day risk of stroke, Dr. Birnbaumer said (Lancet 2007;369:283-92). The point system was validated in 4,809 patients, and the study included prospective and retrospective data. In the ABCD2 system, points were assigned as follows: Age. At least 60 years = 1 point. Blood pressure. Systolic BP greater than 140 and/or diastolic greater than 90 at presentation = 1 point. Clinical features. Unilateral weakness = 2 points; speech impairment only = 1 point. Duration of TIA symptoms. At least 60 minutes = 2 points; 10-59 minutes = 1 point. Diabetes. 1 point. The researchers found that the 21% of patients who had a score of 6-7 had an 8% risk of stroke within 2 days, explained Dr. Birnbaumer. The 45% of patients who had 4-5 points had a 4% risk of stroke in 2 days, and the 34% of patients with 0-3 points had a 1% risk of stroke in 2 days. Although the ABCD2 scoring system helps better identify patients at high risk of having a stroke very soon, Dr. Birnbaumer said she still saw a need for caution in the treatment of all TIA patients. “I’ll tell you the problem I have with this: Is a 1% risk low enough for you?” Dr. Birnbaumer asked. She added that her hospital admits all TIA patients. Dr. Birnbaumer said she had no relevant financial disclosures. ■ For acute, painful musculoskeletal conditions Prompt, Effective Relief With Minimal Sedation 1,2 Prescribe SKELAXIN® TID/QID to help ensure an effective course of therapy • Fast-acting with rapid improvement in mobility • Onset of action occurs within 1 hour with peak plasma levels reached in as early as 2 hours 1 1 • Minimal sedation with low incidence of side effects and drowsiness 1, 2 • Well-established safety and efficacy profile 1, 2 To learn more about patient education materials and savings offers, please log on to www.kingondemand.com or call 1-866-RXSPASM (1-866-797-7276). SKELAXIN® (metaxalone) is indicated as an adjunct to rest, physical therapy, and other measures for the relief of discomforts associated with acute, painful musculoskeletal conditions. The mode of action of this drug has not been clearly identified, but may be related to its sedative properties. Metaxalone does not directly relax tense skeletal muscles in man. Important Safety Information Taking SKELAXIN® with food may enhance general CNS depression. Elderly patients may be especially susceptible to this CNS effect. The most frequent reactions to metaxalone include nausea, vomiting, gastrointestinal upset, drowsiness, dizziness, headache, and nervousness or “irritability.” Please see full Prescribing Information on adjacent page. References: 1. Gross L. Metaxalone: a review of clinical experience. J Neurol Orthop Med Surg. 1998;18(1):76-79. 2. Dent RW Jr, Ervin DK. A study of metaxalone (Skelaxin) vs. placebo in acute musculoskeletal disorders: a cooperative study. Curr Ther Res Clin Exp. 1975;18(3):433-440. http://www.kingondemand.com

Table of Contents Feed for the Digital Edition of ACEP News - June 2008

ACEP News - June 2008 Contents News - Time to Move Tricks of the Trade - Revealing Tips Focus On - Dengue Fever Practice Trends - EMTALA Results

ACEP News - June 2008

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.