Dataset Information

The role of the GP in managing suspected transient ischaemic attack: a qualitative study.

ABSTRACT:

Background

National guidelines recommend patients with suspected transient ischaemic attack (TIA) should be seen by a specialist within 24?h. However, people with suspected TIA often present to non-specialised services, particularly primary care. Therefore, general practitioners (GPs) have a crucial role in recognition and urgent referral of people with suspected TIA. This study aims to explore the role of GPs in the initial management of suspected TIA in the United Kingdom (UK).

Methods

One-to-one, semi-structured interviews with GPs, TIA clinic staff and patients with suspected TIA from two sites in the UK: Cambridge and Birmingham. Thematic analysis was undertaken to explore views on the role of the GP in managing suspected TIA. Thirty semi-structured interviews were conducted with stroke patients (n =?12), GPs (n =?9) and TIA clinic hospital staff (n =?9) from two hospitals and nine GP practices in surrounding areas.

Results

Three overarching themes were identified: (1) multiple management pathways for suspected TIA; (2) uncertainty regarding suspected TIA as an emergency or routine situation; and (3) influences on the urgency of GP management.

Conclusions

Guidelines on the primary care management of TIA describe only a small proportion of the factors which influence GP management and referral of suspected TIA. Efforts to improve treatment, appropriate referral and patient experience should use a real rather than idealised model of the GP role in managing suspected TIA.

SUBMITTER: Edwards D

PROVIDER: S-EPMC6530060 | biostudies-literature | 2019 May

REPOSITORIES: biostudies-literature

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Publications

The role of the GP in managing suspected transient ischaemic attack: a qualitative study.

Edwards Duncan D Turner Grace M GM Virdee Satnam K SK Mant Jonathan J

BMC family practice 20190521 1

<h4>Background</h4>National guidelines recommend patients with suspected transient ischaemic attack (TIA) should be seen by a specialist within 24 h. However, people with suspected TIA often present to non-specialised services, particularly primary care. Therefore, general practitioners (GPs) have a crucial role in recognition and urgent referral of people with suspected TIA. This study aims to explore the role of GPs in the initial management of suspected TIA in the United Kingdom (UK).<h4>Meth ...[more]

PMID: 31113364

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Project description:OBJECTIVE:The diagnosis of transient ischaemic attack (TIA) based on symptoms and signs can be challenging and would greatly benefit from a rapid serum biomarker of brain ischaemia. We aimed to quantify the added diagnostic value of serum biomarkers in patients suspected of TIA beyond symptoms and signs. METHODS:This is a cross-sectional diagnostic accuracy study with a 6-month follow-up period. Participants were patients suspected of TIA by the general practitioner (GP) in whom a blood sample could be collected within 72 hours from symptom onset. A research nurse visited the participant for the blood sample and a standardised interview. The GP referred participants to the regional TIA service. An expert panel of three neurologists classified cases as TIA, minor stroke or any other diagnosis, based on all available diagnostic information including the GP's and neurologist's correspondence and the follow-up period. We used multivariable logistic regression analyses to quantify the diagnostic accuracy of clinical predictors and the improvement of accuracy by seven biomarkers (NR2, NR2 antibodies, PARK7, NDKA, UFD1, B-FABP and H-FABP). RESULTS:206 patients suspected of TIA participated, of whom 126 (61.2%) were diagnosed with TIA (n=104) or minor stroke (n=22) by the expert panel. The median time from symptom onset to the blood sample collection was 48.0 (IQR 28.3-56.8) hours. None of the seven biomarkers had discriminative value in the diagnosis of TIA, with C-statistics ranging from 0.45 to 0.58. The final multivariable model (C-statistic 0.83 (0.78-0.89)) consisted of eight clinical predictors of TIA/minor stroke: increasing age, a history of coronary artery disease, sudden onset of symptoms, occurrence of symptoms in full intensity, dysarthria, no history of migraine, absence of loss of consciousness and absence of headache. Addition of the individual biomarkers did not further increase the C-statistics. CONCLUSIONS:Currently available blood biomarkers have no added diagnostic value in suspected TIA. TRIAL REGISTRATION NUMBER:NCT01954329.

Project description:The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.

Dataset Information

The role of the GP in managing suspected transient ischaemic attack: a qualitative study.

Background

Methods

Results

Conclusions

Publications

The role of the GP in managing suspected transient ischaemic attack: a qualitative study.

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