New transient ischemic attack and stroke - Outpatient management by primary care physicians

Background: Patients with transient ischemic attack (TIA) or stroke frequen tly first contact their primary care physician rather than seeking care at a hospital emergency department. The purpose of the present study was to id entify a group of patients seen by primary care physicians in an office set ting for a first-ever TIA or stroke and characterize their evaluation and m anagement. Methods: Practice audit based on retrospective, structured medical record a bstraction from 27 primary care medical practices in 2 geographically separ ate communities in the eastern United States. Results: Ninety-five patients with a first-ever TIA and 81 with stroke were identified. Seventy-nine percent of those with TIA vs 88% with stroke were evaluated on the day their symptoms occurred (P=.12). Only 6% were admitte d to a hospital for evaluation and treatment on the day of the index visit (2% TIA; 10% stroke; P=.03); only an additional 3% were admitted during the subsequent 30 days. Specialists were consulted for 45% of patients. A brai n imaging study (computed tomography or magnetic resonance imaging) was ord ered on the day of the index visit in 30% (23% TIA, 37% stroke; P=.04), reg ardless of whether the patient was referred to a specialist. Carotid ultras ound studies were obtained in 28% (40% TIA, 14% stroke; P<.001), electrocar diograms in 19% (18% TIA, 21% stroke; P=.60), and echocardiograms in 16% (1 9% TIA, 14% stroke; P=.34). Fewer than half of patients with a prior histor y of atrial fibrillation (n=24) underwent anticoagulation when evaluated at the index visit. Thirty-two percent of patients (31% TIA, 33% stroke; P=.7 0) were not hospitalized and lad no evaluations performed during the first month after presenting to a primary care physician with a first TIA or stro ke. Of these patients, 59% had a change in antiplatelet therapy on the day of the index visit. Conclusions: Further primary care physician education regarding the importa nce of promptly and fully evaluating patients with TIA or stroke may be war ranted, and barriers to implementation of established secondary stroke prev ention strategies need to be carefully explored.