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"Mini Strokes" with Maximum Impact
Susan C. Fagan, Pharm.D., BCPS, FCCP
Review: Rothwell PM, Giles MF, Flossman E, Lovelock CE, Redgrave JNE, Warlow CP, Mehta Z. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischemic attack. Lancet 2005;366:29-36.
If we needed any more convincing that patients who experience a transient ischemic attack (TIA) need prompt medical attention for the institution of appropriate secondary prevention therapies, here it is. In this report from a group of well-known stroke investigators from the UK, a simple method has been developed to predict which patients with a probable or definite TIA are at the highest risk for stroke in 7 days. The ABCD score, standing for, A=age 60 years or greater (1 point); B=blood pressure 140/90 or greater (1 point); C=clinical features of unilateral weakness (2 points) or speech disturbance without weakness (1 point); and D=duration of symptoms either 60 minutes or greater (2 points); 10-59 minutes (1 point), is easy to remember and correctly predicted those at the highest 7-day risk of stroke in two separate cohorts. The first cohort was used to derive the score, based on known predictors of recurrence, and the second, to validate it. The scoring system was very accurate with only 0.4% of patients with scores < 5 experiencing a stroke in 7 days, compared to 12.1% of patients with a score of 5 and 31.4% of patients getting the maximal 6 points.
The retrospective nature of the data used does not allow comment or comparisons between patients on different preventive therapies but it is likely that reductions in recurrence rates would be seen with optimal pharmacotherapeutic interventions started quickly after a TIA. In the UK, where TIA patients are often seen in busy outpatient clinics after delays of 2 weeks or more, the authors plead for sweeping changes in policy to make sure that the most "high-risk" TIA patients are seen urgently. This can be applied to other health care systems where decisions regarding prioritization of care must be made to ensure the patients at greatest need are seen first.
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