Browsing by Subject "Transient ischemic attack"
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Item Diagnosing and Treating Sleep Apnea in Patients With Acute Cerebrovascular Disease(American Heart Association, 2018-08-21) Bravata, Dawn M.; Sico, Jason; Vaz Fragoso, Carlos A.; Miech, Edward J.; Matthias, Marianne S.; Lampert, Rachel; Williams, Linda S.; Concato, John; Ivan, Cristina S.; Fleck, J.D.; Tobias, Lauren; Austin, Charles; Ferguson, Jared; Radulescu, Radu; Iannone, Lynne; Ofner, Susan; Taylor, Stanley; Qin, Li; Won, Christine; Yaggi, H. Klar; Medicine, School of MedicineBackground Obstructive sleep apnea ( OSA ) is common among patients with acute ischemic stroke and transient ischemic attack. We evaluated whether continuous positive airway pressure for OSA among patients with recent ischemic stroke or transient ischemic attack improved clinical outcomes. Methods and Results This randomized controlled trial among patients with ischemic stroke/transient ischemic attack compared 2 strategies (standard or enhanced) for the diagnosis and treatment of OSA versus usual care over 1 year. Primary outcomes were National Institutes of Health Stroke Scale and modified Rankin Scale scores. Among 252 patients (84, control; 86, standard; 82, enhanced), OSA prevalence was as follows: control, 69%; standard, 74%; and enhanced, 80%. Continuous positive airway pressure use occurred on average 50% of nights and was similar among standard (3.9±2.1 mean hours/nights used) and enhanced (4.3±2.4 hours/nights used; P=0.46) patients. In intention-to-treat analyses, changes in National Institutes of Health Stroke Scale and modified Rankin Scale scores were similar across groups. In as-treated analyses among patients with OSA, increasing continuous positive airway pressure use was associated with improved National Institutes of Health Stroke Scale score (no/poor, -0.6±2.9; some, -0.9±1.4; good, -0.3±1.0; P=0.0064) and improved modified Rankin Scale score (no/poor, -0.3±1.5; some, -0.4±1.0; good, -0.9±1.2; P=0.0237). In shift analyses among patients with OSA, 59% of intervention patients had best neurological symptom severity (National Institutes of Health Stroke Scale score, 0-1) versus 38% of controls ( P=0.038); absolute risk reduction was 21% (number needed to treat, 4.8). Conclusions Although changes in neurological functioning and functional status were similar across the groups in the intention-to-treat analyses, continuous positive airway pressure use was associated with improved neurological functioning among patients with acute ischemic stroke/transient ischemic attack with OSAItem Have clinicians adopted the use of brain MRI for patients with TIA and minor stroke?(American Academy of Neurology, 2017-01-17) Chaturvedi, Seemant; Ofner, Susan; Baye, Fitsum; Myers, Laura J.; Phipps, Mike; Sico, Jason J.; Damush, Teresa; Miec, Edward; Reeves, Mat; Johanning, Jason; Williams, Linda S.; Arling, Greg; Cheng, Eric; Yu, Zhangsheng; Bravata, Dawn; Biostatistics, School of Public HealthBACKGROUND: Use of MRI with diffusion-weighted imaging (DWI) can identify infarcts in 30%-50% of patients with TIA. Previous guidelines have indicated that MRI-DWI is the preferred imaging modality for patients with TIA. We assessed the frequency of MRI utilization and predictors of MRI performance. METHODS: A review of TIA and minor stroke patients evaluated at Veterans Affairs hospitals was conducted with regard to medical history, use of diagnostic imaging within 2 days of presentation, and in-hospital care variables. Chart abstraction was performed in a subset of hospitals to assess clinical variables not available in the administrative data. RESULTS: A total of 7,889 patients with TIA/minor stroke were included. Overall, 6,694 patients (84.9%) had CT or MRI, with 3,396/6,694 (50.7%) having MRI. Variables that were associated with increased odds of CT performance were age >80 years, prior stroke, history of atrial fibrillation, heart failure, coronary artery disease, anxiety, and low hospital complexity, while blood pressure >140/90 mm Hg and high hospital complexity were associated with increased likelihood of MRI. Diplopia (87% had MRI, p = 0.03), neurologic consultation on the day of presentation (73% had MRI, p < 0.0001), and symptom duration of >6 hours (74% had MRI, p = 0.0009) were associated with MRI performance. CONCLUSIONS: Within a national health system, about 40% of patients with TIA/minor stroke had MRI performed within 2 days. Performance of MRI appeared to be influenced by several patient and facility-level variables, suggesting that there has been partial acceptance of the previous guideline that endorsed MRI for patients with TIA.Item Identifying transient ischemic attack (TIA) patients at high-risk of adverse outcomes: development and validation of an approach using electronic health record data(BMC, 2022-07-12) Myers, Laura J.; Perkins, Anthony J.; Zhang, Ying; Bravata, Dawn M.; Medicine, School of MedicineBackground: Risk-stratification tools that have been developed to identify transient ischemic attack (TIA) patients at risk of recurrent vascular events typically include factors which are not readily available in electronic health record systems. Our objective was to evaluate two TIA risk stratification approaches using electronic health record data. Methods: Patients with TIA who were cared for in Department of Veterans Affairs hospitals (October 2015-September 2018) were included. The six outcomes were mortality, recurrent ischemic stroke, and the combined endpoint of stroke or death at 90-days and 1-year post-index TIA event. The cohort was split into development and validation samples. We examined the risk stratification of two scores constructed using electronic health record data. The Clinical Assessment Needs (CAN) score is a validated measure of risk of hospitalization or death. The PREVENT score was developed specifically for TIA risk stratification. Results: A total of N = 5250 TIA patients were included in the derivation sample and N = 4248 in the validation sample. The PREVENT score had higher c-statistics than the CAN score across all outcomes in both samples. Within the validation sample the c-statistics for the PREVENT score were: 0.847 for 90-day mortality, 0.814 for 1-year mortality, 0.665 for 90-day stroke, and 0.653 for 1-year stroke, 0.699 for 90-day stroke or death, and 0.744 for 1-year stroke or death. The PREVENT score classified patients into categories with extreme nadir and zenith outcome rates. The observed 1-year mortality rate among validation patients was 7.1%; the PREVENT score lowest decile of patients had 0% mortality and the highest decile group had 30.4% mortality. Conclusions: The PREVENT score had strong c-statistics for the mortality outcomes and classified patients into distinct risk categories. Learning healthcare systems could implement TIA risk stratification tools within electronic health records to support ongoing quality improvement.Item Impact of Hospital Admission for Patients with Transient Ischemic Attack(Elsevier, 2017-08) Cheng, Eric M.; Myers, Laura J.; Vassar, Stefanie; Bravata, Dawn M.; Medicine, School of MedicineOBJECTIVES: To determine the impact of admission among transient ischemic attack (TIA) patients in the emergency department (ED). STUDY DESIGN: Retrospective cohort study using national Veterans Health Administration data (2008). METHODS: We first analyzed whether admitted patients were discharged from the hospital with a diagnosis of TIA. We then analyzed whether admission was associated with a composite outcome (new stroke, new myocardial infarction, or death in the year after TIA) using multivariate logistic regression modeling with propensity score matching. RESULTS: Among 3623 patients assigned a diagnosis of TIA in the ED, 2118 (58%) were admitted to the hospital or placed in observation compared with 1505 (42%) who were discharged from the ED. Among the 2118 patients who were admitted, 903 (43% of admitted group) were discharged from the hospital with a diagnosis of TIA, and 548 (26% of admitted group) were discharged with a diagnosis of stroke. Admitted patients were more likely than nonadmitted patients to receive processes of care (i.e., brain imaging, carotid imaging, echocardiography). In matched analyses using propensity scores, the 1-year composite outcome in the admitted group (15.3%) was not lower than the discharged group (13.3%, OR 1.17 [.94-1.46], P = .17). CONCLUSIONS: Less than half of patients admitted with a diagnosis of TIA retained that diagnosis at hospital discharge. Although admitted patients were more likely to receive diagnostic procedures, we did not identify improvements in outcomes among admitted patients; however, evaluating care for patients with TIA is limited by the reliability of secondary data analysis.Item Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack(SpringerLink, 2021-02) Damush, T.M.; Miech, E.J.; Rattray, N.A.; Homoya, B.; Penney, Lauren S.; Cheatham, A.; Baird, S.; Myers, J.; Austin, C.; Meyers, L.J.; Perkins, A.J.; Zhang, Y.; Giacherio, B.; Kumar, M.; Murphy, L.D.; Sico, J.J.; Bravata, D.M.; Medicine, School of MedicineBackground: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA). Objective: We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019). Design: A stepped-wedge implementation trial with six geographically diverse sites. Participants: The six facility QI teams were multi-disciplinary, clinical staff. Interventions: PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback. Main measures: Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year. Key results: Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation. Conclusions: The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system.Item Incidence of Transient Ischemic Attack and Association With Long-term Risk of Stroke(American Medical Association, 2021-01-26) Lioutas, Vasileios-Arsenios; Ivan, Cristina S.; Himali, Jayandra J.; Aparicio, Hugo J.; Leveille, Tarikwa; Romero, Jose Rafael; Beiser, Alexa S.; Seshadri, Sudha; Neurology, School of MedicineImportance: Accurate estimation of the association between transient ischemic attack (TIA) and risk of subsequent stroke can help to improve preventive efforts and limit the burden of stroke in the population. Objective: To determine population-based incidence of TIA and the timing and long-term trends of stroke risk after TIA. Design, setting, and participants: Retrospective cohort study (Framingham Heart Study) of prospectively collected data of 14 059 participants with no history of TIA or stroke at baseline, followed up from 1948-December 31, 2017. A sample of TIA-free participants was matched to participants with first incident TIA on age and sex (ratio, 5:1). Exposures: Calendar time (TIA incidence calculation, time-trends analyses), TIA (matched longitudinal cohort). Main outcomes and measures: The main outcomes were TIA incidence rates; proportion of stroke occurring after TIA in the short term (7, 30, and 90 days) vs the long term (>1-10 years); stroke after TIA vs stroke among matched control participants without TIA; and time trends of stroke risk at 90 days after TIA assessed in 3 epochs: 1954-1985, 1986-1999, and 2000-2017. Results: Among 14 059 participants during 66 years of follow-up (366 209 person-years), 435 experienced TIA (229 women; mean age, 73.47 [SD, 11.48] years and 206 men; mean age, 70.10 [SD, 10.64] years) and were matched to 2175 control participants without TIA. The estimated incidence rate of TIA was 1.19/1000 person-years. Over a median of 8.86 years of follow-up after TIA, 130 participants (29.5%) had a stroke; 28 strokes (21.5%) occurred within 7 days, 40 (30.8%) occurred within 30 days, 51 (39.2%) occurred within 90 days, and 63 (48.5%) occurred more than 1 year after the index TIA; median time to stroke was 1.64 (interquartile range, 0.07-6.6) years. The age- and sex-adjusted cumulative 10-year hazard of incident stroke for patients with TIA (130 strokes among 435 cases) was 0.46 (95% CI, 0.39-0.55) and for matched control participants without TIA (165 strokes among 2175) was 0.09 (95% CI, 0.08-0.11); fully adjusted hazard ratio [HR], 4.37 (95% CI, 3.30-5.71; P < .001). Compared with the 90-day stroke risk after TIA in 1948-1985 (16.7%; 26 strokes among 155 patients with TIA), the risk between 1986-1999 was 11.1% (18 strokes among 162 patients) and between 2000-2017 was 5.9% (7 strokes among 118 patients). Compared with the first epoch, the HR for 90-day risk of stroke in the second epoch was 0.60 (95% CI, 0.33-1.12) and in the third epoch was 0.32 (95% CI, 0.14-0.75) (P = .005 for trend). Conclusions and relevance: In this population-based cohort study from 1948-2017, the estimated crude TIA incidence was 1.19/1000 person-years, the risk of stroke was significantly greater after TIA compared with matched control participants who did not have TIA, and the risk of stroke after TIA was significantly lower in the most recent epoch from 2000-2017 compared with an earlier period from 1948-1985.Item Inhibitory synpatic transmission in striatal neurons after transient cerebral ischemia(2009-10) Li, Yan; Xu, Zao C.; Cummins, Theodore R.; Yang, Charles R.; Zhou, Feng C.In the striatum, large aspiny (LA) interneurons survive transient cerebral ischemia while medium spiny (MS) neurons die. Excitotoxicity is believed to be the major cause for neuronal death after ischemia. Since inhibitory tone plays an important role in the control of neuronal excitability, the present study is aimed at examining if there are any changes in inhibitory synaptic transmission in striatal neurons after ischemia and the possible mechanisms. Transient forebrain ischemia was induced in male Wistar rats using the four-vessel occlusion method. Inhibitory postsynaptic currents (IPSCs) were evoked intrastriatally and whole-cell voltage-clamp recording was performed on striatal slices. The expression of glutamate decarboxylase65 (GAD65) was analyzed using immunohistochemical studies and Western blotting. Muscimol (a specific GABAA receptor agonist) was injected intraperitoneally to the rats (1 mg/kg) to observe ischemic damage, evaluated by counting the survived cells in the striatum after hematoxylin & eosin (HE) staining. The amplitudes of evoked IPSCs were significantly increased in LA neurons while depressed in MS neurons after ischemia. This enhancement was due to the increase of presynaptic release. Muscimol (1 μM) presynaptically facilitated inhibitory synaptic transmission in LA neurons at 24 h after ischemia. The optical density of GAD65-positive terminals and the number of GAD65-positive puncta was significantly increased in the striatum at both 1 day and 3 days after ischemia. Consistently, data from western blotting suggested an increased expression of GAD65 in the striatum after ischemia. For the rats treated with muscimol, the number of survived cells in the striatum was greatly increased compared to the non-treatment group. The present study demonstrates an enhancement of inhibitory synaptic transmission in LA neurons after ischemia, which is contributed by two mechanisms. One is the increased presynaptic release of GABA mediated by presynaptic GABAA receptors. The other is the increased expression of GAD. Facilitation of inhibitory synaptic transmission by muscimol protects striatal neurons against ischemia. Therefore, the enhancement of inhibitory synaptic transmission might reduce excitotoxicity and contribute to the selective survival of LA neurons after ischemia.Item Patient Insights on Integrating Sleep Apnea Testing into Routine Stroke and TIA Care(Sage, 2024-12-29) Rattray, Nicholas A.; Story, K. Maya; Burrone, Laura; Sexson, Ali E.; Koo, Brian B.; Bravata, Dawn M.; Perkins, Anthony J.; Myers, Laura; Daggy, Joanne K.; Taylor, Stanley E.; Fields, Barry G.; Kunisaki, Ken M.; Daley, Joseph; Palacio, Santiago; Hermann, Lisa D.; Sico, Jason J.; Medicine, School of MedicineAHA/ASA guidelines recommend patients with ischemic stroke or transient ischemic attack (TIA) be considered for obstructive sleep apnea (OSA) evaluation, given the high prevalence of OSA and improved outcomes for cerebrovascular disease when OSA is treated. However, OSA testing has not been incorporated into routine cerebrovascular management. We interviewed 30 patients hospitalized for acute stroke/TIA at six Veterans Affairs facilities participating in a stepped-wedge implementation trial to improve timely OSA testing after stroke/TIA. Thematic analysis of semi-structured interviews explored the experiences of care received, sleep testing, and education about the association between OSA and cerebrovascular disease. Patients perceived OSA testing as an integrated component of stroke/TIA care and reported few barriers to OSA testing. Patients had limited recall of details concerning sleep testing during hospitalization and education about OSA but expressed preferences about the timing, setting, and importance of caregiver participation. Patients expressed high levels of acceptance of sleep testing as a routine part of cerebrovascular care. Facilities could use these results to implement guideline-concordant screening for OSA, post-stroke/TIA.Item The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods(BMC, 2019-11-20) Bravata, D. M.; Myers, L. J.; Homoya, B.; Miech, E. J.; Rattray, N. A.; Perkins, A. J.; Zhang, Y.; Ferguson, J.; Myers, J.; Cheatham, A. J.; Murphy, L.; Giacherio, B.; Kumar, M.; Cheng, E.; Levine, D. A.; Sico, J. J.; Ward, M. J.; Damush, T. M.; Medicine, School of MedicineBackground Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles. Methods This stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability. Discussion PREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines.Item The impact of the COVID-19 pandemic on blood pressure control after a stroke or transient ischemic attack among patients at VA medical centers(Elsevier, 2023) Arling, Greg; Miech, Edward J.; Myers, Laura J.; Sexson, Ali; Bravata, Dawn M.; Neurology, School of MedicineObjective: To study factors associated with systolic blood pressure(SBP) control for patients post-discharge from an ischemic stroke or transient ischemic attack(TIA) during the early months of the COVID-19 pandemic compared to pre-pandemic periods within the Veterans Health Administration(VHA). Materials and methods: We analyzed retrospective data from patients discharged from Emergency Departments or inpatient admissions after an ischemic stroke or TIA. Cohorts consisted of 2,816 patients during March-September 2020 and 11,900 during the same months in 2017-2019. Outcomes included primary care or neurology clinic visits, recorded blood pressure readings and average blood pressure control in the 90-days post-discharge. Random effect logit models were used to compare clinical characteristics of the cohorts and relationships between patient characteristics and outcomes. Results: The majority (73%) of patients with recorded readings during the COVID-19 period had a mean post-discharge SBP within goal (<140 mmHg); this was slightly lower than the pre-COVID-19 period (78%; p=0.001). Only 38% of the COVID-19 cohort had a recorded SBP in the 90-days post-discharge compared with 83% of patients during the pre-pandemic period (p=0.001). During the pandemic period, 29% did not have follow-up primary care or neurologist visits, and 33% had a phone or video visit without a recorded SBP reading. Conclusions: Patients with an acute cerebrovascular event during the initial COVID-19 period were less likely to have outpatient visits or blood pressure measurements than during the pre-pandemic period; patients with uncontrolled SBP should be targeted for follow-up hypertension management.