Is the evaluation and treatment of transient ischemic attack performed according to current knowledge? A nationwide Israeli registry

Background: Patients with transient ischemic attack (TIA) at a high risk of stroke can be identified and should be managed urgently. Objectives: To investigate whether recognized recommendations are being implemented in Israel. Methods: An Israeli nationwide registry (NASIS) on patients admitted with stroke and TIA was conducted in all acute care hospitals within 2 successive months during 2004, 2007 and 2010. A revised ABCD2 score was applied retrospectively. Patients with TIA were divided into a low risk group (LRG, 0-3 points) and a high risk group (HRG, 4-6 points) and were compared to patients with minor ischemic strokes (MIS, NIHSS score ≤ 5 points). Results: A total of 3336 patients were included (1023 with TIA: LRG 484, HRG 539, and MIS 2313). LRG patients were younger and had lower rates of most traditional risk factors as compared with HRG and MIS patients. Brain imaging was performed in almost all the patients. Ancillary tests (vascular and cardiac) were overall underused, yet were performed more in LRG (53.2% and 26.9% respectively) than in HRG patients (41.6%, 18.9%). Between periods there was no change in usage of ancillary tests for the LRG and a modest increase in both HRG and MIS patients. For performance of vascular investigations overall, the odds ratio was 1.69 (95% confidence interval 1.42-2.00) comparing 2010 with 2004, but 0.7 (95% CI 0.5-0.9) comparing HRG with LRG. Between periods an increase in statin usage was observed in all groups (OR 2.69, 95% CI 2.25-3.21) but was more marked in MIS patients (OR 3.06, 95% CI 2.47-3.8). Conclusions: The approach to TIA risk stratification and management in Israeli hospitals does not follow standards set by current guidelines. Standardized protocols for TIA should be used to assure effective management.