From Medscape Medical News
Pauline Anderson
April 22, 2010 — About 70% of patients who suffer a minor stroke or transient ischemic attack (TIA) do not correctly recognize their symptoms, and 30% delay seeking medical attention for more than 24 hours, a new study concludes.
Delays in seeking treatment were unrelated to age, sex, social class, or educational level, the study also found.
These results suggest that public awareness campaigns should emphasize the importance of seeking urgent medical attention, as well as recognizing symptoms, and that targeting such campaigns at specific groups such as the socially disadvantaged is unlikely to have significant benefit, said lead author Arvind Chandratheva, MRCP, a clinical research fellow in the Stroke Prevention Research Unit at the University of Oxford, United Kingdom.
"What you need is a national media campaign that highlights that any symptoms that are sudden onset, particularly with face or arm weakness and speech disturbance, should necessitate urgent medical attention," Dr. Chandratheva said.
The study results were published online April 15 in the journal Stroke: Journal of the American Heart Association.
Seeking Prompt Treatment
The researchers used the Oxford Vascular Study, a population-based study of all vascular events, including stroke and TIA, in about 91,000 people registered with 63 general practitioners in Oxfordshire in the United Kingdom. The current analysis includes consecutive cases of incident or recurrent TIA and minor stroke from April 2002 to April 2007.
Researchers recorded baseline characteristics of all patients and collected information on demographics, risk factors, social class, and educational level. Standard definitions were used to classify cases as TIA or stroke. The authors decided to study TIA separately from minor stroke, as it appears to behave differently; few previous studies have analyzed TIA separately.
The authors determined the delay from symptom onset to first seeking medical attention in relation to whether patients correctly identified the cause of their symptoms, demographic data, risk factors, symptomatology, and the day on which the TIA occurred. They performed a separate analysis on patients who did not seek medical attention for their initial symptoms and presented only after recurrent stroke.
Of the first 1000 consecutive patients, 459 presented after TIA and 541 after minor stroke. Of these, complete data were available on 945 patients. Their mean age was 73 years, and 335 (35%) were aged 80 years or older.
Of patients with TIA, 208 (47%) sought medical attention within 3 hours, the window of time during which thrombolytic therapy is optimally administered, as did 234 (46%) minor stroke patients; 300 (67%) TIA patients and 400 (74%) of those with minor stroke sought medical attention within 24 hours.
Prior stroke and atrial fibrillation were associated with less delay, but prior TIA, myocardial infarction, hypertension, and history of smoking were not. "I presume that people with atrial fibrillation are told that one of the things they have to worry about is a stroke, and so they're aware of what symptoms to look for," said Dr. Chandratheva.
Assumed Incorrect Causes
Among those who sought medical attention, 457 (99.6%) TIA and 535 (98.9%) minor stroke patients could recall their initial perception of the cause of their symptoms or were with a spouse or caregiver who could. In 32% of TIA and 30% of minor stroke patients, their initial impression was correct. The remaining 68% of TIA and 69% of minor stroke patients did not know the cause of their symptoms or assumed incorrect causes.
TIA patients with a lower predicted early risk for stroke were more likely to delay than those at higher risk, especially if they had no motor and speech symptoms (P < .001), the event lasted less than 60 minutes (P < .001), or they were younger than 60 years (P = .075).
"What was slightly reassuring was that people with high-risk characteristics such as motor symptoms or speech disturbance or longer duration of events do tend to present more quickly, so I suppose that even if they don't know what their symptoms are, at least those high-risk patients are presenting earlier," said Dr. Chandratheva.
Longer Delays on Weekends
In patients with TIA, occurrence on the weekend was associated with the longest delays, with a median delay of 41.96 hours on Saturday and 24.00 hours on Sunday compared with 3.5 hours on Monday. "I think the reason for the delay on the weekend was that patients were waiting to see their primary care physician," said Dr. Chandratheva. "We have to emphasize that sudden onset of symptoms such as motor symptoms and speech symptoms should necessitate urgent medical attention, and that patients shouldn't just wait to see their primary care physician."
Indeed, the study found that first healthcare provider contacted by patients after the event was the family practitioner in 355 (77%) patients with TIAs and 390 (72%) patients with minor stroke.
The study results did not change across several demographic factors. "Social class didn't make a difference, economic status didn't make a difference, and educational level didn't make a difference," said Dr. Chandratheva, adding that this makes it difficult to target a national campaign to a specific group.
Although some people who did recognize their symptoms still delayed getting treatment, correct recognition of symptoms was associated with significantly shorter delays to presenting to medical attention for patients with TIA (2.3 vs 7.3 hours; P = .005).
Of the 129 patients with TIA or minor stroke who had a recurrent stroke within 90 days, 41 (31%) did not seek medical attention after their initial event. "These are people who just came into hospital with their recurrent stroke and never even sought medical attention for their initial event," commented Dr. Chandratheva.
Few Can Identify TIA Symptoms
The authors noted that a telephone survey of randomly sampled US adults found that only 8.6% could identify a typical symptom of a TIA, and a Swiss survey found that only 2.8% identified TIA as a disease requiring urgent attention.
According to the authors, the lack of awareness about the need to seek medical attention was likely underestimated in the study, as all study participants did eventually report their symptoms. "There is an unknown proportion of patients who have 1 TIA and never present to medical attention so we may never know about them," added Dr. Chandratheva.
Another possible limitation of the study is that it relied on data from Oxfordshire, a county with a slightly higher educational level and socioeconomic status than other areas. "You'd expect people who are more educated and have more economic wealth to have more health awareness, but we didn't find this to be the case, so if anything, the figures were slightly underestimated," said Dr. Chandratheva.
He also pointed out that the vast majority of patients in the study were white.
Urgent Attention
Reached for a comment, Ralph L. Sacco, MD, chairman of neurology at the Miller School of Medicine, University of Miami, and chief of neurology at Jackson Memorial Hospital, Miami, Florida, and a spokesperson for the American Academy of Neurology, said the study emphasizes the fact that too many people do not realize that calling 911 is the most important action to take if they have warning symptoms of a stroke.
"We need to not only educate the public about the warning symptoms, but also about the need to get urgent attention," he said in an email to Medscape Neurology. "We urge people to call 911 and get to the closest stroke center, rather than calling their primary care doctor."
However, educating the public about recognizing stroke symptoms and getting immediate attention for them can be "tricky," said Gary Abrams, MD, professor of neurology at the University of California–San Francisco, and a spokesperson for the American Academy of Neurology.
"Unlike crushing chest pain, which heralds a heart attack and gets people to emergency attention quickly, symptoms of stroke can sometimes be subtle; they can be transient and reversible," he said.
Although he supports public awareness campaigns and thinks they should continue, Dr. Abrams said he is not sure he has "great hopes" for significantly changing patient behavior. "And I wonder if you could almost get an overreaction, with emergency rooms being flooded every time patients felt dizzy or had trouble finding the right word. It's a tough educational project; worthy but tough."
The study was supported by the UK Medical Research Council, the National Institute of Health Research, the Stroke Association, the Dunhill Medical Trust, and the National Institute of Health Researcher Biomedical Research Centre, Oxford. The authors have disclosed no relevant financial relationships.
Stroke. Published online April 15, 2010.
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