The problem – the most difficult clinical situations are the ones where we need a handy decision tool – and the hardest to come up with an effective one. Syncope rules, PE prediction rules, ACS prediction rules, and now TIA evaluation.
The most important number to come out of this paper is probably 1.8% – the number of patients with a TIA who went on to have a stroke in the next seven days. That’s 38 out of their 2056 patients enrolled. The next number is 2.7%, which is the 56 patients who had another TIA within 7 days. So somehow a rule has to magically pick out that tiny proportion of patients who are going to have bad outcomes without excessively testing the remaining supermajority.
Nearly everyone had a CT of the head, nearly everyone had an EKG, very few (15% with an ABCD2 score ≤ 5 and 22.% with a score > 5) had consultation with a neurologist, and even fewer were admitted. The specificity for stroke within 7 days with a score >2 – the AHA definition of “high risk” – is only 12.5%. Not only that, but there was significant disagreement between enrolling physicians and the study center regarding the correct ABCD2 score for a patient.
So, in the end, ABCD2 is difficult to apply and only minimally useful. You’re going to miss half the strokes at 7 days if you apply it in a situation where the specificity is >50% – so, sure, a sky-high score tells you they’re in trouble, but that still doesn’t help you discharge the majority of your TIAs safely for outpatient follow-up.
“Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack.”
www.ncbi.nlm.nih.gov/pubmed/21646462