Stroke Risk after Nonstroke Emergency Department Dizziness Presentations: A Population-based Cohort Study

The Journal of Emergency Medicine, Vol. 48, No. 1, pp. 130–135, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

Abstracts Comments: In ED patients with suspected ACS but initial troponin and ECG without evidence of ischemia or infarct, identification of a high-risk plaque on CTA increases the likelihood of ACS during the patient’s index hospitalization, independent of significant stenosis and clinical risk assessment.

, HIGH-RISK PLAQUE DETECTED ON CORONARY CT ANGIOGRAPHY PREDICTS ACUTE CORONARY SYNDROMES INDEPENDENT OF SIGNIFICANT STENOSIS IN ACUTE CHEST PAIN: RESULTS FROM THE ROMICAT-II TRIAL. Puchner SB, Liu T, Mayrhofer T, et al. J Am Coll Cardiol 2014;64:684 92. Coronary computed tomography angiography (CTA) is an imaging tool used to risk stratify emergency department (ED) patients without initial objective evidence for acute coronary syndrome (ACS). The objective of this study was to determine whether highrisk plaque features, as detected by ED CTA, improved diagnostic certainty of ACS in patients with acute chest pain with an initial troponin and electrocardiogram (ECG) not indicative of myocardial ischemia or infarct. High-risk plaques were defined as those with positive remodeling, < 30 Hounsfield units, napkin-ring sign, and spotty calcium. The original study, ROMICAT-II (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography II), enrolled patients from April 2010 to January 2012 who presented with chest pain, cardiovascular risk factors, and a clinical suspicion for ACS at nine United States EDs. This study was a secondary data analysis of 472 of the 1000 total patients randomized to the coronary CTA arm of the ROMICAT-II trial. Using logistic regression analysis, the study controlled for significant coronary artery disease (CAD) and clinical risk assessment to determine if one or more high-risk plaques on CTA were associated with ACS during the index hospitalization. Significant CAD was defined as stenosis $ 50%. Clinical risk assessment was determined using age, sex, and number of cardiovascular risk factors. High-risk plaques were a statistically significant predictor of ACS (odds ratio [OR] = 8.9; 95% confidence interval 1.8 43.3), even when adjusted for clinical risk assessment and significant CAD. Although significant CAD and clinical risk assessment are still important predictors, these results suggest the identification of a high-risk plaque on CTA increases the likelihood of ACS during the patient’s index hospitalization. The number of ACS outcomes (n = 37) in the study limited the ability of investigators to include additional variables in the multivariable models, thereby potentially impacting the analyses. The small sample size may also limit the generalizability of the study findings. [Stephanie Oberfoell, MD Denver Health Medical Center, Denver, CO]

, SUPPORT FROM HOSPITAL TO HOME FOR ELDERS: A RANDOMIZED TRIAL. Goldman LE, Sarkar U, Kessell E, et al. Ann Intern Med 2014;161:472 81. The study investigated whether providing peri-discharge support for low-income, culturally and linguistically diverse seniors may be associated with decreased readmission percentages. This was a randomized controlled trial at a publicly funded, urban hospital of 700 patients 55 years of age or older with anticipated discharge. The patients either received usual care or a nurse-led intervention. The intervention entailed individual, in-hospital disease-specific, self-management education by a language-concordant registered nurse and telephone follow-up after discharge from a nurse practitioner. The primary outcome of the study was emergency department (ED) visits or readmissions at 30, 90, and 180 days. The study calculated the hazard ratio (HR) with a 95% confidence interval (CI) comparing the nurse-led intervention and usual care. The study found no significant difference in ED visits or readmissions at 30, 90, or 180 days (HR = 1.26 [95% CI 0.89 1.78] at 30 days, HR = 1.21 [95% CI 0.91 1.62] at 90 days, and HR = 1.11 [95% CI 0.86 1.43] at 180 days). There was a trend toward increased ED visits and readmissions in the intervention group. The study may not have captured all ED visits or readmissions for the patients, given that there were many other hospitals in the region. In addition, the patients who received the intervention might have been more likely to return to the index hospital after given more detailed instructions, possibly impacting study findings. [Stephanie Oberfoell, MD Denver Health Medical Center, Denver, CO] Comments: For low-income, ethnically diverse older adults, a nurse-led peri-discharge intervention of individualized, inhospital, language-concordant instructions by a registered nurse and a telephone follow-up after discharge by a nurse practitioner had no significant impact on ED visits and readmission percentages at 30, 90, and 180 days.

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The Journal of Emergency Medicine , STROKE RISK AFTER NONSTROKE EMERGENCY DEPARTMENT DIZZINESS PRESENTATIONS: A POPULATIONBASED COHORT STUDY. Kerber KA, Zahuranec DB, Brown DL, et al. Ann Neurol 2014;75:899 907. Dizziness is a common presentation to the emergency department (ED), with acute stroke as one potential etiology of the patient’s symptoms. The goal of this study was to quantify the percentage of patients who initially presented with dizziness and who subsequently developed a stroke. Patients who were 45 years of age or older who presented to the ED with a chief complaint of vertigo, dizziness, or imbalance (n = 1245) were included in the study. Patients with an acute stroke were excluded from participation. Patients were enrolled by active and passive surveillance. Research assistants scanned the ED boards by chief complaint. In addition, an automated ICD-9 based computer algorithm selected patients for potential participation, and abstractors conducting a stroke surveillance study in the same community also identified patients with stroke who had previous ED visits with dizziness symptoms. Of the 1273 patients identified for participation, 28 were excluded due to acute stroke (2.2%; 95% confidence interval [CI] 1.5 3.2%). Of the 1245 patients enrolled, 15 patients (1.2%) had a stroke. The risk of stroke was 0.48% (95% CI 0.22 1.07%) at 2 days, 0.48% (95% CI 0.22 1.07%) at 7 days, 0.56% (95% CI 0.27 1.18%) at 30 days, 0.56% (95% CI 0.27 1.18%) at 90 days, and 1.42% (95% CI 0.85 2.36%) at 12 months. The patient-enrollment technique of retrospectively enrolling patients who presented with an acute stroke and mining for prior ED visits with dizziness may have led to selection bias in the study. The inclusion criteria used in this approach were subjective, using the clinician’s judgment of the ‘‘main’’ chief complaint at the previous ED visit. [Stephanie Oberfoell, MD Denver Health Medical Center, Denver, CO] Comments: For patients older than 45 years and with a chief complaint of dizziness who presented to the ED, the study reports a 0.48% risk of stroke in the next 7 days. These data are important for emergency physicians considering risk stratification and management of patients with dizziness in the ED. , INABILITY TO CONSENT DOES NOT DIMINISH THE DESIRABILITY OF STROKE THROMBOLYSIS. Chiong W, Kim AS, Huang IA, et al. Ann Neurol 2014;76:296 304. Recently, the American Academy of Neurology and the American Heart Association/American Stroke Association have endorsed the use of thrombolysis in incapacitated persons without surrogate decision makers. The rationale for this position is that a reasonable person would consent to treatment if asked. The goal of this study was to evaluate the influence of the inability to consent and of personal health-related values on older adults’ emergency treatment preferences for both ischemic stroke and cardiac arrest.

131 To determine if being unable to give informed consent made intervention less desirable, 2154 adults age 50 years of age and older were surveyed. Participants were randomly sampled and presented with hypothetical scenarios of either stroke or cardiac arrest and asked if they would want thrombolysis and cardiopulmonary resuscitation (CPR), respectively. To characterize whether these decisions were influenced by personal healthrelated values, patients were surveyed on their attitudes toward patient-centered vs physician-centered medical decision making, dependence, longevity, confidence in the medical system, and reliance on statistical information in decision making for thrombolysis or cardiopulmonary resuscitation. Logistical regression was used to determine the association between inability to consent with treatment preferences. Results of the survey showed older adults were no less likely to desire thrombolysis when unable to consent (76.2%; odds ratio [OR] = 1.1; 95% confidence interval [CI] 1.1 2.4). Participants were significantly more likely to want treatment with CPR when unable to consent compared to when they could consent. The influence of being unable to consent did not differ significantly across demographic characteristics, except for marital status, where inability to consent made thrombolysis less desirable in widowed participants, but more desirable for divorced participants. Increased desirability of treatment in the absence of consent was higher in adults with lower educational attainment. There was not a significant difference in responses based on personal health-related values, although there were trends toward desiring thrombolysis in patients with higher confidence in the medical system and reliance on statistical information in medical decision making. Limitations of the study include those inherent to surveys, such as sample and response bias. Another limitation of the study addressed by the authors was the fact that the study did not take into account the gray zone of decision making, where patients may not be incapacitated, but may lack ability to understand the benefits and harms of treatment in stroke. [Skylar Johnson, MD Denver Health Medical Center, Denver, CO] Comments: This article is relevant to emergency medicine physicians who may be presented with immediate ethical dilemmas regarding intervention for stroke and cardiac arrest in patients unable to consent. Based on this study, approximately 75% of patients would want interventions regardless of their ability to consent. This suggests the chances of making a decision in accordance with the patient’s values is higher if intervention is undertaken, and those that would desire intervention when able to consent would also likely desire it when unable to consent. , PROTECTIVE EQUIPMENT AND PLAYER CHARACTERISTICS ASSOCIATED WITH THE INCIDENCE OF SPORT-RELATED CONCUSSION IN HIGH SCHOOL FOOTBALL PLAYERS. McGuine TA, Hetzel S, McCrea M, Brooks, MA. Am J Sports Med 2014;42:2470. This study from the University of Wisconsin sought to determine whether the type of protective equipment (helmet and