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Ominous 'Mini-Strokes' Often Dismissed by Primary Care Doctors

WebMD Health News

Feb. 10, 2000 (New Orleans) -- New research presented here at a meeting of the American Stroke Association suggests that stroke is much more common in the United States than previously believed. But all too often, physicians treating mini-strokes -- a known precursor to stroke -- are sending patients home without even an aspirin.

Both the rise in stroke incidence and the laissez-faire attitude of the nation's primary care physicians have alarmed stroke experts meeting here. Larry B. Goldstein, MD, of Duke University, tells WebMD that his study of stroke treatment by primary care physicians has convinced him that patients with symptoms should "go directly to the nearest emergency department -- don't call the doctor, where one can get caught in voice-mail hell." A complete diagnostic workup and time are both crucial to a good outcome with strokes, he says. His study suggests that primary care physicians are dropping the ball in both areas.

Goldstein, who spoke at a press conference, says that his study of records from 27 general medical practices in the Durham, N.C., area and in Rochester, N.Y., showed that about 90% of patients who call a primary care physician with symptoms of a transient ischemic attack (TIA) -- the so-called mini-stroke -- are seen that day. "But only a small number -- just 6% -- are hospitalized, and only 3% are hospitalized within 30 days," he says.

Goldstein says that although the hospitalization rates are "interesting," the more troublesome finding was that "about a third of the patients had no specific evaluation, and yet 60% of those without a specific workup neither had antiplatelet therapy initiated nor had therapy adjusted."

These figures are especially worrisome, says Goldstein, because most people with stroke or TIA "are never seen by a neurologist, and virtually none are seen by a stroke neurologist. Most of the care is by primary care physicians." If primary care physicians aren't doing a complete evaluation, he says, they can't make use of new treatments, such as surgery to clean out the arteries that carry blood to the brain or use of new clot-busting drugs.

The symptoms of TIA are actually the same as symptoms of stroke: sudden numbness or weakness of the face, arm, or leg -- especially if it is one-sided; confusion; trouble speaking or understanding; vision problems; difficulty walking; or sudden severe headache. But unlike stroke, the symptoms are fleeting and thus can easily be ignored by patients. Nonetheless, TIA is "an ominous sign," says S. Claiborne Johnson, MD, an assistant professor at the University of California, San Francisco. He has compiled data that back up that claim.

Johnson tells WebMD that among 1,707 people who presented to 16 Kaiser-Permanente emergency departments with symptoms of a TIA, "10.5% had a stroke within 3 months of presentation, about 2.6% died in three months, 2.5% had a cardiovascular event such as a [heart attack] or congestive heart failure, and 13.5% had recurrent TIAs. The total incident rate was 26%. And 50% of the patients who had strokes had [them] within two days of the TIA."

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