Multicenter Study

. 2021 Feb 4:372:n49.

doi: 10.1136/bmj.n49.

Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study

Jeffrey J Perry^{1

2}, Marco L A Sivilotti³, Marcel Émond^{4

5}, Ian G Stiell^{6

2}, Grant Stotts⁷, Jacques Lee^{8

9}, Andrew Worster¹⁰, Judy Morris¹¹, Ka Wai Cheung¹², Albert Y Jin¹³, Wieslaw J Oczkowski¹⁴, Demetrios J Sahlas³, Heather E Murray⁴, Ariane Mackey^{5

15}, Steve Verreault^{5

15}, Marie-Christine Camden^{5

15}, Samuel Yip¹⁶, Philip Teal¹⁶, David J Gladstone¹⁷, Mark I Boulos¹⁷, Nicolas Chagnon¹⁸, Elizabeth Shouldice¹⁹, Clare Atzema¹⁰, Tarik Slaoui¹², Jeanne Teitlebaum¹², Kasim Abdulaziz², Marie-Joe Nemnom², George A Wells², Mukul Sharma³

Affiliations

¹ Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada jperry@ohri.ca.
² Ottawa Hospital Research Institute, Ottawa, ON, Canada.
³ Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.
⁴ CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, QC, Canada.
⁵ Division of Emergency Medicine, Université Laval, Québec City, QC, Canada.
⁶ Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
⁷ Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁸ Schwartz\Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada.
⁹ Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁰ McMaster University, Hamilton, ON, Canada.
¹¹ Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, QC, Canada.
¹² University of British Columbia, Vancouver, BC, Canada.
¹³ Division of Neurology, Queen's University, Kingston, ON, Canada.
¹⁴ Division of Neurology, McMaster University, Hamilton, ON, Canada.
¹⁵ Division of Neurology, Laval University, Quebec City, QC, Canada.
¹⁶ Division of Neurology, University of British Columbia, Vancouver, BC, Canada.
¹⁷ Sunnybrook Research Institute and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada.
¹⁸ Department of Emergency Medicine, Montfort Hospital and University of Ottawa, Ottawa, ON, Canada.
¹⁹ Queensway Carleton Hospital and University of Ottawa, Ottawa, ON, Canada.

PMID: 33541890
PMCID: PMC7859838
DOI: 10.1136/bmj.n49

Multicenter Study

Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study

Jeffrey J Perry et al. BMJ. 2021.

. 2021 Feb 4:372:n49.

doi: 10.1136/bmj.n49.

Authors

Affiliations

¹ Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada jperry@ohri.ca.
² Ottawa Hospital Research Institute, Ottawa, ON, Canada.
³ Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.
⁴ CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, QC, Canada.
⁵ Division of Emergency Medicine, Université Laval, Québec City, QC, Canada.
⁶ Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
⁷ Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁸ Schwartz\Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada.
⁹ Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁰ McMaster University, Hamilton, ON, Canada.
¹¹ Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, QC, Canada.
¹² University of British Columbia, Vancouver, BC, Canada.
¹³ Division of Neurology, Queen's University, Kingston, ON, Canada.
¹⁴ Division of Neurology, McMaster University, Hamilton, ON, Canada.
¹⁵ Division of Neurology, Laval University, Quebec City, QC, Canada.
¹⁶ Division of Neurology, University of British Columbia, Vancouver, BC, Canada.
¹⁷ Sunnybrook Research Institute and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada.
¹⁸ Department of Emergency Medicine, Montfort Hospital and University of Ottawa, Ottawa, ON, Canada.
¹⁹ Queensway Carleton Hospital and University of Ottawa, Ottawa, ON, Canada.

PMID: 33541890
PMCID: PMC7859838
DOI: 10.1136/bmj.n49

Erratum in

Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study.
[No authors listed] [No authors listed] BMJ. 2021 Feb 18;372:n453. doi: 10.1136/bmj.n453. BMJ. 2021. PMID: 33602669 Free PMC article. No abstract available.

Abstract

Objective: To validate the previously derived Canadian TIA Score to stratify subsequent stroke risk in a new cohort of emergency department patients with transient ischaemic attack.

Design: Prospective cohort study.

Setting: 13 Canadian emergency departments over five years.

Participants: 7607 consecutively enrolled adult patients attending the emergency department with transient ischaemic attack or minor stroke.

Main outcome measures: The primary outcome was subsequent stroke or carotid endarterectomy/carotid artery stenting within seven days. The secondary outcome was subsequent stroke within seven days (with or without carotid endarterectomy/carotid artery stenting). Telephone follow-up used the validated Questionnaire for Verifying Stroke Free Status at seven and 90 days. All outcomes were adjudicated by panels of three stroke experts, blinded to the index emergency department visit.

Results: Of the 7607 patients, 108 (1.4%) had a subsequent stroke within seven days, 83 (1.1%) had carotid endarterectomy/carotid artery stenting within seven days, and nine had both. The Canadian TIA Score stratified the risk of stroke, carotid endarterectomy/carotid artery stenting, or both within seven days as low (risk ≤0.5%; interval likelihood ratio 0.20, 95% confidence interval 0.09 to 0.44), medium (risk 2.3%; interval likelihood ratio 0.94, 0.85 to 1.04), and high (risk 5.9% interval likelihood ratio 2.56, 2.02 to 3.25) more accurately (area under the curve 0.70, 95% confidence interval 0.66 to 0.73) than did the ABCD2 (0.60, 0.55 to 0.64) or ABCD2i (0.64, 0.59 to 0.68). Results were similar for subsequent stroke regardless of carotid endarterectomy/carotid artery stenting within seven days.

Conclusion: The Canadian TIA Score stratifies patients' seven day risk for stroke, with or without carotid endarterectomy/carotid artery stenting, and is now ready for clinical use. Incorporating this validated risk estimate into management plans should improve early decision making at the index emergency visit regarding benefits of hospital admission, timing of investigations, and prioritisation of specialist referral.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: the study was funded by the Canadian Institutes of Health Research; JJP is supported by a mid-career award from the Heart and Stroke Foundation of Ontario; JL is supported by the Schwartz/Reisman Emergency Medicine Institute inaugural research chair in geriatric emergency medicine; no other relationships or activities that could appear to have influenced the submitted work.

Figures

**Fig 1**
Receiver operating characteristic (ROC) curve for comparison of Canadian TIA Score with ABCD2 and ABCD2i scores for subsequent stroke or carotid revascularisation within 7 days (n=7607)

**Fig 2**
Net reclassification index comparing Canadian TIA Score with ABCD2 and ABCD2i for subsequent stroke or carotid revascularisation within 7 days (n=7607). *Low risk defined by risk of outcome of <1%, medium risk 1-5%, and high risk >5%

See this image and copyright information in PMC

Comment in

Does the Canadian TIA Score adequately risk stratify patients for subsequent stroke and revascularization in the emergency department?
Maguire K, Harris D, Barbic D. Maguire K, et al. CJEM. 2022 Mar;24(2):131-132. doi: 10.1007/s43678-021-00221-9. Epub 2021 Nov 3. CJEM. 2022. PMID: 34734377 No abstract available.

References

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Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study

Affiliations

Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study

Authors

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Erratum in

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Conflict of interest statement

Figures

Comment in

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