Diagnosis and management of transient ischemic attacks in primary care: A systematic review

Abstract

INTRODUCTION: Many patients who suffer a transient ischaemic attack (TIA) present to their general practitioner (GP). Early identification and treatment reduces the risk of subsequent stroke, disability and mortality. AIM: To review the accuracy of TIA diagnosis in primary care, immediate management and interventions to assist GPs with the condition. METHODS: This study included the search of Medline, Embase, Web of Science and Scopus databases (1995-2015). Relevant titles and abstracts were obtained using structured criteria (diagnosis, immediate management or intervention of TIAs in primary care), with full review and data extraction for eligible publications. Two reviewers independently assessed quality and extracted information from the 24 eligible studies. The studies had heterogeneous methodology rendering meta-analysis inappropriate, so a narrative synthesis was undertaken. RESULTS: Most studies found limitations in GPs’ knowledge and ability to diagnose TIAs to varying extent over time and between countries. GPs tended to over-interpret non-specific symptoms (e.g. isolated vertigo) when considering a TIA diagnosis. Reported referral behaviour varied between countries, with some favouring admission and others preferring outpatient management. Consistent under-referral and under-use of effective medication was reported. However, GPs may refer some patients to exclude rather than confirm a final diagnosis. This, alongside evidence of under-referral, suggests the need for education and decision support tools to enhance referral patterns. Intervention studies suggested that electronic decision support may increase referrals and timely management. CONCLUSION: This review revealed deficiencies in knowledge and clinical practice, and identified potential avenues to addressing these. Issues for future research were also identified.