News Release

Primary care physicians need more education about stroke diagnosis and treatment

Peer-Reviewed Publication

Duke University Medical Center

NEW ORLEANS -- The closest emergency room, and not a primary care practice, may be the best place to go for patients experiencing the possible symptoms of a stroke, according to the results of a Duke University Medical Center study.

Almost one-third, 32 percent, of patients were not hospitalized or prescribed any specialized tests by their primary care physician (PCP) within 30 days of their first visit after complaining of symptoms characteristic of stroke or so-called mini-strokes, transient ischemic attacks (TIA). The PCPs called for specialist consultations in 45 percent of cases.

"While this study was not intended to determine how these patients fared, the results showed that primary care physicians often didn't take actions that could potentially prevent a much larger stroke in the future," said Duke neurologist Dr. Larry Goldstein, who prepared the results of his team's study for presentation Thursday (Feb. 10) at the American Heart Association's 25th International Stroke Conference.

These early and often seemingly minor symptoms of stroke or TIA are strong predictors of future and more severe events, Goldstein said. If caught early, physicians have treatments available to lower the future risk of a major stroke, whether it be medications to reduce the incidence of blood clots or surgery to remove blockages in vessels supplying blood to the brain. The researchers performed chart reviews of 176 patients in 27 different primary care medical practices in two states (North Carolina and New York). The multi-physician practices saw patients with a mix of both managed care and traditional insurance policies, the researchers said.

"Based on the current results, we need to stress the need for urgent evaluation of patients presenting to their primary care physician with symptoms of cerebrovascular disease," Goldstein said. "Clearly, there needs to be more education about the diagnostic and treatment options available for people at risk for stroke."

The researchers looked retrospectively at physician records for patients who came to their PCP practice without any prior history of cerebrovascular disease. Goldstein said patients who had the dramatic symptoms of a major stroke probably went straight to an emergency room, so these patients were not reflected in the study.

"While our study did not look at the reasons for the primary care physicians' decisions, it is possible that they did not take further action because their patients' symptoms appeared minor or transient, so they were given less weight," Goldstein said. "However, all of the patients included in the study were diagnosed by the primary care physician as having a TIA or stroke and the physicians would be expected to respond accordingly." The common symptoms of stroke include sudden onset of slurred speech, difficulty walking, weakness on one side of the body, blindness in one eye and double vision. In this study, the majority of patients' complaints were limb weakness or numbness and/or speech disturbances.

"I always say the best way to treat a stroke is not to have one," Goldstein said. "Prevention is the cornerstone of management of patients with cerebrovascular disease and primary care physicians are the key providers of medical information and preventive measures." Not too long ago, there were very few treatment options for people suffering from a major stroke, but with the advent of new medications -- particularly the clot buster t-PA (tissue plasminogen activator) -- physicians can treat and even reverse the damage done by a stroke caused by a blockage if administered within three hours of onset of symptoms.

The study also found that specialized imaging studies to determine if patients had blockages in vessels or heart rhythm abnormalities were probably under-utilized by PCPs, Goldstein said. In addition, only 21 percent of TIA and 35 percent of stroke patients received MRI (magnetic resonance imaging) or CT (computed tomography) scans on their first visit.

Atrial fibrillation, an abnormal heart beat, is known to cause clots that can then travel to the brain and cause TIAs or stroke. To test for the condition, PCPs ordered electrocardiograms in 19 percent of cases and echocardiograms in 16 percent of cases.

Each year, more than 700,000 Americans suffer a stroke; of those, more than 150,000 will die, making stroke the third leading cause of death and a leading cause of adult disability in the U.S.

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The study was funded by the U.S. Agency for Health Care Policy Research as a part of its Stroke Prevention Patient Outcomes Research Team.


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