He tells you that about 4 hours previously he was talking to a colleague at work when he noticed his speech suddenly became very slurred. On specific questioning, he says that after about 7-8 minutes it completely resolved and has been normal since. There were no other symptoms at all, in particular headache or motor weakness. This has never happened before.
Duc is usually fit and well, with no significant PMH and on no regular medications. He is a non-smoker and has no FHx of premature CVD.
You suspect a TIA and discuss the need for appropriate investigation and specialist review. However, Duc tells you that he is ‘desperately busy’ at work and not in a position to get the tests done for a few days.
What is the role of the ABCD2 score as a risk stratification tool to help guide urgency of investigation and management?
The ABCD2 score is a widely known tool used to stratify risk of recurrent stroke in adults with suspected TIA. It calculates stroke risk based on the patient’s age, BP, nature and duration of symptoms, and presence of diabetes.
You calculate Duc’s ABCD2 score as 1 point, or ‘low risk’, equating to a 7 day stroke risk of 1.2%.
Risk stratification in TIA patients using ABCD2 has been widely used in the past in an attempt to prioritise urgency of investigation, especially in settings with limited resources. However, a systematic review from 2015 found that ABCD² does not reliably discriminate those at low and high risk of recurrent stroke, and in particular does not identify many patients with carotid stenosis or AF needing urgent intervention.1
The Australian Clinical Guidelines for Stroke Management recommend that ‘use of the ABCD2 risk score in isolation to determine the urgency of investigation may delay recognition of atrial fibrillation and symptomatic carotid stenosis in some patients and should be avoided.’
Therefore, regardless of his low risk score on ABCD2, Duc needs urgent assessment. The stroke guidelines recommend:
Emergencies in General Practice course
Management of emergencies in general practice, as with Duc, is a continually evolving field. Join us from the comfort of your own home on Wednesday 20 July from 8:00PM (AEST). This course will cover the latest in research and practice updates to help you deliver better patient care.
The webinars are delivered by experienced Australian GP medical educators and promise to be practical, relevant and interactive. They will address recent practice updates through a series of emergency scenarios.
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1. Wardlaw JM, Brazzelli M, Chappell FM, Miranda H, Shuler K, Sandercock PAG, Dennis MS. ABCD2 score and secondary stroke prevention. Neurology 2015;85(4):373-380