Recent research suggests that exposure to stressful aspects of emergency department (ED) and inpatient care may increase risk for subsequent posttraumatic stress disorder (PTSD) and recurrent cardiovascular events in patients who present to the ED with transient ischemic attacks and minor strokes (TIAMS). There are currently no established clinical guidelines for emergency department (ED) management of TIAMS after the initial evaluation and safety determination. This study will compare psychological and long-term cardiovascular outcomes associated with the two most widely employed strategies for managing TIAMS patients in US EDs. We will use an observational design to compare TIAMS-induced PTSD symptoms, 30-day rehospitalization, and 1-year cardiovascular disease (CVD)/mortality outcomes in TIAMS patients managed according to (1) ED evaluation followed by inpatient admission strategy, versus (2) rapid ED evaluation and discharge with a scheduled next-day outpatient neurology follow-up. Further, we will assess autonomic nervous system (ANS) reactivity to the 2 strategies using ambulatory ECG. This study design is possible because of a newly established Rapid Access Vascular Evaluation- Neurology (RAVEN) TIAMS care pathway, which will be available for 2 weeks per month (on alternating weeks) at Columbia University Medical Center. We hypothesize that patients treated during RAVEN weeks will have lower PTSD symptoms, reduced 30d rehospitalization, and lower 1- year CVD/mortality risk relative to those treated during the inpatient admission strategy weeks. We will explore whether ANS markers of stress (ambulatory heart rate (HR) and heart rate variability (HRV) in the 3 days after ED presentation) explain any group differences in study outcomes. Nearly 1 in 5 TIA/MS survivors screen positive for PTSD in the month after the event, and research in other CVD patients suggests that PTSD may increase risk for recurrent CVD events. To date, research linking ED/inpatient exposure with subsequent PTSD has been unable to disentangle the stress that results from the medical event itself from stress resulting from the hectic ED/inpatient stay. If our hypothesis is correct -- that rapid ED discharge and outpatient follow-up reduces PTSD symptoms and improves clinical outcomes in TIAMS survivors-- the results of our study will impact clinical guidelines immediately. Furthermore, the study will have broader implications for the clinical calculus of ED care versus outpatient follow-up for many other diseases, such as acute coronary syndrome, traditionally managed with prolonged ED observation and inpatient care.
More than 1 in 5 survivors of transient ischemic attack (TIA) and minor stroke develop PTSD, which may increase risk for subsequent cardiovascular events and mortality. We will capitalize on current clinical equipoise for whether TIA and minor stroke patients should be managed in the ED or discharged to rapid outpatient neurology follow-up to test the hypothesis that prolonged exposure to the ED and inpatient environments increases PTSD after cardiovascular events. If our hypothesis is correct, the knowledge gained from this study could shift clinical decision making?not only for TIA and minor stroke patients, but for all patients for whom ED/inpatient stays may be unnecessary and potentially harmful.
