The Diagnosis and Management of Transient Ischemic Attacks (TIA) in Primary Care: a Systematic Review

Background Many patients with Transient Ischaemic Attack (TIA) present to their general practitioner. Early identification and treatment reduces the risk of subsequent stroke and consequent disability and mortality. Objectives To review the accuracy of diagnosis of TIA in Primary Care, immediate management and interventions to assist GPs with the condition. Methods Articles were obtained by searching Medline, Embase, Web of Science and Scopus databases (1995 to 2015). Titles and abstracts deemed relevant using structured criteria were retained (diagnosis, immediate management and/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 selected studies. The studies had heterogeneous methodology rendering meta-analysis inappropriate and so a narrative synthesis was undertaken. Results Most studies found limitations in GPs knowledge and ability to diagnose TIA, the extent of which varied 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 evidence of under-referral and under-use of effective medication was reported. However, it is expected that GPs will refer some patients to exclude rather than confirm a final diagnosis. With this point, alongside the evidence of under referral suggests the need for education and/or decision support tools to enhance referral patterns. Intervention studies suggested that Electronic Decision Software (EDS) may increase referrals and timely management. Conclusion This review has revealed deficiencies in knowledge and clinical practice, and identified potential avenues to addressing these. We have also identified issues for future research. Prospero registration number: CRD42016032995