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Primary Care Physicians Need More Education About Stroke Diagnosis and Treatment

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Duke Health News 919-660-1306

NEW ORLEANS, LA -- 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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