Testing a rapid outpatient management strategy on PTSD, cardiovascular and rehospitalization risk in TIA and minor stroke survivors evaluated in the Emergency Department

最近的研究表明，暴露在急诊科(ED)和 住院护理可能会增加随后发生创伤后应激障碍(PTSD)和复发的风险 到急诊室就诊的短暂性脑缺血发作和轻度患者的心血管事件 中风(TIAMS)。目前，急诊科尚无既定的临床指南。 (Ed)在初步评估和安全确定之后对TIAMS的管理。这项研究将 比较两者最广泛相关的心理和长期心血管结果 美国急诊室对TIAMS患者的管理策略。 我们将使用观察性设计来比较TIAMS诱发的PTSD症状，30天 TIAMS患者的再住院和1年心血管疾病(CVD)/死亡率结果 根据(1)急诊评估和住院治疗策略进行管理，而不是(2)快速 ED评估和出院，并安排第二天门诊神经学随访。此外， 我们将使用动态心电图评估自主神经系统(ANS)对这两种策略的反应性。 这项研究设计是可能的，因为新建立了一项快速访问血管评估- 神经病学(瑞文)TIAMS护理路径，每月提供2周(在 每隔几周)在哥伦比亚大学医学中心。我们假设病人治疗了 在乌鸦周期间，创伤后应激障碍症状较少，30天再住院时间减少，1- 年心血管疾病/死亡风险相对于在住院策略周期间接受治疗的患者。我们 将探索ANS应激标志物(动态心率(HR)和心率变异性 (心率变异性在ED报告后3天内)解释研究结果的任何组差异。 近五分之一的TIA/MS幸存者在事件发生后的一个月内筛查出创伤后应激障碍，研究 在其他心血管疾病患者中，创伤后应激障碍可能会增加复发心血管事件的风险。到目前为止， 将ED/住院患者暴露与随后的创伤后应激障碍联系起来的研究一直无法解开 医疗事件本身造成的压力，以及急诊科/住院病人忙碌时产生的压力 留下来。如果我们的假设是正确的--快速的ED出院和门诊随访可以减少创伤后应激障碍 TIAMS幸存者的症状和改善临床结果--我们的研究结果将影响 立即发布临床指南。此外，这项研究将对 急诊护理与许多其他疾病的门诊随访的临床计算，如急性 冠状动脉综合征，传统上通过长时间的ED观察和住院护理来管理。

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.