Response to Letter by Bray et al
We thank Dr Bray et al for their interest in our work on the predictive value of the ABCD score.1 They raise a number of interesting points on what should come next: should the ABCD/D2 scores be widely implemented in the ED? And if so, how and by which health professionals?
We think that an effective tool for stratifying risk of stroke after a TIA is bound to become popular, if nothing else because it holds promise of being cost effective. By solving the question of who should be immediately and aggressively targeted after a TIA, healthcare providers can actually expect to improve quality of care, meanwhile possibly saving some expenditures. In fact, we have already been asked by the Regional Health Commision to draft a proposal for triaging TIAs in the ER according to a prognostic tool and designate different pathways depending on risk stratification: such institutional support will help attain wider implementation of the score.
As for who should be educated to use the score, we think that, at least in countries such as ours, where a widespread network of neurologists is in place, they should be the first target, as they are almost always called on to decide how a suspected TIA should be managed. But targets should vary depending on local health systems, and we agree that as Bray et al rightly state: “The uptake of the ABCD score is fraught with the same difficulties as introducing any protocols in the ED”. Indeed, we all remember how diffficult it was to alert ED staff to activate pathways leading to thrombolysis,2 but we are getting there, even if it takes time.
Finally, in order to obtain widespread use of prognostic scores after TIAs, it is very important that the scientific community continue validating and perfecting them, showing their efficacy and cost-effectiveness.
Sciolla R, Melis F; for the SINPAC Group. Rapid identification of high-risk transient ischemic attacks: prospective validation of the ABCD score. Stroke. 2008; 39: 297–302.
California Acute Stroke Pilot Registry (CASPR) Investigators. Prioritizing interventions to improve rates of thrombolysis for ischemic stroke. Neurology. 2005; 64: 654–659.