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

测试针对 PTSD、TIA 心血管和再住院风险以及急诊科评估的轻微中风幸存者的快速门诊管理策略

• 批准号: 9754258
• 负责人: Bernard P. Chang
• 金额: $ 67.56万
• 依托单位: COLUMBIA UNIVERSITY HEALTH SCIENCES
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-08-01 至 2023-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9754258
• 关键词: Academic Medical Centers; Accelerometer; Accident and Emergency department; Acute; Admission activity; Affect; Autonomic nervous system; Blood Vessels; Calculi; Cardiovascular Diseases; Cardiovascular system; Caring; Clinic; Clinical; Clinical Practice Variations; Cohort Studies; Development; Devices; Diagnostic Imaging; Disease; Disease Outcome; Electrocardiogram; Eligibility Determination; Emergency Care; Emergency Department evaluation; Enrollment; Environment; Equipoise; Ethics; Evaluation; Event; Exposure to; Funding; Guidelines; Heart Rate; Home environment; Hospitalization; Hour; Infrastructure; Inpatients; Intuition; Ischemia; Knowledge; Link; Measures; Medical; Minor; Monitor; National Heart, Lung, and Blood Institute; Natural experiment; Neurologic Dysfunctions; Neurology; Outcome; Outcome Study; Outpatients; Participant; Pathway interactions; Patient-Focused Outcomes; Patients; Physiological; Post-Traumatic Stress Disorders; Randomized; Recurrence; Relative Risks; Research; Research Design; Risk; Safety; Schedule; Stress; Stroke; Survivors; Symptoms; Testing; Time; Transient Ischemic Attack; United States National Institutes of Health; Variant; acute coronary syndrome; acute stress; adjudicate; cardiovascular disorder risk; clinical decision-making; cost; design; disorder risk; follow-up; heart rate variability; hospital readmission; improved; indexing; inpatient service; mortality; mortality risk; patient-clinician communication; post stroke; primary outcome; psychologic; secondary outcome; stroke patient; stroke risk; stroke survivor; stroke symptom

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.

最近的研究表明，暴露在急诊科 (ED) 和 住院治疗可能会增加随后发生创伤后应激障碍 (PTSD) 和复发的风险 因短暂性脑缺血发作和轻微症状而到急诊室就诊的患者的心血管事件 中风（TIAMS）。目前尚无针对急诊科的既定临床指南 (ED) 初步评估和安全性确定后的 TIAMS 管理。这项研究将 比较与两种最广泛相关的心理和长期心血管结局 采用在美国急诊室管理 TIAMS 患者的策略。 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) 急诊室评估和住院策略进行管理，对比 (2) 快速 急诊室评估和出院，并安排第二天的门诊神经科随访。更远， 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。 这项研究设计之所以成为可能，是因为新建立的快速血管评估 - 神经病学 (RAVEN) TIAMS 护理途径，每月将提供 2 周（于 交替几周）在哥伦比亚大学医学中心。我们假设接受治疗的患者 在 RAVEN 周期间，PTSD 症状会减少，30 天再住院次数会减少，并且 1- 与住院策略周期间接受治疗的患者相比，一年的 CVD/死亡风险。我们 将探讨 ANS 压力标记（动态心率 (HR) 和心率变异性）是否 （HRV）在 ED 报告后 3 天）解释研究结果的任何组间差异。 近五分之一的 TIA/MS 幸存者在事件发生后一个月内筛查出 PTSD 呈阳性，并且研究 其他 CVD 患者的研究表明，PTSD 可能会增加 CVD 事件复发的风险。迄今为止， 将急诊室/住院患者接触与随后的创伤后应激障碍联系起来的研究未能理清这一问题 因医疗事件本身而产生的压力，因忙碌的急诊室/住院病人而产生的压力 停留。如果我们的假设是正确的——快速急诊出院和门诊随访可以减少 PTSD 症状并改善 TIAMS 幸存者的临床结果——我们的研究结果将影响 立即提供临床指南。此外，这项研究还将对以下领域产生更广泛的影响： 急诊室护理的临床计算与许多其他疾病（例如急性疾病）的门诊随访的比较 冠状动脉综合征，传统上通过长期急诊观察和住院护理来治疗。