Transient Ischaemic Attack (TIA) Prediction Rules
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National Institute for Health and Care Excellence 1 Draft for consultation Stroke (update) Evidence review B: transient ischaemic attack (TIA) prediction rules NICE guideline Prognostic evidence review November 2018 Draft for consultation This evidence review was developed by the National Guideline Centre STROKE (UPDATE): DRAFT FOR CONSULTATION Contents 1 Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian. Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © NICE 2018. All rights reserved. Subject to Notice of rights. STROKE (UPDATE): DRAFT FOR CONSULTATION Contents Contents 1 Risk prediction scores ................................................................................................. 5 1.1 Review question: How accurately do scoring systems predict the risks of future ischaemic stroke or transient ischaemic attack (TIA) within the first 7 days in people with suspected TIA? ...................................................................... 5 1.2 Introduction ........................................................................................................... 5 1.3 PICO table ............................................................................................................. 5 1.4 Methods and process ............................................................................................ 6 1.5 Clinical evidence ................................................................................................... 6 1.5.1 Included studies ......................................................................................... 6 1.5.2 Excluded studies ........................................................................................ 8 1.5.4 Quality assessment of clinical studies included in the evidence review .... 11 1.6 Economic evidence ............................................................................................. 15 1.6.1 Included studies ....................................................................................... 15 1.6.2 Summary of studies included in the economic evidence review ............... 16 1.6.3 Unit costs ................................................................................................. 19 1.7 Resource costs ................................................................................................... 19 1.8 Evidence statements ........................................................................................... 19 1.8.1 Clinical evidence statements .................................................................... 19 1.8.2 Health economic evidence statements ..................................................... 20 1.9 Recommendations .............................................................................................. 20 B2. Do not use scoring systems, such as ABCD2, to assess risk of subsequent stroke. [2019] ........................................................................ 20 1.10 Rationale and impact ........................................................................................... 20 1.10.1 Why the committee made the recommendations ...................................... 20 1.10.2 Impact of the recommendations on practice ............................................. 21 1.11 The committee’s discussion of the evidence ........................................................ 22 1.11.1 Interpreting the evidence .......................................................................... 22 1.11.2 Cost effectiveness and resource use ....................................................... 23 1.11.3 Other factors the committee took into account ......................................... 24 Appendices ........................................................................................................................ 33 Appendix A: Review protocols ................................................................................... 33 Appendix B: Literature search strategies ................................................................... 38 B.1 Clinical search literature search strategy ...................................................... 38 B.2 Health Economics literature search strategy ................................................. 43 B.2.1 Health economics search ................................................................ 43 Appendix C: Clinical evidence selection ..................................................................... 48 Appendix D: Clinical evidence tables ......................................................................... 49 Appendix E: Health economic evidence selection ...................................................... 62 Appendix F: Health economic evidence tables .......................................................... 64 3 STROKE (UPDATE): DRAFT FOR CONSULTATION Contents Appendix G: Excluded studies.................................................................................... 67 G.1 Excluded clinical studies ............................................................................... 67 1 4 STROKE (UPDATE): DRAFT FOR CONSULTATION Risk prediction scores 1 1 Risk prediction scores 1.1 2 Review question: How accurately do scoring systems 3 predict the risks of future ischaemic stroke or transient 4 ischaemic attack (TIA) within the first 7 days in people with 5 suspected TIA? 1.2 6 Introduction 7 Patients who have experienced a TIA are at increased risk of having a stroke in the days and 8 weeks following the TIA. Scoring systems have been developed to stratify TIA patients 9 according to their individual future risk of stroke or TIA. The results of these TIA risk scoring 10 systems have been used to guide decisions about the rapidity of access to specialist 11 assessment following a TIA; however these tools are not applied consistently in practice. The 12 committee considered how accurately these scoring systems predicted the risk of stroke or 13 TIA in the first seven days following a TIA and whether these should be used to guide current 14 practice. 1.3 15 PICO table 16 For full details see the review protocol in appendix A. 17 Table 1: PICO characteristics of review question Population People aged over 16 with suspected TIA Risk tool Validated risk stratification tools/scoring systems (ABCD2 and other variants e.g. ABCD2-I, ABCD3, ABCD3-I) Target Stroke or TIA within 7 days condition Outcomes Discrimination (area under curve [c statistic]) Calibration (R2, Brier Score, Hosmer-Lemeshow test statistic; Somers’ D statistic), Calibration plot Reclassification These will be assessed for the following outcomes: Critical Risk of stroke (stroke at 24 hours, 72 hours and 7 days) Mortality (7 day) Important Functional outcomes – modified Rankin scale (mRS) 90 days and 1 year Quality of life Study design Prospective observational studies Systematic reviews and meta-analyses of the above Exclusions: derivation studies/internal validation studies © NICE 2018. All rights reserved. Subject to Notice of rights. 5 STROKE (UPDATE): DRAFT FOR CONSULTATION Risk prediction scores 1.4 1 Methods and process 2 This evidence review was developed using the methods and process described in 3 Developing NICE guidelines: the manual.19 Methods specific to this review question are 4 described in the review protocol in appendix A. 5 Declarations of interest were recorded according to NICE’s 2014 conflicts of interest policy 6 upto March 2018, and NICE’s 2018 conflicts of interest policy from April 2018. 7 Risk of bias was assessed using the prediction study risk of bias assessment tool 8 (PROBAST) risk of bias checklist for primary studies or the ROBIS checklist for systematic 9 reviews, including individual patient data (IPD) meta-analyses. IPD analyses were included in 10 the same way as published systematic reviews, with the outcomes reported as described in 11 the IPD analysis and risk of bias assessed for the IPD analysis per outcome. 12 Note that this question is an update and included in the previous guideline. Search strategies 13 run from 2008 onward. The previous guideline included 4 studies,10, 42, 74, 82 none of which 14 meet the protocol for this review. Three of these studies related