Standing in stark contrast to the public’s response to major stroke, the extensive FAST-based public education campaign has not improved the response to transient ischaemic attack (TIA) or minor stroke in the UK, concluded a recent study published in JAMA Neurology. The authors, Frank J Wolters and colleagues, University of Oxford, Oxford, UK, stressed that this data highlights the need for future campaigns to become tailored specifically to transient and less severe symptoms.
Wolters and colleagues acknowledged that the risk of major stroke is high in the hours, and even days, following a TIA or minor stroke, but can be drastically reduced by urgent medical treatment. The Face, Arm, Speech, Time (FAST) test was adopted as a tool to improve symptom recognition after stroke and has since formed the basis of public education in many countries. The campaign was presented as an ongoing television public awareness campaign in the UK, subsequently improving the public’s response to major stroke. However, what remained unclear was the association of the campaign with response behaviour after TIA or minor stroke, especially considering the differences in the presentation of symptoms, including event duration, severity and coverage by the FAST acronym.
In light of this, Wolters and the team prospectively studied patient perception and behaviour after TIA and stroke in a population-based study before and after the ongoing FAST campaign. Additionally, they investigated the number of early strokes after a TIA for which no medical attention was sought. The sample includes all consecutive incident TIA and stroke cases, with the exception of subarachnoid haemorrhage, that occurred outside the hospital between April 2002 and March 2014. Data analysis was carried out from July 2013 to March 2015.
Among 2243 consecutive patients with first TIA or stroke (mean age: 73.6 years; 50.2% female; 96.3% of white ethnicity), 1656 (73.8%) had a minor stroke or TIA. With regards to response behaviour to major stroke following the FAST campaign, patients more often sought medical attention within three hours (odds ratio [OR]: 2.56; 95% CI: 1.11, 5.90; p=0.03), compared to before the campaign.
In contrast, for TIA and minor stroke, there was no improvement in use of emergency medical services (OR: 0.79; 95% CI: 0.50, 1.23; p for interaction=0.03 vs. major stroke) or time to first seeking medical attention within 24 hours (OR: 0.75; 95% CI: 0.48, 1.19; p for interaction=0.006 vs. major stroke). Moreover, patient perception of symptoms after TIA and minor stroke was found to be associated with more urgent behaviour, but correct perception declined after the FAST campaign (from 37.3% [289 of 774] to 27.6% [178 of 645]; OR: 0.64; 95% CI: 0.51, 0.80; p<0.001). Furthermore, 188 had a stroke within 90 days of their initial TIA or stroke, of whom 93 (49.5%) followed unattended TIAs for which no medical attention was sought; similar before and after the FAST campaign (43 of 538 [8.0%] before vs 50 of 615 [8.1%] after, p=0.93).
In discussion of these findings, Wolters and colleagues noted that as the percentage of strokes that followed shortly after an initial TIA remained unchanged after the FAST campaign, approximately 100 strokes per one million people a year could have been prevented. “These ignored events are an important target for stroke prevention,” stated the authors. They further alluded to the high effectiveness of preventive strategies within the first hours and days after TIA and noted that the influence of public education will largely depend on a campaign’s ability to convince patients to take action within this crucial window of time.
With regards to the decline in correct symptom perception that was observed following the FAST campaign for TIA and minor stroke, the authors attributed this finding to the fact that patients may be falsely reassured when their symptoms do not match the severe symptoms presented via the campaign.
Although Wolters et al maintained that the findings are valid and hold the ability to guide future public education campaigns, they noted a couple of caveats present in the current study. For instance, the retrospective diagnosis of unattended TIAs preceding stroke is subjective, and hence may be prone to recall bias. The authors also acknowledged that they did not ask about individual exposure to and awareness of the campaign that was being investigated. Lastly, increased but slow presentation of otherwise non-presenters after the FAST campaign may have biased time trends of TIA and minor stroke towards the null.
Concluding the study, Wolters and colleagues noted that in contrast to major stroke, the extensive FAST-based public education has not improved the response to TIA and minor stroke in the UK, in turn highlighting the need for campaigns to become tailored specifically to transient and less severe symptoms, in view to encouraging urgent patient response to imminent stroke warning signs.