Fast stroke assessment
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Fast Stroke Assessment: Comparing FAST, BEFAST, and Other Prehospital Scales
Introduction to Stroke Assessment Scales
Stroke is a medical emergency that requires rapid identification and treatment to minimize brain damage and improve patient outcomes. Various prehospital stroke assessment scales have been developed to aid in the quick identification of stroke symptoms. Among these, the Face, Arm, Speech Test (FAST) and the Balance, Eyes, Face, Arm, Speech, Time (BEFAST) scales are widely used. This article synthesizes recent research comparing the effectiveness of these scales and others in fast stroke assessment.
FAST vs. BEFAST in Acute Ischemic Stroke
Sensitivity and Specificity
The FAST scale, which assesses facial drooping, arm weakness, and speech difficulties, has been a cornerstone in stroke identification. However, the BEFAST scale adds two additional components: balance and eye movement, aiming to improve detection accuracy. A meta-analysis comparing these scales found that FAST had a sensitivity of 0.77 and specificity of 0.60, while BEFAST had a sensitivity of 0.68 and specificity of 0.85. The area under the ROC curve was higher for BEFAST (0.86) compared to FAST (0.76), indicating that BEFAST may offer better diagnostic accuracy for acute ischemic stroke 1.
In-Hospital vs. Community Settings
Research has also evaluated the performance of BEFAST in different settings. In a study of in-hospital stroke alerts, BEFAST demonstrated a sensitivity of 85% for diagnosing acute ischemic stroke, which was slightly lower than its performance in community settings (94%). However, for inpatients with an intact level of consciousness, BEFAST's sensitivity was comparable to community settings at 92% 3. This suggests that BEFAST is a highly sensitive tool for both in-hospital and community stroke detection.
FAST vs. ROSIER in Prehospital Settings
Another study compared the FAST scale with the Recognition of Stroke in the Emergency Room (ROSIER) tool in prehospital settings. Both scales showed similar sensitivities for stroke recognition, but ROSIER demonstrated higher specificity 2. This indicates that while both tools are effective, ROSIER may reduce false positives more effectively than FAST.
FAST-ED and Other Scales for Large Vessel Occlusion (LVO)
FAST-ED Scale
The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale was developed to identify large vessel occlusion strokes (LVOS), which require rapid intervention. FAST-ED has shown comparable accuracy to the National Institutes of Health Stroke Scale (NIHSS) and higher accuracy than other scales like the Rapid Arterial Occlusion Evaluation (RACE) and Cincinnati Prehospital Stroke Severity (CPSS) scales 46. A study found that a FAST-ED score of 4 or higher had a sensitivity of 77.78% and specificity of 65.34% for identifying LVOS 10.
Comparison of Multiple Scales
A comprehensive study compared eight prehospital stroke scales, including RACE, Los Angeles Motor Scale (LAMS), and G-FAST, among others. The RACE scale had the highest area under the ROC curve (0.83), followed closely by G-FAST and CG-FAST, indicating that these scales are highly effective for detecting intracranial large-vessel occlusion 7. The CG-FAST scale, in particular, showed higher accuracy than other prehospital prediction scales, making it a promising tool for rapid stroke identification 8.
Impact of Public Education Campaigns
Public education campaigns, such as the UK's FAST TV campaign, have significantly improved the speed at which stroke patients seek medical attention. Following the campaign, patients were more likely to present directly to emergency services and arrive at the hospital within three hours, reducing delays in treatment 5. This highlights the importance of public awareness in improving stroke outcomes.
Conclusion
In summary, while the FAST scale remains a valuable tool for stroke identification, the BEFAST scale offers improved diagnostic accuracy by including additional symptoms. For identifying large vessel occlusion strokes, the FAST-ED and other scales like RACE and CG-FAST show high effectiveness. Public education campaigns further enhance the timely response to stroke symptoms, underscoring the critical role of awareness in stroke management.
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Most relevant research papers on this topic
A Systematic Review and Meta-Analysis Comparing FAST and BEFAST in Acute Stroke Patients
BEFAST has a higher diagnostic value than FAST in acute ischemic stroke, potentially playing a crucial role in fast recognition of the condition.
Meta-AnalysisBET 2: FAST or ROSIER to identify suspected stroke in the prehospital setting?
Both FAST and ROSIER screening tools have similar sensitivity in recognizing stroke in the prehospital setting, with ROSIER showing higher specificity.
Systematic ReviewBE-FAST: A Sensitive Screening Tool to Identify In-Hospital Acute Ischemic Stroke.
BE-FAST is a very sensitive tool for screening in-hospital acute ischemic strokes, including those candidates for acute reperfusion therapy.
Observational StudyField Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes
The FAST-ED scale is a simple, accurate prehospital scale that can identify large vessel occlusion strokes, potentially enabling rapid patient triage.
Observational Study
Very Rigorous Journal
Highly CitedSustained impact of UK FAST-test public education on response to stroke: a population-based time-series study
The UK FAST-test public education campaign significantly reduced delays in seeking medical attention after major stroke, with nearly 90% of patients seeking help bystander-led.
Observational StudyVery Rigorous JournalHighly CitedLetter by Heldner et al Regarding Article, "Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes".
The FAST-ED scale is a simple and accurate prehospital scale for detecting large vessel occlusion strokes, showing similar discrimination capacity to the total NIHSS score and higher discrimination capacity than the Rapid Arterial Occlusion Evaluation and Cincinnati Prehospital Stroke Severity scale.
Observational StudyVery Rigorous JournalComparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study
Prehospital stroke scales can effectively identify patients with large-vessel occlusion in suspected stroke patients, ensuring timely transport to endovascular treatment centers.
Observational StudyHighly CitedConveniently-Grasped Field Assessment Stroke Triage (CG-FAST): A Modified Scale to Detect Large Vessel Occlusion Stroke
The CG-FAST scale is an effective and simple tool for accurately detecting large vessel occlusion stroke in acute ischemic stroke patients.
Observational StudyPrognostic Value of BEFAST vs. FAST to Identify Stroke in a Prehospital Setting
Adding coordination and diplopia assessments to the BEFAST scale does not improve stroke detection in the prehospital setting.
Observational StudyPrehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes
The FAST-ED is a useful secondary stroke screen in prehospital settings, but its specificity is lower than the CPSS, suggesting EMS agencies should consider single versus secondary scales and ideal sensitivity and specificity.
Observational Study