Prompt attention may limit recurrence risk in TIA patients

By Eleanor McDermid

Centres with procedures in place for the rapid assessment of patients with transient ischaemic attack (TIA) or minor stroke achieve low recurrence rates in these patients, a multinational study shows.

As reported in The New England Journal of Medicine, just 3.7% of patients had an ischaemic stroke within 90 days of assessment. This is markedly lower than reported rates for patients not routinely given prompt assessment, which range from 12% to 20%, say Pierre Amarenco (Bichat Hospital, Paris, France) and study co-authors.

Indeed, the 1-year rate of cardiovascular events, comprising cardiovascular mortality, nonfatal stroke and nonfatal acute coronary syndromes, was just 6.2%, they report.

In an accompanying editorial, Ralph Sacco and Tatjana Rundek, from the University of Miami in Florida, USA, agree that the event rates "are substantially lower than expected".

The 4583 patients were part of the TIAregistry.org and were admitted to 61 clinics in 21 countries. The clinics all had dedicated systems for the care of TIA patients and had admitted at least 100 patients per year over the previous 3 years.

The findings show "that the widespread, systematic implementation of specialized TIA units across multiple sites, countries, and continents can make a difference in the care of these patients", say the editorialists.

Almost all (96.5%) patients underwent brain imaging, with acute infarcts detected in 33.4%. And around 80% underwent vascular imaging, with 13.5% found to have intracranial stenosis and 15.5% extracranial stenosis. Cardiac investigations uncovered arrhythmia in 5.0% of patients and other abnormalities in 4.4%.

As a result of the investigations, 90.2% of the patients received urgent antiplatelet therapy and 8.1% anticoagulation. In addition, 26.9% of patients with carotid stenosis underwent revascularisation with 3.6% doing so urgently. Many patients also received new or intensified antihypertensive treatment and lipid-lowering therapy.

"Therefore, rapid diagnosis by stroke specialists led to effective implementation of evidence-based preventive treatments", say Sacco and Rundek in their editorial.

The researchers identified three independent baseline predictors of 1-year outcomes: multiple acute infarcts on imaging; large-artery atherosclerosis; and an ABCD² stroke risk score of 6 or 7. However, they caution that limiting assessment to patients with an ABCD² score of 4 or more would miss one in five patients with early recurrent strokes.

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