COMMENTARY

Prognosis After a Transient Ischemic Attack or Minor Stroke

Hans-Christoph Diener, MD, PhD

Disclosures

May 17, 2016

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Dear colleagues, I am Christoph Diener, a neurologist from the University of Essen in Germany. My topic today is the prognosis of transient ischemic attack (TIA) and minor stroke. Let me remind you that these patients have a relatively high risk for recurrent stroke or a cardiovascular event. There are data from between 1997 and 2003 showing that people who had a TIA or minor stroke had a risk of having an ischemic stroke or an acute coronary event within the next 3 months somewhere between 12% and 20%.[1,2] This was reinvestigated by the TIAregistry.org investigators who recently published their findings in the New England Journal of Medicine.[3]

These investigators looked at the 1-year risk for stroke and the combined endpoint of stroke, acute coronary syndrome, and cardiovascular deaths in patients who had a TIA or a minor stroke. They also used the ABCD2 score, which uses age, blood pressure, clinical symptoms, duration of TIA, and diabetes. This score runs between 0 and 7 and helps determine stroke risk in the next 7 days and if the patient should be admitted.

This study was done between 2009 and 2011, and it recruited 4789 patients with a TIA or a minor stroke from 21 different countries. What they found was that 33% of these patients had infarction on brain imaging, irrespective of whether the clinical symptoms were TIA or a minor stroke; 23% had large vessel disease (ie, stenosis of the brain-supplying arteries of 50% or more); and 10% had atrial fibrillation. Within 1 year, the rate for the composite endpoint of stroke, acute coronary syndrome, and vascular deaths was 6.2%. The 2-day, 7-day, 30-day, 90-day, and 1-year stroke rates were 1.5%, 2.1%, 2.8%, 3.7%, and 5.1%, respectively.

The investigators also identified predictors for stroke and the composite endpoint. The most important predictors were multiple infarcts on imaging, which usually indicates a cardiac source of embolism, the presence of large vessel disease, and an ABCD2 score of 6 or 7.

The most important point in this study is that quite obviously the risk for stroke is much lower than it was 10 years ago. This is very reassuring because it shows that these patients are taken care of very quickly. They are seen in TIA clinics, or they are admitted to stroke units, and the doctors quickly initiate secondary stroke prevention in terms of antiplatelet therapy or anticoagulation. Patients also get antihypertensive drugs and statins, and a lot of other risk factors are controlled.

The other important issue for me is that I don't think that patients who have had a TIA should be referred to a TIA clinic. They need to be admitted to a stroke unit. Like patients who have a stroke, their diagnostic procedures have to be done immediately, and secondary prevention needs to start on the same day.

These are very reassuring data, as the risk for stroke in vascular events decreased in the last 10 years due to the much better care that we give patients with TIA or minor strokes.

I'm Christoph Diener, a stroke neurologist, from the University of Essen in Germany. Thank you very much for listening.

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