http://www.medpagetoday.com/Cardiology/Strokes/57447?xid=nl_mpt_cardiodaily_2016-04-20&eun=g424561d0r
International registry shows risk much lower than in studies prior to 2004
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Findings from 1-year follow-up the international TIAregistry.org project showed that the risk of stroke was 1.5% at 2 days, 2.1% at 7 days, and 3.7% at 90 days after symptom onset, Pierre Amarenco, MD, of the Stroke Center at Bichat Hospital in Paris, and colleagues reported online in the New England Journal of Medicine.
Previously, the risk of stroke or an acute coronary syndrome had been estimated at 12% to 20% during the first 3 months after a TIA or minor stroke in studies from the 1997-2003 era.
But in Amarenco's non-U.S. registry, the Kaplan-Meier estimate of the 1-year event rate of the composite of stroke, acute coronary syndrome, or death from cardiovascular causes altogether was only 6.2%.
"We observed a lower rate of cardiovascular events after a TIA or minor stroke than that in historical cohorts," the researchers wrote. "Our findings probably reflect the contemporary risk of recurrent cardiovascular events among patients with a TIA or minor stroke who are admitted to TIA clinics and who receive risk-factor control and antithrombotic treatment as recommended by current guidelines."
The risk of stroke was more than doubled in the presence of multiple infarctions on brain imaging, large-artery atherosclerosis, or an ABCD2 (age, blood pressure, clinical findings, duration of symptoms, and presence or absence of diabetes) score of 6 or 7, the researchers said.
However, they added, not all patients needing immediate treatment are identified by an ABCD2 score of 4 or more.
"Although we found that the ABCD2 score was a good predictor of risk, our findings suggest that limiting urgent assessment to patients with a score of 4 or more would miss approximately 20% of those with early recurrent strokes," the researchers emphasized.
The findings also suggested that large-artery atherosclerosis is associated with a significantly higher risk than other stroke subtypes (P<0.001). "In the event of cardiac disease (e.g., atrial fibrillation), anticoagulant therapy in addition to risk-factor control is so effective that the residual risk of stroke after these interventions is probably very low," said the researchers. "In patients with small-vessel disease, blood pressure-lowering therapy is very effective when combined with other risk-factor management and antiplatelet therapy."
The prospective, observational TIAregistry.com project enrolled 4,789 patients with a TIA or minor ischemic stroke within the prior 7 days at 61 sites in 21 countries from 2009 through 2011, with planned 5 year follow-up.
This report on 1-year outcomes showed showed that more than three-quarters of patients were evaluated by stroke specialists within 24 hours of symptom onset. A total of 33.4% of the patients had an acute brain infarction, 23.2% had at least one extracranial or intracranial stenosis of 50% or more, and 10.4% had atrial fibrillation.
In an accompanying editorial, Ralph L. Sacco, MD, and Tatjana Rundek, MD, PhD, from the University of Miami, said this study underscores the need for changes to systems of stroke care to provide the most effective treatment not just for patients with acute stroke but also for those with TIA or minor stroke.
"The TIAregistry.org results support the value of organizing specialized units for the care of patients with a TIA or minor stroke where rapid diagnostic evaluations and evidence-based preventive treatments by stroke specialists can be initiated promptly and lead to reduced early and late risks of stroke," they wrote. "The study showed 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."
The excellent adherence rates of self-reported medication use at 3 months and 12 months seen in the TIAregistry.com project were in stark contrast to those often seen when patients are discharged from hospital-based specialized units into an outpatient setting, the editorialists noted. In the latter, breakdowns in communication between care providers can lead to poor adherence, they explained. "Both early institution and sustained adherence of evidence-based stroke-prevention treatments are necessary to achieve better outcomes."
Also, while the ABCD2 score can help predict risk of stroke recurrence, the study showed that 22% of strokes actually took place in patients with a score of less than 4, indicating there were other factors at work.
"Although an ABCD2 score of 6 or 7 identified patients with suspected TIA at high risk for stroke, the authors found other independent predictors of stroke risk including large-artery atherosclerosis and multiple infarctions on MRI that require rapid diagnostic testing," Sacco and Rundek said. "The latter, new finding may be useful for inclusion in risk-prediction models."
Limitations of the study included the fact that all participating sites were expert specialized programs and not randomly selected. In addition, no U.S. sites participated and patients from just three countries -- Germany, Spain and France -- made up 48% of the study population, they pointed out.
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