Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison

Rothwell, Peter M.; Giles, Matthew F.; Chandratheva, Arvind; Marquardt, Lars; Geraghty, Olivia; Redgrave, Jessica; Lovelock, Caroline; Binney, Lucy E; Bull, Linda; Cuthbertson, Fiona C.; Welch, Sarah; Bosch, Shelley; Carasco-Alexander, Faye; Silver, L E; Gutnikov, Sergei A.; Mehta, Ziyah

doi:10.1016/s0140-6736(07)61448-2

Cited by 1,088 publications

(984 citation statements)

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“…9,10 The rapid initiation of antiplatelet agents and early assessment in a dedicated stroke prevention clinic can cut this risk dramatically, and both interventions were used in our cohort, 14,21,22 as evidenced by a relatively low overall rate of stroke. Despite these interventions, patients with isolated aphasia in this study had double the rate of stroke at all time points assessed and a 7.3% rate of stroke at 90 days.…”

Section: Discussionmentioning

confidence: 99%

Isolated transient aphasia at emergency presentation is associated with a high rate of cardioembolic embolism

Wasserman

Perry

Dowlatshahi

et al. 2015

CJEM

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Objective: A cardiac source is often implicated in strokes where the deficit includes aphasia. However, less is known about the etiology of isolated aphasia during transient ischemic attack (TIA). Our objective was to determine whether patients with isolated aphasia are likely to have a cardioembolic etiology for their TIA. Methods: We prospectively studied a cohort of TIA patients in eight tertiary-care emergency departments. Patients with isolated aphasia were identified by the treating physician at the time of emergency department presentation. Patients with dysarthria (i.e., a phonation disturbance) were not included. Potential cardiac sources for embolism were defined as atrial fibrillation on history, electrocardiogram, Holter monitor, atrial fibrillation on echocardiography, or thrombus on echocardiography. Results: Of the 2,360 TIA patients identified, 1,155 had neurological deficits at the time of the emergency physician assessment and were included in this analysis, and 41 had isolated aphasia as their only neurological deficit. Patients with isolated aphasia were older (73.9 ± 10.0 v. 67.2 ± 14.5 years; p = 0.003), more likely to have a history of heart failure (9.8% v. 2.6%; p = 0.027), and were twice as likely to have any cardiac source of embolism (22.0% v. 10.6%; p = 0.037). Conclusions: Isolated aphasia is associated with a high rate of cardioembolic sources of embolism after TIA. Emergency patients with isolated aphasia diagnosed with a TIA warrant a rapid and thorough assessment for a cardioembolic source. RÉSUMÉObjectif: L'origine cardiaque est souvent incriminée dans les accidents vasculaires cérébraux dans lesquels le déficit neurologique comprend de l'aphasie. Cependant, on connaît peu de choses sur la cause de l'aphasie isolée durant les accidents ischémiques transitoires (AIT). L'étude visait donc à déterminer si les patients atteints d'aphasie isolée étaient plus susceptibles de subir un AIT d'origine cardioembolique. Méthode: Il s'agit d'une étude prospective de cohortes, composées de patients qui ont subi un AIT et qui ont été examinés dans 8 services d'urgence (SU) de soins tertiaires. Ceux qui présentai-ent des signes d'aphasie isolée étaient reconnus par le médecin traitant au moment de la consultation au SU. Les malades souffrant de dysarthrie (c'est-à-dire de troubles de la phonation) ont été écartés. Les sources possibles d'embolie d'origine cardiaque comprenaient la mention d'antécédents de fibrillation auriculaire (FA) à l'anamnèse; la présence de FA à l'électrocardio-graphie, à l'enregistrement de Holter ou à l'échocardiographie; ou encore la présence de thrombus à l'échocardiographie. Résultats: Sur 2360 patients qui avaient subi un AIT, 1155 présentaient un déficit neurologique au moment de l'évalua-tion par l'urgentologue et ont été sélectionnés aux fins de l'analyse; parmi ceux-ci, 41 avaient comme seul déficit neurologique de l'aphasie isolée. Les patients atteints d'aphasie isolée étaient plus âgés que ceux qui étaient épargnés (73,9 ± 10,0 contre [c.] 67,2 ± 14,...

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Section: Discussionmentioning

confidence: 99%

Isolated transient aphasia at emergency presentation is associated with a high rate of cardioembolic embolism

Wasserman

Perry

Dowlatshahi

et al. 2015

CJEM

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“…Urgent secondary prophylactic treatment(s) decrease the risk of (recurrent) stroke considerably after TIA or minor stroke due to arterial thromboembolism (Rothwell et al., 2007). However, the risk of recurrent stroke did not decrease over time with APT in patients with arterial embolisms (Lemmens et al., 2009).…”

Section: Introductionmentioning

confidence: 99%

Secondary prophylactic treatment and long‐term prognosis after TIA and different subtypes of stroke. A 25‐year follow‐up hospital‐based observational study

Eriksson

2016

Brain and Behavior

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ObjectivesTo assess long‐term prognosis after transient ischemic attack (TIA)/subtypes of stroke relative to secondary prophylactic treatment(s) given.Materials and MethodsRetro/prospective follow‐up of patients hospitalized in the Stroke Unit or in the Department of Neurology, Linköping, in 1986 and followed up to Feb. 2011.ResultsA total of 288 men were followed up for 2254 years (mean 7.8 years) and 261 women for 1984 years (mean 7.6 years). In men, the distribution to anticoagulants (AC) (warfarin treatment) was 18%, antiplatelet therapy (APT) usually ASA 75 mg/day 54%, untreated 27%, unknown 2%. In women, the distribution to AC was 15%, APT 60%, untreated 23%, unknown 2%, respectively. Mortality rates at 1 year, 10 years, and 25 years for men were 21%, 67%, and 93%, respectively, versus the rates in women of 24%, 71%, and 90%, respectively. Survival curves showed markedly increased risk of death compared to the normal population. AC treatment was more favorable for men regarding the annual risk of stroke, compared with APT (9.4% vs. 9.8%), as well as the risks of MI, (5.6% vs. 6.7%), and death (8.1% vs. 10.3%), compared to women for stroke (11.6% vs. 8.8%) and MI (5.3% vs. 3.7%) but not for death (8.3% vs. 8.4%). The risk of fatal bleeding was 0.86% annually on AC compared to 0.17% on APT. According to Cox regression analysis included patients with TIA/ischemic stroke, first‐line treatment had beneficial effects on survival: AC OR 0.67 (0.5–0.9), APT 0.67 (0.52–0.88) versus untreated.ConclusionsPatients with a history of TIA/stroke had a higher mortality rate versus controls, providing support for both primary and secondary prophylaxis regarding vascular risk factors for death. This study also provided support for secondary prophylactic treatment with either AC or ASA (75 mg once daily) to reduce the vascular risk of death unless there are contraindications.

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“…5,9,10 Using data from 12 specialized stroke centers in Ontario between 2003 and 2008, Webster et al (2011) found that referral of patients with ischemic stroke or TIA to a designated neurovascular clinic was associated with a 29% reduction in 1-year mortality (HR, 0.71; 95% CI, 0.65-0.84). Similar to our study, Webster et al (2011) found that only 47% of the study population was referred to the neurovascular clinic in follow-up, indicating that outpatient neurovascular clinics may be underutilized.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4] Early assessment in a dedicated neurovascular clinic and immediate initiation of medical and surgical therapy have been shown to reduce the risk of major stroke after TIA by up to 80%. 5 Patients with TIA often present to the emergency department (ED) for initial evaluation. The current Canadian Best Practice Recommendations for stroke (and TIA) stipulate that any patient who presents to the ED with a suspected recent stroke or TIA undergo assessment within 24 hours that includes brain imaging, noninvasive vascular imaging (for suspected carotid territory events), electrocardiogram (ECG), initiation or modification of secondary prevention therapy (antihypertensive, lipid-lowering, glucose-lowering, or anticoagulation therapy), and referral to a designated stroke prevention clinic for risk factor assessment.…”

Section: Introductionmentioning

confidence: 99%

Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic

Hosier

Phillips

Doucette

et al. 2016

CJEM

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Objectives: 1) To evaluate whether transient ischemic attack (TIA) management in emergency departments (EDs) of the Nova Scotia Capital District Health Authority followed Canadian Best Practice Recommendations, and 2) to assess the impact of being followed up in a dedicated outpatient neurovascular clinic. Methods: Retrospective chart review of all patients discharged from EDs in our district from January 1, 2011 to December 31, 2012 with a diagnosis of TIA. Cox proportional hazards models, Kaplan-Meier survival curve, and propensity matched analyses were used to evaluate 90-day mortality and readmission. Results: Of the 686 patients seen in the ED for TIA, 88.3% received computed tomography (CT) scanning, 86.3% received an electrocardiogram (ECG), 35% received vascular imaging within 24 hours of triage, 36% were seen in a neurovascular clinic, and 4.2% experienced stroke, myocardial infarction, or vascular death within 90 days. Rates of antithrombotic use were increased in patients seen in a neurovascular clinic compared to those who were not (94% v. 86.3%, p < 0.0001). After adjustment for age, sex, vascular disease risk factors, and stroke symptoms, the risk of readmission for stroke, myocardial infarction, or vascular death was lower for those seen in a neurovascular clinic compared to those who were not (adjusted hazard ratio 0.28; 95% confidence interval 0.08-0.99, p = 0.048). Conclusion: The majority of patients in our study were treated with antithrombotic agents in the ED and investigated with CT and ECG within 24 hours; however, vascular imaging and neurovascular clinic follow-up were underutilized. For those with neurovascular clinic follow-up, there was an association with reduced risk of subsequent stroke, myocardial infarction, or vascular death. RÉSUMÉObjectifs: L'étude visait, d'une part, à examiner si la prise en charge des accidents ischémiques transitoires (AIT) au service des urgences de la région sanitaire Nova Scotia Capital District Health Authority respectait les recommandations canadiennes en matière de pratiques exemplaires, et, d'autre part, à évaluer l'incidence du suivi dans un service de consultations externes, spécialisé en maladies neurovasculaires. Méthode: Les auteurs ont procédé à un examen rétrospectif des dossiers de tous les patients chez qui avait été posé un diagnostic d'AIT et qui avaient reçu leur congé du SU, dans la région mentionnée, et ce, du 1 er janvier 2011 au 31 décembre 2012. La mortalité et le taux de réadmission au bout de 90 jours ont été calculés à l'aide de modèles de risques proportionnels de Cox, de la méthode d'estimation de Kaplan-Meyer et d'analyses appariées de propension. Résultats: Sur 686 patients examinés au SU pour un AIT, 88,3% ont été soumis à une tomodensitométrie (TDM); 86,3%, à un ECG; 35%, à un examen par imagerie vasculaire dans les 24 heures suivant le triage et 36% ont été vus dans un service de consultations spécialisé en maladies neurovasculaires; 4,2% ont subi un accident vasculaire cérébral (AVC) ou un infarctus du myocarde (...

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Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison

Cited by 1,088 publications

References 54 publications

Isolated transient aphasia at emergency presentation is associated with a high rate of cardioembolic embolism

Isolated transient aphasia at emergency presentation is associated with a high rate of cardioembolic embolism

Secondary prophylactic treatment and long‐term prognosis after TIA and different subtypes of stroke. A 25‐year follow‐up hospital‐based observational study

Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic

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