A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack

Abstract

IMPORTANCE Management of transient ischemic attack (TIA) has gained significant attention during the past 25 years after several landmark studies indicated the high incidence of a subsequent stroke.OBJECTIVE To calculate the pooled event rate of subsequent ischemic stroke within 2, 7, 30, and 90 days of a TIA and compare this incidence among the population with TIA recruited before 1999 (group A), from 1999 to 2007 (group B), and after 2007 (group C).DATA SOURCES All published studies of TIA outcomes were obtained by searching PubMed from 1996, to the last update on January 31, 2020, irrespective of the study design, document type, or language.STUDY SELECTION Of 11 516 identified citations, 175 articles were relevant to this review. Both the classic time-based definition of TIA and the new tissue-based definition were accepted. Studies with a combined record of patients with TIA and ischemic stroke, without clinical evaluation for the index TIA, with diagnosis of index TIA event after ischemic stroke occurrence, with low suspicion for TIA, or duplicate reports of the same database were excluded. DATA EXTRACTION AND SYNTHESISThe study was conducted and reported according to the PRISMA, MOOSE, and EQUATOR guidelines. Critical appraisal and methodological quality assessment used the Quality in Prognosis Studies tool. Publication bias was visualized by funnel plots and measured by the Begg-Mazumdar rank correlation Kendall τ 2 statistic and Egger bias test. Data were pooled using double arcsine transformations, DerSimonian-Laird estimator, and random-effects models. MAIN OUTCOMES AND MEASURESThe proportion of the early ischemic stroke after TIA within 4 evaluation intervals (2, 7, 30, and 90 days) was considered as effect size.RESULTS Systematic review yielded 68 unique studies with 223 866 unique patients from 1971 to 2019. The meta-analysis included 206 455 patients (58% women) during a span of 4 decades. The overall subsequent ischemic stroke incidence rates were estimated as 2.4% (95% CI, 1.8%-3.2%) within 2 days, 3.8% (95% CI, 2.5%-5.4%) within 7 days, 4.1% (95% CI, 2.4%-6.3%) within 30 days, and 4.7% (95% CI, 3.3%-6.4%) within 90 days. There was a recurrence risk of 3.4% among group A in comparison with 2.1% in group B or 2.1% in group C within 2 days; 5.5% in group A vs 2.9% in group B or 3.2% in group C within 7 days; 6.3% in group A vs 2.9% in group B or 3.4% in group C within 30 days, and 7.4% in group A vs 3.9% in group B or 3.9% in group C within 90 days.CONCLUSIONS AND RELEVANCE These findings suggest that TIA continues to be associated with a high risk of early stroke; however, the rate of post-TIA stroke might have decreased slightly during the past 2 decades.

One-Year Risk of Stroke After Transient Ischemic Attack or Minor Stroke in Hunter New England, Australia (INSIST Study)

“…Transient ischemic attack and minor stroke (TIAMS) account for up to 58% of all cerebral ischemic events ( 1 , 2 ). Although recurrent vascular event rates post-TIAMS have been declining over the past two decades ( 3 , 4 ), 5–8% of patients have disabling stroke, 1.1–1.3% have coronary artery events, and 0.6–0.7% die from cardiovascular causes in the year following TIAMS ( 5 – 7 ). Short-term dual antiplatelet therapy (DAPT) is the current gold standard for secondary prevention in high-risk TIAMS patients with non-cardioembolic sources ( 8 ).…”

Efficacy and Safety of Adherence to dl-3-n-Butylphthalide Treatment in Patients With Non-disabling Minor Stroke and TIA—Analysis From a Nationwide, Multicenter Registry

“…There was substantial heterogeneity between studies. Furthermore, in a most recent systematic review and meta-analysis of 206,455 patients in 68 unique studies during 5 decades, the subsequent risk of ischemic stroke was 4.7% within 90 days and the incidence was gradually decreased by the time of trials, among the study population recruited before 1999 was significantly higher ( 25 ). Second of all, the definition of stroke recurrence varies between studies, resulting in different incidences of observed stroke recurrence.…”

“…First of all, previous reports of stroke risk after TIA is highest in the first 7 days and in patients without immediate treatment (11.0%; 95% CI, 8.6-13.5%) (24). Over the past two decades, new treatment strategies and early management of TIA and minor strokes have significantly reduced stroke recurrence rates (25). The lowest risks were seen in studies of emergency treatment in specialist stroke services [0.9% (95% CI, 0.0-1.9)] (26)(27)(28)(29) and the highest risks in population-based studies without urgent treatment [11.0% (8.6-13.5)] (30)(31)(32).…”

A Novel Clinical Nomogram to Predict Transient Symptomatic Associated with Infarction: The ABCD3-SLOPE Score

“…The 7-day risk of stroke was higher on DWI-positive than DWI-negative patients (1.2% versus 12.3%) [13]. The subsequent risk of ischemic stroke after TIA was 2.4% in 2 days, 3.8% in 7 days, 4.1% in 30 days, and 4.7% in 90 days according to a systematic review and meta-analysis of 206455 unique patients [19]. It is reasonable to assume higher rates of subsequent ischemic stroke in 30 or 90 days in the TSI population.…”