Risk of cardiac events in atypical transient ischaemic attack or minor stroke

Koudstaal, Peter J.; Latum, J.C. van; Algra, Ale; Kappelle, L. Jaap; Gijn, J. van; Pop, Gheorghe

doi:10.1016/0140-6736(92)92170-k

Cited by 48 publications

(55 citation statements)

References 21 publications

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“…Two were ED-based studies, 156,161 one included patients from ED and TIA clinics and reported the results for each setting separately and so contributed two independent data points, 73 and one recruited patients as part of a hospital-based clinical trial. 271 The 16 studies included a total of 14,542 participants, and all provided data on frequency of mimics compared with true TIA/minor stroke; 7,73,122,156,161,173,183,257,263,[265][266][267][268][269][270][271] 11 studies with a total of 3786 participants reported the main causes of non-CV events 7,122,156,161,173,263,[266][267][268][269][270] and five studies with a total of 8596 participants reported prognosis data. 122,156,265,270,271 One study deliberately excluded patients with some specific diagnoses other than TIA (i.e.…”

Section: Number Of Included/excluded Studiesmentioning

confidence: 99%

“…Forty-one per cent of the data related to frequency and 66% of the data related to differential diagnosis came from two studies, 173,270 and 41% of the data for prognosis came from one study. 271 Follow-up was at least 1 year in all but one study assessing prognosis.…”

Section: Number Of Included/excluded Studiesmentioning

confidence: 99%

“…122,156,265,270,271 One retrospective study enrolled 3533 participants with TIA and non-CV events and 3915 control subjects without any neurological symptoms. A prospective population-based study enrolled 548 patients with transient neurological attacks and 5514 control subjects; however, the definite diagnosis of each event was derived retrospectively from medical records.…”

Section: Outcomes For Transient Ischaemic Attack Compared With Non-camentioning

confidence: 99%

“…The 16 included studies 7,73,122,156,161,173,257,263,[265][266][267][268][269][270][271] varied in terms of their primary objectives. Three were population-based studies assessing the incidence of TIA in the general population in UK, the Netherlands and Spain (OCSP, Rotterdam Study and a community-based register in Segovia, respectively).…”

Section: Number Of Included/excluded Studiesmentioning

confidence: 99%

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An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Wardlaw

Brazzelli

Miranda

et al. 2014

Health Technol Assess

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BackgroundPatients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.ObjectivesIs MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as ‘one-stop’ brain-carotid imaging? What is the current UK availability of services for stroke prevention?Data sourcesPublished literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.Review methodsSystematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.ResultsThe pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35–41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40–45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51–54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with ‘CT scan all patients’ MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. ‘One-stop’ CT/MR angiographic-plus-brain imaging was not cost-effective.LimitationsData on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.ConclusionsMagnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Number Of Included/excluded Studiesmentioning

confidence: 99%

Section: Number Of Included/excluded Studiesmentioning

confidence: 99%

Section: Outcomes For Transient Ischaemic Attack Compared With Non-camentioning

confidence: 99%

Section: Number Of Included/excluded Studiesmentioning

confidence: 99%

See 2 more Smart Citations

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Wardlaw

Brazzelli

Miranda

et al. 2014

Health Technol Assess

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“…10 Furthermore, follow up of patients referred to TIA clinics shows that those 'reassured' that they have not had a TIA are in fact at higher risk of cardiac events and death than a population of patients attending hospital clinics matched for cardiovascular risk factors but who have not had an episode of transient neurological symptoms. 6 A community-based cohort study also found that patients with transient neurological symptoms that were again atypical for TIA (they had mixed focal and non-focal symptoms) had a higher risk of cardiovascular death, cardiac disease, and dementia than patients with purely focal transient neurological events that are more typical for TIA.…”

Section: Is Stroke the Only Risk After Transient Neurological Symptoms?mentioning

confidence: 99%

Recognition and management of transient ischaemic attack in primary care

Lasserson

2013

Br J Gen Pract

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Incidence and Prognosis of Transient Neurological Attacks

Bos¹,

Rijn²,

Witteman³

et al. 2007

JAMA

128

142

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HE FIRST INTERNATIONALLY ACcepted clinical classification for cerebrovascular disorders was formulated in 1975. 1 It included diagnostic criteria for transient attacks of neurological dysfunction, which in the present article we will call transient neurological attacks (TNAs). The classification attempted to create a formal distinction between TNAs with an unfavorable clinical course (which were presumed to be of vaso-occlusive origin and were therefore called transient ischemic attacks [TIAs]) and more benign attacks. Transient ischemic attacks were defined as temporary attacks (commonly 2-15 minutes, maximum 24 hours) with focal symptoms, which are attributable to dysfunction of one arterial territory of the brain. The remaining TNAs, with diffuse, nonlocalizing cerebral symptoms, were considered more benign. We will call these TNAs either nonfocal TNAs, if they present with only nonfocal symptoms, or mixed TNAs, if they present with a mix of focal and nonfocal symptoms.Although the conventional diagnostic criteria for TIA are clear, it is uncertain how mixed TNAs should be classified and treated. In our experience, mixed TNAs have mostly been classified as TIAs until now, both by neurologists and by general practitioners, 2,3 but it seems reasonable to assume that some physicians may take a wait-and-see attitude in patients with mixed attacks. For nonfocal TNAs, a wide variety of diagnoses is commonly applied and none fulfills criteria for TIA. The relations between symptoms, the conventional clinical classification, and the classification used in this article follows: conventional classifies focal symptoms as TIAs and nonfocal symptoms as nonspecific, which could include syncope, confusion or transient global amnesia. The conventional classification is ambiguous on mixed symptoms. The proposed TNA classification categorizes the symp-See also p 2912 and Patient Page.

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Risk of cardiac events in atypical transient ischaemic attack or minor stroke

Cited by 48 publications

References 21 publications

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Recognition and management of transient ischaemic attack in primary care

Incidence and Prognosis of Transient Neurological Attacks

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