High-risk Transient Ischaemic Attack Patients Research Articles

Uptake of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack at a University Hospital.

Multiple randomized controlled trials have demonstrated that dual antiplatelet therapy (DAPT) significantly reduces the risk of subsequent stroke as compared to aspirin monotherapy after high-risk transient ischemic attack (TIA) or minor ischemic stroke. We sought to evaluate the uptake of DAPT after high-risk TIA at a single center. We conducted a retrospective cohort study of consecutive TIA patients admitted via the Emergency Department (ED) of Bern University Hospital (1/1/2018-12/31/2019). We use descriptive statistics to detail cohort characteristics and compared patients treated with DAPT to those not treated. Statistical significance was set at α = 0.05 and all tests of comparison were two-sided. A total of 383 TIA patients were seen during the study period, 247 were eligible for DAPT. Among those eligible for DAPT, mean age was 72years and 51% were female. A total of 49 (19.8%) eligible TIA patients were treated with DAPT; use of DAPT significantly increased from 2018 to 2019. Patients admitted to the stroke unit or intensive care unit (n = 33) had a significantly higher proportion of DAPT treatment as compared to those admitted to the general neurology ward or discharged to home from the ED. DAPT use was also significantly higher in patients with large artery atherosclerotic disease (n = 23) as compared to other etiological subtypes and significantly higher among patients who arrived to the ED within 24h of symptom onset (n = 178). In conclusion, we found that only 2 out of every 10 high-risk TIA patients received DAPT in the years following its introduction in the clinical practice. Our results suggest that strategies to improve the uptake of new, evidence-based secondary stroke prevention treatment after high-risk TIA are needed.

Aminotransferase Level and the Effects of Dual Antiplatelet in Minor Stroke or Transient Ischemic Attack: A post hoc Analysis of a Randomized Control Trial

Introduction: This study was intended to evaluate whether the safety and efficacy of dual antiplatelet treatment in patients with minor ischemic stroke (MIS) or transient ischemic attack (TIA) could be modified by the aminotransferase level. Also, we sought to assess the interaction between aminotransferase level and CYP2C19 loss-of-function status on the efficacy of dual antiplatelet therapy. Methods: This study is a post hoc analysis of the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) study, a double-blinded randomized control trial. We included 5,133 patients with a complete workup of baseline alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. The primary outcome is stroke or TIA recurrence within 90 days. Cox proportional hazard models were used in the evaluation of the efficacy of antiplatelet treatment in patients with different aminotransferase levels and subgroups categorized by the aminotransferase level × CYP2C19 loss-of-function status. Results: The median age of all the included patients was 62 years; 66.3% of the patients were male. More recurrent stroke or TIA occurred in patients with elevated ALT and AST levels within 90 days compared to patients with normal ALT and AST levels (14.5 vs. 11.2%, p = 0.029). Dual antiplatelet treatment with aspirin and clopidogrel reduced recurrence compared with aspirin alone in patients with both normal (adjusted hazard ratio [HR], 95% confidence interval [CI]: 0.72 [0.60–0.86], p < 0.001) and elevated (adjusted HR [95% CI]: 0. 57 [0. 35–0. 92], p = 0. 020) ALT and AST levels (p = 0.64 for interaction). No significant difference in treatment efficacy on 90-day all-cause death or bleeding events was found. Conclusions: Dual antiplatelet treatment was safe for minor stroke or high-risk TIA patients with mildly elevated aminotransferase. Mild elevation of ALT or AST did not undermine the protective efficacy of the dual antiplatelet regimen in reducing recurrent stroke or TIA within 90 days after MIS or TIA. The interaction between the CYP2C19 loss-of-function allele carrier status and aminotransferase level on the efficacy of dual antiplatelet treatment was not observed.

Under Treatment of High-Risk TIA Patients with Clopidogrel-Aspirin in the Emergency Setting

BackgroundTreating high-risk transient ischemic attack (TIA) with dual antiplatelet therapy (DAPT) reduces subsequent ischemic stroke risk yet current rates of clopidogrel-aspirin treatment are uncertain. Materials and MethodsWe conducted a retrospective cohort study of consecutive TIA patients who presented to any of the four emergency departments (ED) of a single urban health system from 1/1/2018-3/1/2020. Medical record review was used to describe the cohort and assess clopidogrel-aspirin treatment. Patient eligibility for clopidogrel-aspirin was determined using relevant criteria from the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trial. Comparisons among eligible patients who received versus did not receive clopidogrel-aspirin were conducted using t-test, chi-squared, and Mann-Whitney as indicated. ResultsWe identified 248 TIA patients of whom 95 met eligibility criteria for clopidogrel-aspirin treatment. Among these 95 patients, mean age was 69.5 (SD: 12), 68.4% were women, and median ABCD2 score was 5 (IQR: 4-6). A total of 26/95 (27.4%) eligible patients received clopidogrel-aspirin within 24 hours of symptom onset. Appropriate clopidogrel-aspirin use was associated with having a stroke code called upon ED arrival (88.5% vs. 34.8%; P<0.001), being evaluated by a vascular neurologist (88.5% vs. 21.1%; P<0.001), and not presenting to the community ED site wherein only a single patient received clopidogrel-aspirin. ConclusionsIn a multisite, single health system study, nearly three-fourths of high-risk TIA patients eligible for clopidogrel-aspirin treatment did not receive it. Appropriate clopidogrel-aspirin use was highest among patients seen by vascular neurologists and lowest at the community ED, though under treatment was evident at all sites.

Oxidized low-density lipoprotein (LDL) and LDL cholesterol are associated with outcomes of minor stroke and TIA

Background and aimsLow-density lipoprotein (LDL) and oxidized low-density lipoprotein (oxLDL) levels are thought to be related to recurrent stroke. However, the joint association of circulating LDL and oxLDL levels with the outcomes of acute minor ischemic stroke and transient ischemic attack (TIA) remains unclear. The goal of the study was to evaluate whether LDL and oxLDL have a combined effect on outcomes of acute minor stroke and TIA. MethodsIn the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial, a subgroup of 3019 patients with baseline oxLDL and LDL levels were analyzed. Patients were divided into four groups according to different combinations of LDL (LDL < 3.37 mmol/L, LDL ≥ 3.37 mmol/L) and oxLDL levels (oxLDL <13.96 μg/dL, oxLDL ≥ 13.96 μg/dL). The primary outcome was any stroke within 90 days. The secondary outcomes included any stroke within 1 year and ischemic stroke and combined vascular events within 90 days and 1 year. The poor functional outcome included modified Rankin Scale (mRS) 3–6 at 90-day and 12-month follow-up. The association of LDL and oxLDL with the prognosis of patients was examined using multivariable Cox regression models. ResultsAmong 3019 patients included in this study, the medians (interquartile range) of oxLDL and LDL were 13.96 (6.65–28.81) μg/dL and 3.1 (2.5–3.8) mmol/L, respectively. The cumulative occurrence of recurrent stroke, ischemic stroke, and combined vascular events was 9.74%, 9.54%, and 9.80% within 90 days of follow-up. Compared with those with low LDL and oxLDL levels (LDL < 3.37 mmol/L with oxLDL <13.96 μg/dL), patients with high levels of LDL and oxLDL (LDL ≥3.37 mmol/L, oxLDL ≥13.96 μg/dL) had significantly increased risk of recurrent stroke at 90 days (HR,1.57; 95% CI, 1.10–2.24) and 1 year (HR,1.49; 95% CI, 1.10–2.04). Patients in groups with LDL ≥3.37 mmol/L, oxLDL <13.96 μg/dL (HR,1.35; 95% CI, 0.94–1.93) or LDL < 3.37 mmol/L with oxLDL ≥13.96 μg/dL (HR,1.11; 95% CI, 0.77–1.59) showed no statistical difference for stroke recurrence. Similar results were found for functional outcomes. ConclusionsThe presence of higher combined serum oxLDL and LDL levels was associated with increased risk of recurrent stroke and poor functional outcomes in minor stroke or high-risk TIA patients.

LO89: A multi-disciplinary quality improvement project to improve adherence to best practice guidelines for emergency department patients with transient ischemic attack

Background: Canadian Stroke Guidelines recommend that Transient Ischemic Attack (TIA) patients at highest risk of stroke recurrence should undergo immediate vascular imaging. Computed tomography angiography (CTA) of the head and neck is recommended over carotid doppler because it allows for enhanced visualization of the intracranial and posterior circulation vasculature. Imaging while patients are in the emergency department (ED) is optimal for high-risk patients because the risk of stroke recurrence is highest in the first 48 hours. Aim Statement: At our hospital, a designated stroke centre, less than 5% of TIA patients meet national recommendations by undergoing CTA in the ED. We sought to increase the rate of CTA in high risk ED TIA patients from less than 5% to at least 80% in 10 months. Measures &amp;amp; Design: We used a multi-faceted approach to improve our adherence to guidelines including: 1) education for staff ED physicians; 2) agreements between ED and radiology to facilitate rapid access to CTA; 3) agreements between ED and neurology for consultations regarding patients with abnormal CTA; and 4) the creation of an electronic decision support tool to guide ED physicians as to which patients require CTA. We measured the rate of CTA in high risk patients biweekly using retrospective chart review of patients referred to the TIA clinic from the ED on a biweekly basis. As a balancing measure, we also measured the rate of CTA in non-high risk patients. Evaluation/Results: Data collection is ongoing. An interim run chart at 19 weeks shows a complete shift above the median after implementation, with CTA rates between 70 and 100%. At the time of submission, we had no downward trends below 80%, showing sustained improvement. The CTA rate in non-high risk patients did also increase. Disucssion/Impact: After 19 weeks of our intervention, 112 (78.9%) of high risk TIA patients had a CTA, compared to 10 (9.8%) in the 19 weeks prior to our intervention. On average, 10-15% of high risk patients will have an identifiable lesion on CTA, leading to immediate change in management (at minimum, an inpatient consultation with neurology). Our multi-faceted approach could be replicated in any ED with the engagement and availability of the same multi-disciplinary team (ED, radiology, and neurology), access to CTA, and electronic orders.

Abstract TP405: Dual Antiplatelet Therapy Reduced Stroke Risk in High-risk Transient Ischemic Attack Patients Assessed by ABCD3-I Score

Introduction: Studies showed dual antiplatelet therapy (DAPT) benefited TIA patients with an ABCD2 score ≥4. The present study aims to investigate whether the ABCD3-I score could be a more appropriate tool for TIA patients’ selection to use DAPT in the real-world experience. Methods: We derived data from the TIA database of the First Affiliated Hospital of Zhengzhou University. The predictive outcome was ischemic stroke at 90-day. Cox proportional hazards regression was used to examine the interaction effect between risk score and antiplatelet treatment. The Kaplan-Meier curves were plotted to present cumulative stroke rates in different risk patients with monotherapy and DAPT. Results: Among 785 patients, the mean (SD) age was 56.95 (12.73) years and 38.3% were female (n =301). A percentage of 36.9% patients used DAPT during hospitalization, and 77 patients (9.8%) had an ischemic stroke at 90-day. The Kaplan-Meier curves showed a significant difference between patients with monotherapy and DAPT in high-risk TIA patients (p= 0.021, Figure 1). After adjustment for confounding factors, DAPT only reduced 90-day stroke risk in high-risk TIA patients assessed by ABCD3-I score (HR= 0.402, 95%CI 0.189-0.859, p= 0.019, Table 1 and 2). Conclusions: High-risk TIA patients assessed by ABCD3-I score received the most pronounced clinical benefit from DAPT in the real-clinical experience.

Abstract NS2: A Rapid Care Evaluation Transient Ischemic Attack Clinic by Nurse Practitioners

Background: Prompt evaluation and management of patients having a transient ischemic attack (TIA) with the ABCD2 triage score has been shown to decrease the risk of stroke and potentially life-long disability. However, creating an organized, well-coordinated approach that provides rapid access for patients is a challenge at many high-volume stroke centers. Purpose: We sought to determine the feasibility of a nurse practitioner (NP)-led Rapid Access Care Execution for Transient Ischemic Attack (RACE-TIA) Clinic as part of an Outpatient Stroke Nurse Practitioner Clinic. Methods: Our RACE-TIA Clinic Algorithm uses ABCD2 score triaging, and outlines the care process for TIA patients who present either through the Emergency Department (ED), Outpatient Clinic or via telephone triage. Patients with possible TIA are triaged using the ABCD2 tool. Those who present to the ED are evaluated by a member of the Acute Stroke Team and patients with a score ≥ 3 remain in the ED Clinical Decision Unit (CDU) for evaluation. Patients with a score &lt; 3 are scheduled in the RACE-TIA Clinic staffed by two stroke-trained NPs. Referrals to the RACE-TIA clinic from the electronic medical record (EMR) referral or the dedicated phone line are triaged by a registered nurse who was trained to complete the ABCD2 scoring. All appointments are scheduled within 24-48 hours of receiving a referral. Results: Since initiating the RACE-TIA Clinic Algorithm in January 2017 a total of 20 patients were seen as outpatients for TIA evaluation. Six patients were directly referred to the RACE-TIA Clinic for acute TIA evaluation and of those, 5 were referred from the ED and 1 from a primary care office. Another 14 patients were scheduled for follow-up after having an initial TIA evaluation at either an outside hospital (3), the ED (2), ED CDU (3) or after inpatient hospitalization (6). The average time from referral to clinic visit was 34 hours. Conclusion: Our NP-led RACE-TIA Clinic has successfully evaluated patients with low risk TIA in the outpatient setting in a timely way and also provided close follow-up for high risk TIA patients after the acute evaluation without expanding or duplicating existing resources.

Effect of Dietary Nitrate Supplementation on Blood Pressure Variability and Vascular Function in High-Risk Transient Ischemic Attack Patients

Background: Patients presenting with a transient ischemic attack (TIA) are at high risk of stroke despite current treatments. Elevated blood pressure variability (BPV) and vascular dysfunction are known to increase the risk of stroke in TIA patients. Therefore, improving these hemodynamic parameters could help reduce stroke incidences in these patients. Aim: The proposed study will investigate the efficacy of dietary nitrate supplementation on cardiovascular and cerebrovascular hemodynamics in patients recently diagnosed with TIA. Methods: This study is a randomized, placebo-controlled, parallel group clinical trial, with patient recruitment based on strict inclusion/exclusion criteria. Newly diagnosed patients who present within 48 h of symptom onset will be assessed to ascertain their post-TIA, pre-treatment baseline cardiovascular and cerebrovascular parameters. These will include: beat-to-beat BPV, cerebrovascular CO2 reactivity and cerebral autoregulation (indices of cerebrovascular health), brachial artery diameter, central and peripheral blood pressures, vascular risk factors (i.e. resting blood pressure), and plasma nitrate/nitrite concentration. Following pre-treatment assessment, participants will be randomized to take either 7-day dietary nitrate supplementation (sodium nitrate in capsules, 10 mg/kg/day) or 7-day placebo. An identical follow-up assessment will be implemented post-intervention. Conclusion: This study will lay the foundation for clinical trials to assess the therapeutic potential of dietary nitrate supplementation as a secondary strategy for stroke prevention in high-risk patients.

Abstract T P189: Time Trends in Transient Ischemic Attack Admission From the Emergency Department

Background: Prior studies suggest transient ischemic attack (TIA) admission from the Emergency Department (ED) increased over time. We investigated how TIA admission trends may have changed with publication of TIA risk stratification rules involving the ABCD /ABCD2 scores. Methods: We used ED data on TIA from the National Hospital Ambulatory Medical Care Survey. We defined three time periods to account for the initial publication by Johnston et al., highlighting the risk of ischemic stroke following TIA (2000) and related reports on the ABCD (2005) and ABCD2 (2007) scores. We defined 2005 through 2007 as a washout period to allow for any practice change that occurred with the evolution of ABCD/ABCD2 scores. Admission trends were stratified across younger (18-64y) and older (65y+) patients. Results: There were 327,339 TIA visits yearly from 1994 to 2010 in adults 18+ years. We compared three distinct time periods (1994-1999; 2001-2004 and 2008-2010 to reflect the timing of publications above. We observed interaction between time and age with regard to TIA admission (Figure). TIA patients 18-64y showed a decreasing admission trend overall (p = 0.047). Patients 65y+ showed a similar decreasing trend up to 2005-2007, but after 2007 had a marked increase in TIA admissions (p = 0.021). A comparison of stroke admissions during the same time period did not show an increasing trend in the 65+ group. Conclusion: Contrary to prior reports, TIA admissions decreased over time among persons 18-64y. Among older persons 65+, there was a sharp increase in TIA admission after 2007 that was not due to an increase in admissions for stroke or stroke-related diagnosis. The increase in TIA admissions could be related to new tools for the risk-stratification of TIA patients, but a large percentage of TIA patients are discharged from the ED. More research is needed to ensure that all high risk TIA patients receive a rapid evaluation.

Effect of Early Exercise Engagement on Cardiovascular and Cerebrovascular Health in Stroke and TIA Patients: Clinical Trial Protocol

Objective: This study will investigate the efficacy of implementing either an early or delayed exercise intervention on cardiovascular and cerebrovascular health for newly diagnosed stroke and high-risk Transient Ischaemic Attack (TIA) patients. Methods: The study is a randomized, parallel group clinical trial. Patients will be recruited from a local hospital based on inclusion/exclusion criteria. Participants will attend a baseline assessment within 2 to 7 days of stroke or TIA diagnosis. The assessment will consist of a series of cardiovascular and cerebrovascular primary and secondary outcome measures which will be assessed during some or all of the following; at rest, during a postural challenge, during a cerebral autoregulation and CO2 reactivity test and/or during an incremental exercise test. Primary outcome measures include vascular risk factors (resting blood pressure, blood lipid profile etc), arterial stiffness of the carotid artery and blood velocity of the carotid artery and middle cerebral artery. Secondary outcome measures include cerebral autoregulation, physical fitness, and central and peripheral blood pressure. Following the baseline assessment, participants will be randomized to either a 12-week exercise programme which will commence within 7 days (early) or 28 days (delayed) of stroke/TIA diagnosis, or to a usual care control group. The exercise programme will consist of twice weekly, 60 minute, prescribed aerobic exercise sessions, and one 30 minute home-based aerobic exercise session. An identical assessment will be implemented post-intervention. Given the practical implications of the study, the clinical significance of early or delayed exercise engagement will be assessed for each outcome variable. Conclusion: This study will advance our knowledge concerning the timing, importance and viability of exercise as a secondary prevention strategy for improving health outcomes for stroke and TIA patients. The study will provide much needed objective data for stroke and high-risk TIA patients concerning the physiological effect of regular exercise participation.

Delay between symptom onset and clinic attendance following TIA and minor stroke: the BEATS study

rapid specialist assessment of patients with transient ischaemic attack (TIA) reduces the risk of recurrent stroke. National guidelines advise that high-risk patients are assessed within 24 h and low-risk patients within 7 days. to quantify delay and map pathways taken by patients from symptom onset to specialist assessment. retrospective cohort study. rapid access TIA clinic. structured interviews with 278 patients newly diagnosed with TIA (222) or minor stroke (56), and examination of medical records. of the 133 high-risk TIA patients, 11 (8%) attended the clinic within 24 h of symptom onset; of the 89 low-risk TIA patients, 47 (53%) attended within 7 days. Median delay between symptom onset and seeking help from a healthcare professional (HCP) was 4.0 h (IQR 0.5, 41.3). Delay was less if symptoms were correctly interpreted but not reduced by a publicity campaign (FAST) to encourage an urgent response. Most patients (156, 56%) first contacted a general practitioner (GP) and 46 (17%) called an ambulance or attended the emergency department. Over a third (36%) had a second consultation with an HCP before attending the clinic, and this was more likely in those presenting to paramedics, out of hours GP services or optometry. Time to clinic attendance was less if an emergency pathway was used and greater if patients were seen by a second HCP. factors contributing to delay include incorrect interpretation of symptoms and failure to invoke emergency services. Delays after presentation could be addressed by direct referral by out of hours services, paramedics and optometrists.

Abstract WP397: Using Electronic Medical Record System to Influence Management for Patients with High Risk Transient Ischemic Attack

Background: Experts consider health information technology key to improving efficiency and quality of health care. However, little is known on how the use of electronic medical record (EMR) system can affect a clinical outcome by changing its processes of care. We sought to determine if EMR could be utilized to increase urgent carotid evaluation and management of patients with transient ischemic attack (TIA). Methods: Changes were implemented in the standardized EMR TIA order set for Kaiser Permanente Northern California (KPNC) on July 20, 2012 adding: 1) a link to an ABCD2 score calculator, and 2) a recommendation that “acute TIA patients with an ABCD2 score ≥4 should undergo a carotid evaluation within 24 hours of symptom onset.” All patients diagnosed with TIA by Emergency Department physicians in KPNC were identified 6 months pre- and post- changes. EMR were reviewed for demographics, risk factors, imaging studies and clinical outcomes. Carotid evaluation, endarterectomy (CEA), stroke during the 90-day period after index TIA, and timing of CEA were examined. Results: Patient characteristics were similar for pre- and post-EMR order set change [Table]. Rates of carotid evaluations performed within 90 days post TIA were not significantly different between the pre- and post-order set change cohorts (76% vs. 80, p=0.28). However, there was a significant difference in the rates of CEA within 90-day post-TIA (pre=1%, post=4%, p=0.05). Median timing of CEA was shorter in the post-change cohort (30 vs. 2 days, p=0.17). Stroke risks within 90 days were similar between pre- and post- cohorts (13.6% vs. 12.2%, p=0.62). Conclusions: Our results suggest recommendations made in an EMR standardized order set could effectively influence physicians’ practice pattern in managing high-risk TIA patients. Further studies on the use of EMR to affect outcomes are needed.

Abstract TP386: Prompt Preventive Treatment of TIA Could Reduce the Need for Weekend Service

Background: There is 10% risk of stroke in the week after transient ischaemic attack (TIA). Urgent evaluation and early preventive treatment can reduce recurrence after a TIA by 80% at 90 days. Specialist assessment of high risk TIA patients within 24 hours and low risk within a week is recommended. Many centers struggle to provide a 7 day service. In our center, specialist assessment is available on weekdays only but the referrer is asked to initiate preventive treatment (anti-platelets, statins) followed by rapid referral for vascular imaging and TIA clinic. Hypothesis: Prompt treatment started by the referring physician is effective and safe in reducing recurrent cerebrovascular events. Methods: Planned service evaluation of patients referred to TIA service between December 2009 - September 2011 (21 months). Data was collected at 1st presentation to TIA clinic and at 90 day follow up. Results: The TIA service received 537 patients (median age 67 years [range 19 - 96years], 42% over 70 years, 48% females). 60% referrals were from emergency department (rest from primary care). 47 patients did not attend, hence 490 included in final analyses. Referrers started preventive treatment in 436(89%) patients. 12% (54/436) of these patients had side effects [SE] (headaches, GI upset) from early treatment (none required hospitalisation). 62% (303/490) referrals were truly TIA’s on specialist assessment. Recurrent events occurred in 8/303(2.6%) TIA patients. 6 of 8 of these patients did not receive treatment; mean delay of 4.8 days before specialist review. Recurrences were lower in treated patients (2/279 [0.7%] vs.6/24 [25%] in the non-treated group; p&lt;0.0001). Weekend referrals constituted 33% (161/490) vs. 67% (329/490) weekday patients; 110 weekend vs. 193 weekday confirmed TIA’s. 90% weekend referrals had early treatment (16% had SE) vs. 88% weekday referrals (10% had SE). Weekend recurrence rate was 1.8% (2/110) vs. 3% weekday recurrences (6/193) (p=0.7). Median TIA clinic review delay was 1 day in both groups (IQR 0-2days). Conclusion: Weekend TIA service would be desirable. However, prompt treatment before specialist assessment appears to be equally effective and safe in reducing recurrent cerebrovascular events.

Development of a support group for stroke survivors and their carers and/or families

Aims: To develop a focussed support group for stroke survivors, their carers and families using participant's opinions to design and develop the service. Methods: All patients with a diagnosis of stroke or at high risk of transient ischaemic attack (TIA) and their carers were invited to attend a monthly meeting. A structured programme was created for each session. All participants recruited have been seen as either inpatients or outpatients at Imperial College healthcare NHS trust Results: 84 participants have to date attended the Stroke Support Group over 6 months. The participants were made up of ex-patients, carers, high-risk TIA patients and inpatients. Conclusions: Patients were not afraid to speak out as the groups were not too big. Illustration of information in Powerpoint pictures was useful for clarification and better understanding. Patients found the doctors' session most informative. Patients found it worthwhile to share similar experiences. Inpatients generally appreciated receiving information in a setting different from the ward. Recommendations: Too much statistical information on slides was not favourable in view of low concentration span. Future plans: Plans to provide a similar service at the other sites in the trust are underway. The provision of an evening session to benefit patients and carers that work is being reconsidered. A clinical nurse specialist-led surgery for ‘drop-in’ clinics in the evenings on the stroke wards is to be considered to provide support for inpatients and their carers planning discharge.

C-reactive protein predicts further ischemic events in transient ischemic attack patients

Although patients with transient ischemic attack (TIA) experience cardiovascular events frequently, strong clinical predictors of recurrence are lacking. High-sensitivity C-reactive protein (hs-CRP) has been shown to be a powerful predictor of future first-ever and recurrent coronary and cerebral ischemic events. We aimed to investigate the relationship between hs-CRP and the risk of further ischemic events in TIA patients. High-sensitivity C-reactive protein level was determined <24 h after symptom onset among 135 consecutive TIA patients and stroke recurrence or any new vascular event was recorded during 1 year follow-up period. A total of 38 (28.1%) patients experienced an end point event: 28 (20.7%) cerebral ischemic events, six (4.4%) heart ischemic events, four (3%) peripheral arterial disease, and nine (6.7%) vascular deaths. Cox proportional hazards multivariate analyses identified age [hazard ratio (HR) 1.07, 95% confidence interval (CI) 1.01-1.12, P = 0.01], large-artery occlusive disease (HR 2.73, 95% CI 1.16 to 6.41, P = 0.02) and hs-CRP> 4.1 mg/l (HR 2.81, 95% CI 1.12-7.10, P = 0.03) as independent predictors of stroke. Moreover, age (HR 1.05, 95% CI 1.01-1.10, P = 0.02), large-artery occlusive disease (HR 3.12, 95% CI 1.48-6.58, P < 0.01), coronary disease (HR 2.39, 95% CI 1.11-5.16, P = 0.03), and hs-CRP> 4.1 mg/l (HR 2.71, 95% CI 1.16-6.30, P = 0.02) were also independent predictors of any vascular event. High-sensitivity C-reactive protein serum level predicts further ischemic events following TIA. Routine CRP measurement might be a useful tool for identifying high-risk TIA patients in order to plan aggressive diagnostic protocols and prevention therapies.