Index Transient Ischemic Attack Research Articles

Rigorous and long-term cardiac monitoring strategy in cryptogenic stroke or TIA patients in a tertiary care centre results in a two-fold increase in AF detection

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Special Research Fund (Bijzonder Onderzoeksfonds, BOF) Hasselt University. This study is part of Limburg Clinical Research Center, supported by the foundation Limburg Sterk Merk, province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital. Background Atrial fibrillation (AF) is a major cause of ischaemic stroke. Oral anticoagulation is recommended in stroke survivors with AF to prevent recurrence. Prolonged ECG monitoring using insertable cardiac monitors (ICMs) has been shown to increase the detection rate of AF compared to standard 24-hour ECG monitoring in cryptogenic stroke patients. However, prolonged ambulatory ECG monitoring is underutilized, likely contributing to an underdiagnosis of AF and missed anticoagulation treatment opportunities for secondary stroke prevention. Purpose This study aims to evaluate how our evolving cardiac monitoring strategy affected AF detection rates one year after cryptogenic ischaemic stroke or transient ischaemic attack (TIA) in a tertiary care centre. Methods We retrospectively identified all consecutive cryptogenic stroke or TIA patients admitted to our centre between 1/01/2017 – 1/01/2022. Patients with a pacemaker or implantable cardioverter-defibrillator were excluded from the analysis. Data were collected from the electronic medical record. Available cardiac monitoring modalities included 24-hour Holter monitoring, 7-day Holter monitoring, and insertable cardiac monitors (ICM). After October 2020 (i.e., period 2), the latter became part of our routine diagnostic workup for AF detection in case extended (7-day) Holter monitoring was negative. Results All 691 cryptogenic stroke or TIA patients admitted to our hospital during the inclusion period were considered. These were elderly patients (69.7 ± 13.2 years) with a CHA2DS2-VASc score of 3 [2 - 5]. Figure 1 shows evolving trends in the use of the different cardiac monitoring tools before and after October 2020. In particular, the use of 7-day Holter monitoring and long-term continuous monitoring with ICM increased after implementing our new diagnostic protocol compared to 24-hour Holter monitoring (p<.001). ICMs were inserted 95 [66 – 145] days after index stroke or TIA. The new diagnostic protocol detected more AF one year after the index stroke or TIA (3.7% vs. 10.1%, p<.001, Figure 2). In 95.6% of patients with AF detected within one year, oral anticoagulation was initiated. Future research should determine whether adopting a strategy of routine ICM following cryptogenic stroke and, thus, more appropriate anticoagulant therapy may improve clinical outcome in these patients. Conclusions The increased use of prolonged cardiac monitoring in cryptogenic stroke or TIA patients resulted in a two-fold increase in AF detection one year after stroke. Therefore, our results underscore the need to implement guideline-recommended prolonged rhythm monitoring using ICMs in addition to short-term ECG monitoring to ensure adequate secondary stroke prevention.

Ninety‐Day Stroke or Transient Ischemic Attack Recurrence in Patients Prescribed Anticoagulation in the Emergency Department With Atrial Fibrillation and a New Transient Ischemic Attack or Minor Stroke

Background For patients with atrial fibrillation seen in the emergency department (ED) following a transient ischemic attack (TIA) or minor stroke, the impact of initiating oral anticoagulation immediately rather than deferring the decision to outpatient follow-up is unknown. Methods and Results We conducted a planned secondary data analysis of a prospective cohort of 11 507 adults in 13 Canadian EDs between 2006 and 2018. Patients were eligible if they were aged 18 years or older, with a final diagnosis of TIA or minor stroke with previously documented or newly diagnosed atrial fibrillation. The primary outcome was subsequent stroke, recurrent TIA, or all-cause mortality within 90 days of the index TIA diagnosis. Secondary outcomes included stroke, recurrent TIA, or death and rates of major bleeding. Of 11 507 subjects with TIA/minor stroke, atrial fibrillation was identified in 11.2% (1286, mean age, 77.3 [SD 11.1] years, 52.4% male). Over half (699; 54.4%) were already taking anticoagulation, 89 (6.9%) were newly prescribed anticoagulation in the ED. By 90 days, 4.0% of the atrial fibrillation cohort had experienced a subsequent stroke, 6.5% subsequent TIA, and 2.6% died. Results of a multivariable logistic regression indicate no association between prescribed anticoagulation in the ED and these 90-day outcomes (composite odds ratio, 1.37 [95% CI, 0.74-2.52]). Major bleeding was found in 5 patients, none of whom were in the ED-initiated anticoagulation group. Conclusions Initiating oral anticoagulation in the ED following new TIA was not associated with lower recurrence rates of neurovascular events or all-cause mortality in patients with atrial fibrillation.

Abstract WP134: Long-Term Spontaneous Recanalization Rates Of Symptomatic Cervical Carotid Artery Occlusions

Background: Long-term rates of spontaneous recanalization of a previously acutely symptomatic cervical internal carotid artery occlusion (ICAO) have not been well characterized. The purpose of this study was to determine the rate of ICAO recanalization after index transient ischemic attack (TIA)/stroke in patients with serial vessel imaging, and the clinical factors associated with recanalization. Methods: This was a single-center, retrospective analysis from 2012-2020 of patients presenting with TIA/stroke due to an acute cervical ICAO. Patients were included if follow-up neck vessel imaging (CTA, MRA or ultrasound) was performed after index TIA/stroke. Recanalization was classified as the presence of continuous flow within the cervical carotid artery on repeat imaging. Patients were excluded if they received catheterization of the occluded artery during index admission or if the occlusion was previously documented (i.e., chronic). Results: Fifty-five patients were included in this study (mean age 61 ± 12 years, 27% female). The most common etiology for cervical ICAO was atherosclerosis (71%), followed by dissection (22%). Twelve patients (22%) demonstrated recanalization on follow-up imaging at a median of 125 days from index TIA/stroke (range 2-1072 days). Three patients with recanalization underwent carotid revascularization with endarterectomy or stenting. The administration of intravenous alteplase during index stroke admission was associated with recanalization (p=0.008). However, discharge antithrombotic regimen (antiplatelet or anticoagulation) or the etiology of the occlusion were not associated with recanalization (p=0.48 and p=0.73, respectively). There was no difference in 6-month recurrent TIA/stroke rates between those with recanalization (1 patient, 8.3%) and those without recanalization (4 patients, 9.3%), p=1.0. Conclusion: Cervical ICAO recanalization occurred in 12 (22%) patients in our cohort at follow-up and allowed for carotid revascularization procedures in 3 (25%) of these patients. Outpatient follow-up cervical vessel imaging should be considered after symptomatic cervical ICAO, as identifying spontaneous recanalization can alter management.

Abstract 117: Low-to-moderate Risk Transient Ischemic Attack Patients Can Be Safely Discharged From The Emergency Department To A Nurse Practitioner-Led Clinic

Background: Unnecessary admissions fuel rising healthcare costs and take away resources from higher acuity patients without evidence of increased safety. Purpose: The purpose of this quality improvement project was to determine if the care diversion for transient ischemic attack (TIA), from inpatient to a nurse practitioner (NP)-led specialty clinic, resulted in no increase in stroke incidence at 90 days. Methods: The sample included all adults (18 years or older) presenting to the emergency department (ED) with TIA at low-to-moderate risk for stroke. Risks were defined by the ABCD 2 score and non-invasive vessel imaging. Patients who met the criteria were discharged and evaluated by a stroke NP at the TIA clinic within seven days. These patients were compared to those who were admitted to the hospital prior to clinic launch. Chart reviews were conducted to determine stroke incidence at 90 days post TIA. Descriptive statistics were used to evaluate clinical variables, and Fisher’s Exact test was used to assess difference in stroke rates. Patient satisfaction score was collected using the existing institutional survey. Results: Eighty-one participants were included, 40 in the clinic group and 41 in the admission group. The mean ages in the clinic group and the admission group were 72.8 and 75.2 years, respectively ( p =0.37). Females comprised 45% of patients in the clinic group, compared to 51.2% in the admission group ( p =0.58). The mean ABCD 2 scores were 4.08 and 3.95 in the clinic and admission groups, respectively ( p= 0.63). The median clinic follow-up time was six days. There was no stroke incidence in the clinic group and one incidence in the admission group ( p =1.0) within 90 days of index TIA. Patient satisfaction score of the NP was 92.6%. Conclusions: In conclusion, referral to an NP-led clinic in patients with low-to-moderate risk TIA was equally safe as hospital admission.

Abstract 10: Recurrent Ischemic Infarcts And Hemorrhages On MRI Within 30 Days Of Anticoagulation Commencement For Ischemic Stroke: Preliminary Results From The Attune Registry

Introduction: Anticoagulation reduces recurrent ischemic stroke based on clinical definitions in patients with atrial fibrillation (AF). However, neuroimaging registries suggested a significant proportion developed ischemic lesions on magnetic resonance imaging (MRI) at 12 months follow up. The rate of early recurrent ischemic stroke identified by MRI remains unclear. ATTUNE (Atrial fibrillation in stroke - Utility of Neuroimaging Evaluation) is a prospective, multicentre study of clinical and radiological outcomes in patients commenced on anticoagulation after ischaemic stroke or TIA. We aimed to investigate the incidence of early ischemic stroke on MRI in this group of patients who were anticoagulated. Aims/Methods: We performed an interim analysis of the ATTUNE database to determine the proportion of patients with radiological evidence of infarction and haemorrhage on (MRI), one month after index ischemic stroke or transient ischemic attack (TIA). MRIs performed at one month were analysed independently by two experienced neuroimage assessors and the number of new infarcts and haemorrhages determined for each patient. Results: A total of 216 patients were analysed. The median age was 74 (IQR 68-81). Anticoagulation was commenced a median of 4 days after index event (IQR 2-6). Twenty-eight patients had new infarcts on follow-up MRI (13%). Fifty-six had new haemorrhage on follow up MRI (26%). Of these, 41 patients had hemorrhagic transformation of the initial infarct and 15 had a remote haemorrhage. Conclusion: There is a high rate of recurrent ischemic lesions and haemorrhages on MRI in patients commenced on anticoagulation within 30 days of index stroke or TIA.

Predictive Value of the ABCD3-I for Short- and Long-Term Stroke after TIA with or without sICAS.

Aims: We aimed to validate the predictive value of the ABCD3-I score for short-term and long-term stroke risk after transient ischemic attack (TIA) and to evaluate the influence of symptomatic intracranial artery stenosis (sICAS) on the performance of ABCD3-I. Methods: We recruited TIA patients from the Third China National Stroke Registry study. Outcome parameters were stroke events during the 14-day, 3-month, 6-month, and 12-month points. The area under the curve (AUC) was calculated as a measure of predictive ability. A multivariable-adjusted Cox proportional hazards model was used to assess the hazard ratio of risk factors for stroke. Results: Among 986 patients, 3.9%, 5.1%, 6.5 %, and 8.2% of participants experienced a stroke event during the 14-day, 3-month, 6-month, and 12-month points post TIA, respectively. The AUCs of ABCD3-I score for the prediction of stroke were 0.786, 0.732, 0.715, and 0.699 at the 14-day, 3-month, 6-month, and 12-month points, respectively. The AUCs were 0.774, 0.690, 0.617, and 0.611 in patients with sICAS, 0.789, 0.748, and 0.758 and 0.734 in those without sICAS. P values of the interaction between ABCD3-I categories and sICAS were 0.0618 for 14-day, 0.0098 for 3-month, 0.0318 for 6-month, and 0.0294 for 12-month. Conclusions: ABCD3-I score performed well in predicting short-term risk of a stroke after an index TIA in patients with or without sICAS. However, the predictive power decayed with the prolonged period, and the decayed extent was more pronounced among those with sICAS. The assessment of sICAS is a non-ignorable item when using the ABCD3-I score for long-term stroke risk prediction in patients with TIA.

Short and Long-Term Risk of Major Cardiovascular Events after Ischemic Stroke or Transient Ischemic Attack in Myeloproliferative Neoplasms

BACKGROUND. Very few previous studies have estimated the risk of recurrence after cerebral transient ischemic attack (TIA) or ischemic stroke (IS) in patients with myeloproliferative neoplasms (MPN). PRISM (Preventing Ischemic Stroke in Myeloproliferative Neoplasms) is an international investigator-driven study with three purposes: (1) to describe the clinical profile at presentation of ischemic TIA/IS in contemporary patients with polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF); (2) to evaluate the short and long-term outcomes beyond the acute phase and to explore their comparability with non MPN population; (3) to refine the risk assessment for recurrences and cardiovascular mortality.METHODS. From January 2005 through December 2015, 597 patients with objectively proven TIA (n= 270) or IS (n=327) at 22 sites of 5 countries were enrolled. We estimated the 1- and 5-year risk of composite cardiovascular (CV) outcome, including recurrent TIA, IS, myocardial infarction (AMI) and CV deaths, and analyzed the incidence of each single outcome by competing risk method.RESULTS. The distribution of single MPN and baseline blood counts were similar in IS and TIA groups; atrial fibrillation was observed in a minority of cases (4% TIA and 7% IS) as compared with the general population (11-18% and 20%-30%, respectively); other comorbidities were approximately half of those of non-MPN patients [ Weimar C et al, Arch Neurol 2002;59:1584; Buchwald F et al, Stroke 2016;47:2456; Amarenco P et al, N Engl J Med 2016;374:1533 ]; a substantial proportion of TIA cases had a higher history of microvascular disturbances while arterial hypertension was more frequent in IS than TIA. Secondary prophylaxis included aspirin, oral anticoagulants and cytoreductive therapy.After one year since the TIA index event, the incidence of cumulative outcome was 4.21%. However, no IS happened in the first 2 years after TIA and this event after 5 years happened in only 1.24% of cases. The corresponding incidence in the general population was 4.4% to 5.1% after one year and 12-16% after 5 years [ Weimar C et al, Arch Neurol 2002;59:1584; Buchwald F et al, Stroke 2016;47:2456; Amarenco P et al, N Engl J Med 2016;374:1533 ]. In contrast, new TIA episodes progressively increased year by year reaching 12% incidence after 5 years.After the IS index event, new strokes occurred with cumulative incidence lower than in the general population: after 1 and 5 years, the incidence was 2.03% and 6.52% vs 11.1%-12% and 26.4% of non-MPN patients [ Mohan KM et al, Stroke 2011;42:1489; Bergstrom L et al, Stroke 2017 Jul 13, AOP ]. The rate of deep venous thrombosis (DVT) in the first year, was higher after index IS than TIA, but was the same by 5 years (3.68% and 4.60%, respectively; p=0.47).Predictors of recurrent TIA and IS were the same index events (HR=2.41 and 4.41), and for recurrent TIA the remote history of cerebrovascular TIA episodes (HR=3.40) and microvascular disturbances (HR=2.30). Other prognostic factors of recurrent IS were arterial hypertension (HR=4.24) and occurrence of IS during the course of MPN (HR=4.27). On the contrary, cytoreductive therapy emerged as a strong protective factor able to reduce the probability of new strokes in 76% of patients (HR=0.24). The history of peripheral thrombosis, both venous and arterial events, independently predicted the occurrence of AMI (HR=6.30), while age over 60 years (HR=3.98), index IS (HR=3.61), occurrence after MPN diagnosis (HR=2.62), were all prognostically significant for CV mortality. During median follow-up of 4.2 years, major bleeding occurred with a frequency similar to that observed in the general population receiving long-term antiplatelet secondary prophylaxis (0.90 % pts/year) [ Li L et al, Lancet 2017 Jun 13, AOP ].CONCLUSION. Current antithrombotic therapy and cytoreductive drugs after index TIA and IS led to a reduction of cardio-vascular recurrences and mortality in a proportion of MPN patients greater than in general population. This would indicate that ischemic cerebral vascular events recognize a specific pathogenesis of thrombosis linked to the clonal disorder. Although the benefit-risk profile of secondary prophylaxis appears favorable, some high risk categories need new intervention strategies to be defined in prospective studies. DisclosuresIurlo:Novartis: Consultancy, Honoraria; Bristol Myers Squibb: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria. Finazzi:Italfarmaco S.p.A.: Consultancy. Bonifacio:Incyte: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees. Gaidano:Gilead: Consultancy, Honoraria; Roche: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria; Janssen: Consultancy, Honoraria. Vannucchi:Shire: Speakers Bureau; Novartis: Honoraria, Speakers Bureau.

Newly Diagnosed Atrial Fibrillation After Transient Ischemic Attack Versus Minor Ischemic Stroke in the POINT Trial.

BackgroundAtrial fibrillation/flutter (AF) after transient ischemic attack (TIA) has not been well studied. We compared the likelihood of new AF diagnosis after ischemic stroke versus TIA.Methods and ResultsThe POINT (Platelet‐Oriented Inhibition in New TIA and Minor Ischemic Stroke) trial enrolled adults within 12 hours of minor ischemic stroke or high‐risk TIA. Our exposure was index event type (ischemic stroke versus TIA). The primary analysis used the original trial definition of TIA (resolution of symptoms/signs). In secondary analyses, TIA cases with infarction on neuroimaging were reclassified as strokes. Our primary outcome was a new AF diagnosis, ascertained from adverse event and treatment interruption/discontinuation reports. We calculated C‐statistics for variables associated with newly diagnosed AF. We used Kaplan‐Meier survival statistics and Cox models adjusted for demographics and vascular risk factors. Excluding 49 subjects with baseline AF, 2746 patients had index stroke and 2086 patients had index TIA. During the 90‐day follow‐up, 106 patients had newly diagnosed AF. Cumulative risks of AF were 2.7% (95% CI, 2.1%–3.4%) after stroke and 2.0% (95% CI, 1.5%–2.7%) after TIA (P=0.15). After reclassifying index events by neuroimaging, cumulative AF risk was higher after stroke (2.7%; 95% CI, 2.2%–3.4%) than TIA (1.8%; 95% CI, 1.3%–2.5%) (P=0.04). Index event type had negligible predictive utility (C‐statistic, 0.54).ConclusionsAmong patients with cerebral ischemia, the distinction between TIA versus minor stroke did not stratify the risk of subsequent AF diagnosis, implying that patients with TIA should undergo similar heart‐rhythm monitoring strategies as patients with ischemic stroke.

Abstract P158: Outcomes of Patients With a Transient Ischemic Attack Based on Inpatient Versus Urgent Outpatient Evaluations a Systematic Review and Meta-Analysis

Importance: Management of transient ischemic attack (TIA)and the concept of urgent TIA clinic have gained significant attention over the past years. Objective: To calculate the odds of subsequent ischemic stroke within 2, 7, 30, and 90 days and death within 90 days among the TIA patients who received acute care in a TIA clinic versus those admitted to a hospital. Data Sources: We performed a systematic review and meta-analysis of all the published TIA outcome studies. Included studies were obtained by searching Medline, Web of Science, Scopus, All EBM reviews series, International Clinical Trial Registry Platform (ICTRP), Trip database, and CINAHL, last updated in March 2020, irrespective of the study design, document type, or language. Study Selection: We accepted both the classic time-based definition of TIA and the new tissue-based definition and studies with a combined record of TIA and minor ischemic stroke patients. We excluded studies with a diagnosis of index TIA event after ischemic stroke occurrence, low suspicious for TIA, TIA acute care in settings other than an outpatient clinic or hospital, multicentric studies, or duplicate reports of the same database. Data Extraction and Synthesis: The study was conducted and reported according to PRISMA, MOOSE, and EQUATOR guidelines. Critical appraisal and methodological quality were conducted by ROBINS-E tool. Data were pooled under random-effects models. Results: Systematic review yielded to 19,547 reports, of which titles and abstracts of 9,113 reports were screened. The overall subsequent ischemic stroke odds ratios were estimated by meta-analyses as follows: 4 studies within 2 days with 1,829 patients (OR: 0.93, 95% CI: -0.52-2.38), 5 studies within 7 days with 1,801 patients (OR: 0.68, 95% CI: -0.73-2.08), 4 studies within 30 days with 1,768 patients (OR:1.01, 95% CI: -0.72 - 2.73), and 6 studies within 90 days with 2,319 population (OR: 0.94, 95% CI: 0.22-1.66). The 90-day risk of death by analyzing 3 studies, 1162 patients, was calculated as OR:1.29, 95% CI: 0.76-3.34. Conclusion and Relevance: Hospital management of TIA patients in the acute phase may not be associated with a lower risk of stroke and death compared with urgent outpatient management.

Incidence of Transient Ischemic Attack and Association With Long-term Risk of Stroke

Accurate estimation of the association between transient ischemic attack (TIA) and risk of subsequent stroke can help to improve preventive efforts and limit the burden of stroke in the population. To determine population-based incidence of TIA and the timing and long-term trends of stroke risk after TIA. Retrospective cohort study (Framingham Heart Study) of prospectively collected data of 14 059 participants with no history of TIA or stroke at baseline, followed up from 1948-December 31, 2017. A sample of TIA-free participants was matched to participants with first incident TIA on age and sex (ratio, 5:1). Calendar time (TIA incidence calculation, time-trends analyses), TIA (matched longitudinal cohort). The main outcomes were TIA incidence rates; proportion of stroke occurring after TIA in the short term (7, 30, and 90 days) vs the long term (>1-10 years); stroke after TIA vs stroke among matched control participants without TIA; and time trends of stroke risk at 90 days after TIA assessed in 3 epochs: 1954-1985, 1986-1999, and 2000-2017. Among 14 059 participants during 66 years of follow-up (366 209 person-years), 435 experienced TIA (229 women; mean age, 73.47 [SD, 11.48] years and 206 men; mean age, 70.10 [SD, 10.64] years) and were matched to 2175 control participants without TIA. The estimated incidence rate of TIA was 1.19/1000 person-years. Over a median of 8.86 years of follow-up after TIA, 130 participants (29.5%) had a stroke; 28 strokes (21.5%) occurred within 7 days, 40 (30.8%) occurred within 30 days, 51 (39.2%) occurred within 90 days, and 63 (48.5%) occurred more than 1 year after the index TIA; median time to stroke was 1.64 (interquartile range, 0.07-6.6) years. The age- and sex-adjusted cumulative 10-year hazard of incident stroke for patients with TIA (130 strokes among 435 cases) was 0.46 (95% CI, 0.39-0.55) and for matched control participants without TIA (165 strokes among 2175) was 0.09 (95% CI, 0.08-0.11); fully adjusted hazard ratio [HR], 4.37 (95% CI, 3.30-5.71; P < .001). Compared with the 90-day stroke risk after TIA in 1948-1985 (16.7%; 26 strokes among 155 patients with TIA), the risk between 1986-1999 was 11.1% (18 strokes among 162 patients) and between 2000-2017 was 5.9% (7 strokes among 118 patients). Compared with the first epoch, the HR for 90-day risk of stroke in the second epoch was 0.60 (95% CI, 0.33-1.12) and in the third epoch was 0.32 (95% CI, 0.14-0.75) (P = .005 for trend). In this population-based cohort study from 1948-2017, the estimated crude TIA incidence was 1.19/1000 person-years, the risk of stroke was significantly greater after TIA compared with matched control participants who did not have TIA, and the risk of stroke after TIA was significantly lower in the most recent epoch from 2000-2017 compared with an earlier period from 1948-1985.

Risk of Ischemic Stroke after an Inpatient Hospitalization for Transient Ischemic Attack in the United States

Introduction: A diagnosis of transient ischemic attack (TIA) must be followed by prompt investigation and rapid initiation of measures to prevent stroke. Prior studies evaluating the risk of stroke after TIA were conducted in the emergency room or clinic settings. Experience of patients admitted to the hospital after a TIA is not well known. We sought to assess the early risk of ischemic stroke after inpatient hospitalization for TIA. Methods: We used the 2010–2015 Nationwide Readmissions Database to identify all hospitalizations with the primary discharge diagnosis of TIA and investigated the incidence of ischemic stroke readmissions within 90 days of discharge from the index hospitalization. Results: Of 639,569 index TIA admissions discharged alive (mean ± SD age 70.4 ± 14.4 years, 58.7% female), 9,131 (1.4%) were readmitted due to ischemic stroke within 90 days. Male sex, head/neck vessel atherosclerosis, hypertension, diabetes, atrial flutter/fibrillation, previous history of TIA/stroke, illicit drug use, and higher Charlson Comorbidity Index score were independently associated with readmissions due to ischemic stroke. Ischemic stroke readmissions were associated with excess mortality, discharge disposition other than to home, and elevated cost. Conclusions: Patients hospitalized for TIA have a lower risk of ischemic stroke compared to that reported in the studies based on the emergency room and/or outpatient clinic evaluation. Among these patients, those with cardiovascular comorbidities remain at a higher risk of readmission due to ischemic stroke despite undergoing an inpatient evaluation and should therefore be the target for future preventive strategies.

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

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. 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). 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. 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. The 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 τ2 statistic and Egger bias test. Data were pooled using double arcsine transformations, DerSimonian-Laird estimator, and random-effects models. The proportion of the early ischemic stroke after TIA within 4 evaluation intervals (2, 7, 30, and 90 days) was considered as effect size. 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. 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.

Reduction in Stroke After Transient Ischemic Attack in a Province-Wide Cohort Between 2003 and 2015.

Improvements in management of transient ischemic attack (TIA) have decreased stroke and mortality post-TIA. Studies examining trends over time on a provincial level are limited. We analyzed whether efforts to improve management have decreased the rate of stroke and mortality after TIA from 2003 to 2015 across an entire province. Using administrative data from the Canadian Institute for Health Information's (CIHI) databases from 2003 to 2015, we identified a cohort of patients with a diagnosis of TIA upon discharge from the emergency department (ED). We examined stroke rates at Day 1, 2, 7, 30, 90, 180, and 365 post-TIA and 1-year mortality rates and compared trends over time between 2003 and 2015. From 2003 to 2015 in Ontario, there were 61,710 patients with an ED diagnosis of TIA. Linear regressions of stroke after the index TIA showed a significant decline between 2003 and 2015, decreasing by 25% at Day 180 and 32% at 1 year (p < 0.01). The 1-year stroke rate decreased from 6.0% in 2003 to 3.4% in 2015. Early (within 48 h) stroke after TIA continued to represent approximately half of the 1-year event rates. The 1-year mortality rate after ED discharge following a TIA decreased from 1.3% in 2003 to 0.3% in 2015 (p < 0.001). At a province-wide level, 1-year rates of stroke and mortality after TIA have declined significantly between 2003 and 2015, suggesting that efforts to improve management may have contributed toward the decline in long-term risk of stroke and mortality. Continued efforts are needed to further reduce the immediate risk of stroke following a TIA.

Association of Black Race With Early Recurrence After Minor Ischemic Stroke or Transient Ischemic Attack

Stroke incidence is higher among black than white individuals in the United States. It is unclear whether black individuals have a higher risk of stroke recurrence after a minor ischemic stroke or transient ischemic attack (TIA), a high-risk setting in which focused preventive efforts can be effective. To examine the association between black race and early ischemic stroke recurrence. This cohort study analyzed data from the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial conducted at 269 sites from May 28, 2010, to December 19, 2017. The trial enrolled 4881 adults within 12 hours of onset of a minor ischemic stroke (National Institutes of Health Stroke Scale score, 0-3) or high-risk TIA (ABCD2 score, ≥4). For this analysis, we excluded 598 patients enrolled outside the United States and 239 US patients with missing race/ethnicity data. The primary outcome for this analysis was ischemic stroke within 90 days after randomization. Covariates included age, sex, Hispanic ethnicity, study assignment to take clopidogrel vs placebo, index stroke vs TIA, vascular risk factors, statin use, study drug adherence, and index event etiological subtype. Among 4044 patients included in the analysis, 918 (22.7%) were black. In an adjusted Cox model, black race was associated with a higher risk of recurrence compared with white race (hazard ratio, 1.6; 95% CI, 1.1-2.3). Findings were similar in subgroup analyses and in analyses limited to sites that enrolled black patients. Among US participants in the POINT trial, black individuals faced a higher risk of early stroke recurrence after a minor ischemic stroke or TIA. Our findings support research into black-white racial differences in the underlying mechanisms of recurrent stroke. In the meantime, extra effort should be made to ensure that black patients have access to proven secondary prevention measures. clinicaltrials.gov Identifier: NCT00991029.

P6542Early Prolonged Ambulatory Cardiac monitoring in Stroke (EPACS): an open-label randomised controlled trial and economic evaluation

Abstract Background Cardioembolism in paroxysmal atrial fibrillation (PAF) is a preventable cause of transient ischaemic attack (TIA) or ischaemic stroke, however, due its transient nature, a short-duration Holter monitor may miss a significant proportion of events. Methods We conducted an open-label randomised controlled trial of cardiac monitoring after a TIA or ischaemic stroke comparing a 14-day ECG monitoring patch with short-duration Holter monitoring for the detection of PAF. The primary outcome was the detection of one or more episodes of ECG-documented PAF lasting at least 30 seconds within 90 days in each of the study arms. A budget impact analysis from the healthcare perspective was performed to assess the theoretical economic implications of the patch-based service versus Holter monitoring. Based on the AF detection rates found in this study, Hospital Episode Statistics data for the incidence of stroke and TIA (October 2016-September 2017) and National Health Service reference costs, the cost-effectiveness of the patch-based service versus Holter monitoring was calculated. The Sentinel Stroke National Audit Programme estimate of £13,452 was used as the mean year one direct medical cost of a stroke. Results From February 2016 through February 2017, 43 (76.8%) of the 56 patients assigned to the patch-based monitoring group and 47 (78.3%) of the 60 patients assigned to the short-duration Holter monitoring group had successful monitor placement with 90 days of follow-up (Figure 1). Of the 26 protocol failures between the two groups, 23 (88.5%) were due to patient refusal for outpatient short-duration Holter monitor placement, whilst only 1 (3.8%) was due to unsuccessful patch placement. The rate of detection of PAF at 90 days was 16.3% in the patch-based monitoring group (7 patients) compared to 2.1% in the short-duration Holter monitoring group (1 patient), with an odds ratio of 8.9 (95% CI 1.1–76.0; P=0.026). Implementation of the patch-based service at our hospital would result in 10.8 more strokes avoided per year compared to current practice with short-duration Holter monitoring. This would equate to a yearly saving in direct medical costs of £57,481, increasing to £106,342 over 5 years. When social care costs are included, incremental savings of £154,716 can be achieved in the first year and £410,449 at 5 years. In addition, an analysis of the potential reduction in outpatient follow-up appointment costs resulted in a further saving of £56,149, giving a total potential saving of £113,630 over the first year with the use of the patch-based service compared to short-duration Holter monitoring, increasing to £162,491 over 5 years. Figure 1. Study participant flowchart Conclusions Early, prolonged, patch-based monitoring after an index stroke or TIA is superior to short-duration Holter monitoring in the detection of PAF and likely cost-effective for preventing recurrent strokes. Acknowledgement/Funding Bristol-Myers Squibb-Pfizer alliance (Grant Number CV185-475)

Oral anticoagulation in patients with atrial fibrillation and acute ischaemic stroke: design and baseline data of the prospective multicentre Berlin Atrial Fibrillation Registry

The Berlin Atrial Fibrillation Registry was designed to analyse oral anticoagulation (OAC) prescription in patients with atrial fibrillation (AF) and acute ischaemic stroke. This investigator-initiated prospective multicentre registry enrolled patients at all 16 stroke units located in Berlin, Germany. The ongoing telephone follow-up is conducted centrally and will cover 5 years per patient. Within 2014 and 2016, 1080 patients gave written informed consent and 1048 patients were available for analysis. Median age was 77 years [interquartile range (IQR) 72-83], 503 (48%) patients were female, and 254 (24%) had a transient ischaemic attack (TIA). Overall, 470 (62%) out of 757 patients with known AF and a (pre-stroke) CHA2DS2-VASc ≥ 1 were anticoagulated at the time of stroke. At hospital discharge, 847 (81.3%) of 1042 patients were anticoagulated. Thereof 710 (68.1%) received a non-vitamin K-dependent oral anticoagulant (NOAC) and 137 (13.1%) a vitamin K antagonist (VKA). Pre-stroke intake of a NOAC [odds ratio (OR) 15.6 (95% confidence interval, 95% CI 1.97-122)] or VKA [OR 0.04 (95% CI 0.02-0.09)], an index TIA [OR 0.56 (95% CI 0.34-0.94)] rather than stroke, heart failure [OR 0.49 (95% CI 0.26-0.93)], and endovascular thrombectomy at hospital admission [OR 12.9 (95% CI 1.59-104)] were associated with NOAC prescription at discharge. Patients' age or AF type had no impact on OAC or NOAC use, respectively. About 60% of all registry patients with known AF received OAC at the time of stroke or TIA. At hospital discharge, more than 80% of AF patients were anticoagulated and about 80% of those were prescribed a NOAC.

Early prolonged ambulatory cardiac monitoring in stroke (EPACS): an open-label randomised controlled trial

BackgroundCardioembolism in paroxysmal atrial fibrillation (PAF) is a preventable cause of transient ischaemic attack (TIA) or ischaemic stroke; however, due to its transient nature, a short-duration Holter monitor may miss a significant proportion of events.MethodsWe conducted an open-label randomised controlled trial of cardiac monitoring after a TIA or ischaemic stroke comparing a 14-day ECG monitoring patch (Zio® Patch, iRhythm Technologies) with short-duration Holter monitoring for the detection of PAF. The primary outcome was the detection of one or more episodes of ECG-documented PAF lasting at least 30 s within 90 days in each of the study arms. A budget impact analysis from the healthcare perspective was performed.ResultsFrom February 2016 through February 2017, 43 (76.8%) of the 56 patients assigned to the patch-based monitoring group and 47 (78.3%) of the 60 patients assigned to short-duration Holter monitoring group had successful monitor placement with 90 days of follow-up. Of the 26 protocol failures between the two groups, 23 (88.5%) were due to patient refusal for outpatient short-duration ECG monitor placement, whilst only 1 (3.8%) was due unsuccessful ZioPatch placement. The rate of detection of PAF at 90 days was 16.3% in the patch-based monitoring group (seven patients) compared to 2.1% in the short-duration Holter monitoring group (1 patient), with an odds ratio of 8.9 (95% CI 1.1–76.0; P = 0.026). An economic model demonstrated that implementation of the Zio Patch service would result in 10.8 more strokes avoided per year compared to current practice with Holter monitoring with an associated yearly saving in direct medical costs of £113,630, increasing to £162,491 over 5 years.ConclusionsEarly, prolonged, patch-based monitoring after an index stroke or TIA is superior to short-duration Holter monitoring in the detection of PAF and likely cost-effective for preventing recurrent strokes.Trial registrationhttp://www.isrctn.com. Unique identifier: ISRCTN 50253271. Registered 21 January 2016

Potential missed opportunities to prevent ischaemic stroke: prospective multicentre cohort study of atrial fibrillation-associated ischaemic stroke and TIA

ObjectiveWe report on: (1) the proportion of patients with known atrial fibrillation (AF); and (2) demographic, clinical or radiological differences between patients with known AF (and not treated) and patients...

Long-Term Stroke Recurrence after Transient Ischemic Attack: Implications of Etiology.

Background and PurposeTo analyze long-term stroke recurrence (SR) characteristics after transient ischemic attack (TIA) according to initial etiological classification. MethodsA prospective cohort of 706 TIA patients was followed up in a single tertiary stroke center. Endpoint was SR. Etiologic subgroup was determined according to the evidence-based causative classification system. Location of TIA and SR was recorded as right, left, or posterior territory. Disability stroke recurrence (DSR) was defined as modified Rankin Scale (mRS) score >1 or a onepoint increase in those with previous mRS >1 at 3-month follow-up. ResultsDuring a follow-up of 3,493 patient-years (mean follow-up of 58.9±35.9 months), total SR was 125 (17.7%), corresponding to 3.6 recurrences per 100 patient-years. The etiology subgroups with a higher risk of SR were the unclassified (more than one cause) and large-artery atherosclerosis (LAA) categories. Of the SR cases, 88 (70.4%) had the same etiology as the index TIA; again, LAA etiology was the most frequent (83.9%). Notably, cardioaortic embolism was the most frequent cause (62.5%) of SR in the subgroup of 24 patients with undetermined TIA. Overall, SR occurred in the same territory in 74 of 125 patients (59.2%), with significant differences between etiological TIA subgroups (P=0.015). Eighty-two of 125 (65.6%) with SR had DSR, without differences between etiologies (P=0.453). ConclusionsSR occurred mainly with the same etiology and location as initial TIA, although undetermined TIA was associated with a high proportion of cardioaortic embolism SR. More than half of the recurrences caused some disability, regardless of etiology.

Antiplatelet Agents in Secondary Stroke Prevention: Selection, Timing, and Dose.

This narrative review critically evaluated the published studies regarding the systematic use of antiplatelet agents for secondary stroke prevention. Stroke is a leading cause of morbidity and mortality around the world. Multimodal prevention is the most viable strategy for reducing the societal burden of stroke recurrence. For secondary stroke prevention, antiplatelet therapy is at the core of effective long-term vascular risk reduction among survivors of an ischemic stroke or transient ischemic attack (TIA). In addition to aspirin, there are several antiplatelet agents proven to be efficacious in averting recurrent vascular events after an index ischemic stroke or TIA. However, beyond the challenges of keeping up with recent advances in antiplatelet drug options for secondary stroke prevention, questions linger about the most appropriate selection, timing, and dosing of antiplatelet treatment for a given patient. We narratively summarized the pharmacological properties of key antiplatelet drugs; discussed the evidence regarding efficacy, selection, timing, and dosing of various antiplatelet treatment regimens; and highlighted ongoing clinical trials identifying novel therapies with more favorable risk-benefit profiles than currently available antiplatelet agents for patients with a recent history of ischemic or TIA stroke. Finally, we reviewed published data on antiplatelet therapies that could potentially be applied in the management of commonly encountered challenging clinical scenarios.