Rapid assessment and treatment of minor strokes and transient-ischaemic attacks* (TIAs) massively reduces the chances of occurrence of subsequent major stroke, conclude two separate studies, one early Online and in an upcoming edition of The Lancet, and the other early Online and in the November issue of The Lancet Neurology.
The risk of a major stroke occurring in the first month after a minor stroke or TIA is 10%. The Lancet study shows that early initiation of current treatments following a minor stroke or TIA reduces that risk by 80%. Such actions if universally applied could prevent almost 10,000 strokes per year in the UK alone.
Professor Peter Rothwell, Stroke Prevention Research Unit, Radcliffe Infirmary, University of Oxford, UK, and colleagues did a prospective before and after study, with phase one running April 2002 to September 2004 and phase two running Oct 2004 to March 2007. They looked at the effect of urgent assessment and immediate treatment in specialist clinics, compared with subsequent initiation of such treatment in primary care, in all patients with minor stroke or TIA who were not admitted directly to hospital. The study was nested within a rigorous population based study of stroke and TIA (the Oxford Vascular Study, OXVASC), and as such case investigation and follow-up were complete and identical in both phases.
In phase one, the median delay to assessment in clinic was 3 days, while the median time to first prescription of treatment was 20 days. These values were reduced to 1 day for both assessment and prescription in phase two. The researchers found that the 90-day risk of recurrent stroke in phase one patients was 10.3% (32/310 patients), while in phase two the risk was 2.1% (6/281 patients), meaning that immediate assessment and treatment in phase two reduced the risk of recurrence by 80%. Further, they found that the reduction in risk was independent of age and sex, and early treatment did not increase the risk of bleeding or other complications.
The authors say: "Our data indicate that urgent assessment and early initiation of a combination of existing preventative treatments can reduce risk of early recurrent stroke after TIA or minor stroke by about 80%...extrapolated across the UK population, this equates to the prevention of nearly 10000 strokes per year."
They conclude: "Further follow-up is required to determine long-term outcome, but these results have immediate implications for the service provision and public education about TIA and minor stroke."
In a Comment to accompany The Lancet study, Dr Naeem Dean, Royal Alexandra Hospital, Edmonton, Canada, and Dr Ashfaq Shuaib, University of Alberta, Edmonton, Canada, say that Rothwell and colleagues’ findings "are very important and should promote renewed attention to urgent care of patients with TIAs and minor strokes."
They also say there is a pressing need to complete proposed larger randomised trials (FASTER and CAISTA trials), and conclude: "We hope these trials will confirm and complement the findings presented by Rothwell and colleagues, and revolutionise the way we manage cerebrovascular disease. Patients with TIAs and minor strokes are not disabled. If the risk of a disabling stroke can be substantially reduced in this population, we strongly recommend that patients should receive the same urgent attention as is provided for those with acute coronary syndromes."
In the The Lancet Neurology study, Dr Pierre Amarenco, Bichat-Claude Bernard University Hospital, Denis Diderot University and Medical School, Paris, France, and colleagues set up a hospital clinic with 24-hour access specifically to treat patients with suspected cerebral or retinal TIAs.
Patients were admitted if they had sudden retinal or cerebral focal symptoms, related to ischaemia, and if they made a complete recovery. Patients were referred to the clinic by one of the 15,000 family doctors, cardiologists, neurologists, and ophthalmologists in and around Paris who had been sent information about it.
Assessment at the clinic included neurological, arterial, and cardiac imaging, and took place within four hours of admission. The study looked at stroke within 90 days, and stroke, heart attack, and vascular death within one year. The 90 day stroke rate was 1.24%, whereas the rate predicted by ABCD2 scores** was 5.96%. Thus the study showed that immediate treatment through a dedicated clinic reduced the risk of recurrence of TIA by almost 80%. Of 1085 patients admitted by the clinic, 808 (74%) of all patients seen were sent home on the same day.
The authors conclude: "We show that prompt evaluation and treatment of patients with TIA in a dedicated outpatient unit is associated with a lower than expected risk of subsequent stroke. Because almost three-quarters of patients were discharged home on the same day as diagnosis, the TIA clinic is also likely to involve lower costs and greater patient satisfaction about their management than is treatment without such a clinic."
In an accompanying Comment in The Lancet Neurology, Drs Walter Kernan and Joseph Schindler, Yale University School of Medicine, New Haven, CT, USA say: "By reaching out to physicians in the area and by initiating preventative therapy at the point of care, the neurologists in the study by Amarenco and colleagues have modelled a new, more active approach to stroke prevention after TIA."
They conclude: "Rapid assessment and intervention is emerging as the new standard for TIA care…we believe that the time is right to accept this new standard and to begin use of rapid access as a platform for rigorous testing of innovative strategies for TIA care."
Notes to editors:
*A transient ischaemic attack (TIA) causes symptoms that are similar to a stroke, such as slurred speech, dizziness, or numbness on one side of the body, but unlike a stroke symptoms disappear completely over several hours. It is caused by a temporary interruption in blood flow to the brain and can be a warning sign of a major stroke.
** ABCD2 scores are seven point scores calculated on the basis of age, blood pressure, clinical features, diabetes, and duration of symptoms."
Full contact details
Professor Peter Rothwell, Stroke Prevention Research Unit, Radcliffe Infirmary, University of Oxford T) +44 1865 617158 E) peter.rothwell@clinical-neurology.oxford.ac.uk
Dr Ashfaq Shuaib, University of Alberta, Edmonton, Canada T) +1 780 994 3713 E) Ashfaq.shuaib@ualberta.ca
Dr Pierre Amarenco, Bichat-Claude Bernard University Hospital, Denis Diderot University and Medical School, Paris, France T) +33 140 258 725 E) Pierre.amarenco@bch.aphp.fr
Dr Walter N Kernan, Yale University School of Medicine, New Haven, CT, USA T) +1 203-764-7000 E) walter.kernan@yale.edu
Journal
The Lancet