Urgent intervention after a transient ischemic attack by an acute care team followed by nurse-conducted health counseling can substantially reduce the risk of new vascular events within the first year, according to results of the Aarhus TIA study.
Careful evaluation and use of preventive measures helped the team lower the cumulative risk of stroke below predicted levels 7 days and 90 days after TIA.
Immediate intervention is important because TIA can increase patients’ risk of ischemic stroke by more than 30% within the first 3 months after the attack. Studies have shown that urgent intervention can substantially reduce this risk, but little is known about stroke risk beyond 90 days. Additional studies have shown poor treatment and compliance rates for preventive measures such as cholesterol and blood pressure reduction and smoking cessation.
Dr. Paul von Weitzel-Mudersbach and his colleagues at Aarhus (Denmark) University Hospital established an acute TIA team that served patients with TIA on the stroke unit and the TIA clinic, and examined all patients with TIA who were referred to the hospital between March 1, 2007, and Feb. 28, 2008. A total of 306 patients (56.2% men) with a median age of 65.8 years met the study’s inclusion criteria. These patients underwent a detailed diagnostic work-up and received 150 mg aspirin immediately after CT/MRI. Patients with symptomatic carotid or intracerebral stenosis also received 300 mg clopidogrel unless carotid endarterectomy was planned within 1 week. A trained nurse discussed lifestyle changes, including smoking cessation, healthy diet, and physical exercise at baseline and during follow-up telephone interviews at 7 days and 90 days (Eur. J. Neurol. 2011;18:1285-90).
Urgent treatment was associated with a reduced risk of adverse clinical outcomes, the researchers found. Within 1 year, 16 (5%) of the 306 patients had a stroke, non-fatal MI, or vascular death. The cumulative stroke risk was 1.3% after 2 days. The intervention resulted in a significantly lower cumulative stroke risk than what was predicted with ABCD2 criteria after both 7 days (1.6% vs. 4.5%) and 90 days (2% vs. 7.5%).
At the end of 1 year, the cumulated stroke risk was 4.2% (13 patients, all had ischemic stroke), and the cumulated mortality was 2.9%, or 9 patients; 5 of these deaths were due to vascular causes, and the remainder were caused by cancer and sepsis. TIA recurred in the first year in 10.2% of patients. There were no non-fatal MIs.
The investigators found that 8.1% of patients underwent carotid endarterectomy, with a median time to operation of 11 days after the first contact with the acute TIA team, 12.5 days after the call for attention, and 17.5 days after the index TIA.
The number of patients who achieved the secondary prevention target increased from 34% of patients at baseline to 48% after 1 year. The secondary prevention target was considered attained if a patient fulfilled at least three of the following four criteria: systolic blood pressure 130 mm Hg or less and diastolic 80 mm Hg or less; total cholesterol less than 4.5 mmol/L; no smoking; and self-reported adherence to antithrombotic treatment. At least 95% of patients fulfilled at least one prevention measure after 1 year.
Patients with large artery disease (LAD) had the best compliance: 55% reached the secondary prevention target and 100% were adherent to antithrombotic treatment. LAD was not a predictor for vascular events within the first year, possibly due to good adherence to secondary prevention.
The study was supported by the Danish Heart Foundation and the Research Council in the former Aarhus County. The authors had no disclosures.☐