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ORIGINAL ARTICLE
Year : 2012  |  Volume : 60  |  Issue : 2  |  Page : 165-167

Early risk and predictors of cerebrovascular and cardiovascular events in transient ischemic attack and minor ischemic stroke


1 Department of Neurology, Comprehensive Stroke Care Centre, Sree Chitra Thirunal Institute for Medical Sciences and Technology, Trivandrum, India
2 Department of Interventional Radiology and Imaging Sciences, Achutha Menon Centre for Health Sciences Studies, Sree Chitra Thirunal Institute for Medical Sciences and Technology, Trivandrum, India
3 Department of Neurology, Elite Mission Hospital, Thrissur, India
4 Department of Neurology, Achutha Menon Centre for Health Sciences Studies, Sree Chitra Thirunal Institute for Medical Sciences and Technology, Trivandrum, India
5 Department of Neurology, Stroke Unit, Christian Medical College, Ludhiana, India

Date of Submission21-Dec-2011
Date of Decision26-Mar-2012
Date of Acceptance01-Apr-2012
Date of Web Publication19-May-2012

Correspondence Address:
P N Sylaja
Department of Neurology, Sree Chitra Thirunal Institute for Medical Sciences and Technology, Trivandrum-695011
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.96393

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 » Abstract 

Background: Transient ischemic attack (TIA) and minor ischemic stroke (MIS) are associated with early recurrence and deterioration respectively. The aim of the present study was to assess the risk of new cerebrovascular and cardiovascular events in a prospective, emergently enrolled patient cohort with TIA and MIS and the predictors of risk. Materials and Methods: Patients with TIA and MIS (NIH Stroke Scale [NIHSS] ≤ 5) presenting within the first 48 h between July 2008-June 2009 were prospectively enrolled. The primary outcome was new-onset stroke, TIA, cardiovascular events and vascular death at 90 days and early deterioration in patients with minor stroke. The 90-day outcome was also assessed (excellent outcome; modified Rankin scale [mRS] ≤2). Results: Eighteen (15.3%) of the 118 patients enrolled developed new cerebrovascular or cardiovascular events during the 90 days of follow-up, nine (50%) of which occurred within seven days. Of the all new events 5.9% (7/118) had new stroke, 4.2% (5/118) patients developed early deterioration, 2.5% (3/118) patients had recurrent TIA and 2.5% (3/118) had cardiovascular events at 90 days. Eight (6.7%) patients had poor outcome at 90 days (mRS>2). The factors predicting new vascular events were presence of coronary artery disease (CAD), and stroke etiology being large artery atherosclerosis (LAA). Conclusion: In patients with TIA and MIS, despite urgent evaluation and aggressive management, the short-term risk of stroke and other vascular events is high. Those with CAD and LAA should be monitored closely for early deterioration.


Keywords: Death, minor ischemic stroke, predictors, recurrence, transient ischemic attack


How to cite this article:
Kate M, Sylaja P N, Chandrasekharan K, Balakrishnan R, Sarma S, Pandian JD. Early risk and predictors of cerebrovascular and cardiovascular events in transient ischemic attack and minor ischemic stroke. Neurol India 2012;60:165-7

How to cite this URL:
Kate M, Sylaja P N, Chandrasekharan K, Balakrishnan R, Sarma S, Pandian JD. Early risk and predictors of cerebrovascular and cardiovascular events in transient ischemic attack and minor ischemic stroke. Neurol India [serial online] 2012 [cited 2019 Nov 17];60:165-7. Available from: http://www.neurologyindia.com/text.asp?2012/60/2/165/96393



 » Introduction Top


Transient ischemic attack (TIA) and minor ischemic stroke (MIS) are associated with early recurrence and deterioration respectively. One in 10 patients with TIA will develop new-onset stroke within 90 days with more than 50% occurring in the first seven days. [1] A similar high risk of early deterioration is observed in patients with minor stroke. [2] Various scores have been developed to assign risk to triage patients with TIA. The most commonly used scoring system being ABCD2 score. These scores have a limitation and additional factors like imaging and etiology of TIA and MIS have shown better predictability of risk of early stroke. [3],[4],[5] Further, ABCD2 and Essen Stroke Risk Score have shown poor predictive value in MIS. [6] Both TIA and MIS are also associated with elevated early risk for cardiovascular events and mortality which is not considered in the current prognostic scores. [1],[7] The aim of the present study was to assess the risk of new cerebrovascular and cardiovascular events in a prospective, emergently enrolled patient cohort with TIA and MIS and the predictors of risk. predictors.


 » Materials and Methods Top


Patient selection

Consecutive patients reporting to the Emergency Department with TIA and MIS (National Institute of Health Stroke Scale [NIHSS] ≤ 5) presenting within the first 48 h from three tertiary care centers in India were included in the study. They were prospectively enrolled from July 2008 to June 2009 after obtaining informed consent. The study was approved by the local Ethics Committee in each center. All patients were examined by a stroke neurologist. The patients were evaluated and investigated within 48 h.

Investigation

All patients underwent investigations as per protocol which included complete hemogram, blood glucose, renal and liver function tests, fasting lipid profile, electrocardiogram, echocardiogram, Neck vessel Doppler for extra-cranial vasculature, magnetic resonance imaging (MRI) brain (Sequences used T1W, T2W, FLAIR, DWI, ADC map and contrast MR angiography) and Holter testing (in selected cases).

Clinical follow-up and outcome measures

The primary outcome measures were early deterioration, recurrence of TIA, new-onset stroke, acute coronary syndrome, congestive cardiac failure and mortality. Early deterioration was defined as ≥ 2 points' worsening in NIHSS within seven days of symptom onset in minor stroke patients. Study patients were followed for a period of 90 days. Patients were requested emergent follow-up upon occurrence of new events. They received treatment with single or dual anti-platelets, and statins. If personal follow-up was not obtained, home visits or telephonic calls were made by social workers. The 90-day outcome was assessed (excellent outcome; modified Rankin scale [mRS] ≤2).

Statistical analysis

Descriptive statistics was used to define baseline characteristics in the two groups. Fisher's exact test was used to compare discrete variables. Univariate and multivariate analysis was done to identify predictors of early deterioration and new vascular events. Multiple logistic regression model was used to identify significant predictors of new vascular events. All the analysis was done using SPSS 15.0 software.


 » Results Top


Of the 118 patients (mean +/-SD age,58.8+/-11.5 years) recruited, 82 (69.5%) had TIA and 36 (30.5%) had MIS. The cohort was male predominant (2.8:1). The mean time to enrolment after symptom onset was less than 24 h in 84.6% (100/118) of patients and the rest were enrolled in 48 h. The demographic profile of the two groups [Table 1] was similar except, smokers were seen significantly more in the MIS group (12/36, P= 0.01) and undetermined etiology was more in the TIA group (28/82, P= 0.02). Eighteen patients (18/118, 15.3%) had new cerebrovascular or cardiovascular events over 90 days [Table 2], of which nine (50%) occurred within seven days. Of the new events 5.9% (7/118) had new stroke, 4.2% (5/118) patients developed early deterioration, 2.5% (3/118) patients had recurrent TIA and 2.5% (3/118) had cardiovascular events at 90 days. The risk of stroke was 6.1% (5/82) in the TIA group and 13.8% (5/36) of patients with MIS had early deterioration. ABCD2 score was 4 or more in 78% (64/82) of TIA population and 100% in the group with events.
Table 1: Demographic profile of study patients

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Table 2: Characteristics of the new vascular events

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Three (2.5%) patients died during the study period, all were from the TIA group (3.6%), one had death due to MI, other had sudden cardiac death and the last had sepsis after new-onset stroke. The factors predicting occurrence of early deterioration and new vascular events [Table 3] were presence of coronary artery disease (CAD) (P=0.03, odds ratio (OR) 3.6, 95% confidence interval (CI) 1.1-11.5) and stroke etiology being large artery atherosclerosis (LAA) (P=0.02, OR 3.4, 95%CI 1.2-9.5).
Table 3: Predictors of the vascular events in TIA and MIS

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 » Discussion Top


This prospective study confirms that TIA and minor stroke carries an increased early risk of not only stroke, but cardiovascular events and death. The high early risk of all vascular events of 15.3% at 90 days in our study is similar to previous studies. [1],[8] In addition more than 50% of the new vascular events occurred in the first seven days highlighting the importance of urgent evaluation and treatment.

Three (2.5%) patients developed cardiovascular events which was an important cause of mortality at 90 days. Previous studies have looked independently into cardiovascular morbidity and mortality in the TIA and MIS group, but have not addressed the early short-term risk of cardiac events after TIA. [9],[10],[11] In our study we found that cardiac events are an important cause of early morbidity and mortality after TIA and minor stroke. All our patients with cardiovascular events did not have a prior history of CAD, hence it is imperative to have a high index of suspicion and cardiac evaluation in patients with high-risk TIA and MIS.

All our patients with TIA and MIS with early deterioration and new vascular events had ABCD 2 score of 4 or more making it a highly sensitive score with very low specificity, in both the subgroups for prediction of new vascular events. There was a high rate of early deterioration (13.8%) in the MIS patients in seven days which is higher than the 4.5% in the study by Ferrari et al. Univariate analysis of the discrete variables involving risk factors, MRI DWI findings and etiological factors demonstrated CAD and large-vessel atherosclerosis as the most significant predictors of new vascular events at seven days and 90 days. A similar finding has been noted in two recent studies where presence of carotid stenosis was associated with increased risk of new-onset stroke after a TIA. [4],[12]

The strength of the study is early inclusion of the patient within 48 h of the index event and prospective follow-up. To our knowledge this is first multicentre trial from a developing country prospectively looking into early and short-term risk of patients with TIA and MIS. The limitation of our study is the small population size and exclusion of patients who came out of time window of 48 h.

 
 » References Top

1.Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000;284:2901-6.  Back to cited text no. 1
    
2.Ferrari J, Knoflach M, Kiechl S, Willeit J, Schnabl S, Seyfang L, et al. Early clinical worsening in patients with TIA or minor stroke: The Austrian Stroke Unit Registry. Neurology 2010;74:136-41.  Back to cited text no. 2
    
3.Coutts SB, Sylaja PN, Choi YB, Al-Khathami A, SivaKumar C, Jeerakathil TJ, et al. The ASPIRE Approach for TIA Risk Stratification. Can J Neurol Sci 2011;38:78-81.  Back to cited text no. 3
    
4.Merwick A, Albers GW, Amarenco P, Arsava EM, Ay H, Calvet D, et al. Addition of brain and carotid imaging to the ABCD 2 score to identify patients at early risk of stroke after transient ischemic attack: A multicentre observational study. Lancet Neurol 2010;9:1060-9.  Back to cited text no. 4
    
5.Giles MF, Albers GW, Amarenco P, Arsava MM, Asimos A, Ay H, et al. Addition of brain infarction to the ABCD2 Score (ABCD2I): A collaborative analysis of unpublished data on 4574 patients. Stroke 2010;41:1907-13.  Back to cited text no. 5
    
6.Chandratheva A, Geraghty OC, Rothwell PM. Poor performance of current prognostic scores for early risk of recurrence after minor stroke. Stroke 2011;42:632-7.  Back to cited text no. 6
    
7.Touzé E, Varenne O, Chatellier G, Peyrard S, Rothwell PM, Mas JL. Risk of myocardial infarction and vascular death after transient ischemic attack and ischemic stroke. Stroke 2005;36:2748-55.  Back to cited text no. 7
    
8.Selvarajah JR, Smith CJ, Hulme S, Georgiou RF, Vail A, Tyrrell PJ, et al. Prognosis in patients with transient ischaemic attack (TIA) and minor stroke attending TIA services in the North West of England: The NORTHSTAR Study. J Neurol Neurosurg Psychiatry 2008;79:38-43.  Back to cited text no. 8
    
9.Elkins JS, Sidney S, Gress DR, Go AS, Bernstein AL, Johnston SC. Electrocardiographic findings predict short-term cardiac morbidity after transient ischemic attack. Arch Neurol 2002;59:1437-41.  Back to cited text no. 9
    
10.Falke P, Stavenow L, Young M, Lindgärde F. Differences in mortality and cardiovascular morbidity during a 3-year follow-up of transient ischemic attacks and minor strokes. Stroke 1989;20:340-4.  Back to cited text no. 10
    
11.Atanassova PA, Chalakova NT, Dimitrov BD. Major vascular events after transient ischemic attack and minor ischemic stroke: posthoc modelling of incidence dynamics. Cerebrovasc Dis 2008;25:225-33.  Back to cited text no. 11
    
12.Purroy F, Montaner J, Molina CA, Delgado P, Ribo M, Alvarez-Sabín J. Patterns and predictors of early risk of recurrence after transient ischemic attack with respect to etiologic subtypes. Stroke 2007;38:3225-9.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]

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