What is the probability that a patient with a previous TIA experiences a Stroke?

1.

Elsevier ClinicalKey Clinical Overview

Complications and Prognosis Prognosis varies by severity and by cause of disease Short-term risk of stroke or other adverse vascular events is high Stroke Substantial short-term risk of stroke after transient ischemic attack; approximately 3% to 10% at 2 days and 9% to 17% at 90 days Approximately 12% of all strokes are heralded by transient ischemic attack All major cardiovascular events: annual risk of major cardiovascular events is increased after transient ischemic attack Death: in one study, the 1-year mortality rate after a transient ischemic attack was 12% Transient ischemic attack survivors of high-risk period have 10-year stroke risk of approximately 19% and combined stroke, myocardial infarction, or vascular death risk of 43% (4% per year)

2.

Alberts, Mark J. (2022). In Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine (pp. 870). DOI: 10.1016/B978-0-323-72219-3.00045-1

The risk of a stroke or other vascular event (MI, vascular death) after a TIA has evolved over time based the study population and treatment approaches, with more recent studies showing lower event rates. Earlier studies reported an 11% risk of stroke at 90 days, with about half of strokes occurring within 2 days.A larger study of 3847 patients found a 5-year risk of stroke and other vascular events of 13%, of which half occurred in the first year, and the remainder in years 2 to 5.Risk factors for a subsequent event included ipsilateral carotid atherosclerosis, cardioembolic event, and an elevated ABCD2 score. The ABCD2 score was developed to help assess the short-term risk for stroke in patients with TIA (Table 45.18).The risk for stroke within 2 days is low (1%) in those with a score of 0 to 3, moderate (4%) in those with a score of 4 to 5, and high (8%) in those with a score of 6 to 7. Adding the results of emergent brain imaging studies can be used to better predict short-term stroke risk. The ABCD3-I score uses both a time- and tissue-based definition of TIA to predict early and late stroke occurrence.Specific components of ABCD3-I are shown inTable 45.17. Tissue-based imaging with ABCD3-I enhances risk stratification of short-term stroke risk (Fig. 45.11). The treatment of patients with a TIA is medically similar to that for an ischemic stroke in terms of risk factor control and antiplatelet therapy. Short-term treatment with dual antiplatelet therapy, as supported by the POINT and THALES studies (see Antiplatelet Therapy andFigs. 45.4 and 45.5), is now the standard of care. Such patients should be evaluated for the presence of CAD, as this is a common cause of death long term.Future DirectionsThe best way to treat a stroke is to prevent the stroke. Using mega-data approaches has the potential to help develop tools that can more accurately predict which patients are at high versus low risk of an event.

A recurrent stroke, or a stroke after a TIA, is a common and serious event. The risk of a recurrent stroke is typically in the range of 5% to 7% after 1 year and 16% after 5 years. Mortality after a recurrent stroke is quite high, ranging from 16% in whites and 21% in Blacks.,The risk of a stroke after a TIA is typically in the range of 3% to 5% after 2 days and up to 5% to 7% after 90 days. Most importantly, a TIA or stroke is a signal of underling cerebrovascular and cardiovascular disease, and puts the patient at a higher risk of other CVD events (MI, vascular death, etc.)., As noted earlier, antiplatelet agents reduce the risk for recurrent stroke in patients with a history of ischemic stroke or TIA.Aspirinreduces the risk of recurrent stroke after a stroke or TIA by approximately 12% to 17%, and reduced death and disability by about 5%. The risk reduction is more pronounced in the first few days and week after the initial event., Clopidogrelmonotherapy given to patients with a history of MI, stroke, or symptomatic PAD reduces the combined risk of MI, stroke, or vascular death by 8.7% (95% CI 0.3% to 16.5%;P= 0.043) compared with aspirin. The combination of clopidogrel and aspirin does reduce the rate of MI, stroke, or cardiovascular death more than aspirin alone in patients with CVD (including stroke) or multiple risk factors. When tested specifically in patients with a history of stroke, the combination of clopidogrel and aspirin was associated with an increase in bleeding complications without a reduction in ischemic stroke. SPS3 (Stroke Prevention Study 3) similarly found a higher risk for hemorrhage with no reduction in ischemic events after lacunar stroke in those treated with the combination versus aspirin alone.

3.

Goldstein, Larry B. (2024). In Goldman-Cecil Medicine (pp. 2464). DOI: 10.1016/B978-0-323-93038-3.00376-2

TIA is a major risk factor for stroke and requires urgent evaluation to detect specific causes that may require immediate treatment.,Overall, approximately 10% of patients who have a TIA will have a stroke within 90 days, with almost half occurring within 2 days. The strokes that occur are frequently fatal or associated with disabling deficits (E-Table 376-2). Factors associated with higher risk include age older than 60 years, diabetes, impaired speech or weakness, symptoms lasting more than 10minutes, and evidence of ischemic injury on brain MRI. After the acute period, about 20% of patients who had a TIA will have a stroke during the next 10 years. Complete hemianopsia (≥2 on NIHSS question 3) or severe aphasia (≥2 on NIHSS question 9), or Visual or sensory extinction (≥1 on NIHSS question 11), or Any weakness limiting sustained effort against gravity (≥2 on NIHSS question 6 or 7), or Any deficits that lead to a total NIHSS score >5, or Any remaining deficit considered potentially disabling in the view of the patient and the treating practitioner. Clinical judgment is required. Stroke-related mortality varies by age. The 30-day stroke mortality rate is estimated to be 9% for patients aged 65 to 74 years, 13% for patients aged 74 to 84 years, and 23% for patients older than 85 years. About 30% of patients who have had a stroke will have a recurrent stroke within 5 years. Stroke is also a leading cause of disability. Among stroke survivors, approximately 45% have cognitive deficits, 30% are unable to walk without assistance, 25% are institutionalized, and 25% are dependent in activities of daily living after 6 months.

4.

Lioutas VA, Ivan CS, Himali JJ, et al. Jama. 2021;325(4):373-381. doi:10.1001/jama.2020.25071.

Publish date: January 2, 2021.

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).