So our stroke medical world is still failing us massively. Hope you are OK with your doctor knowing nothing concrete on how to prevent that stroke after your TIA.
Has Secondary Prevention Post-TIA Failed?
Rates of stroke still disturbingly high after initial mild events
Past decades of progress in secondary prevention for transient ischemic attack (TIA) patients were not enough to fully mitigate their elevated risk of subsequent stroke, a longitudinal study showed.
In the Framingham Heart Study, TIA incidence was 1.19 per 1,000 person-years from 1948 through 2017 among 14,059 people with no prior TIA or stroke history, according to Vasileios-Arsenios Lioutas, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, and colleagues.
The 435 people who had experienced a TIA had a subsequent stroke in nearly 30% of cases within 9 years -- their estimated 10-year cumulative stroke risk ended up being more than quadruple that of matched TIA-free controls (hazard 0.46 vs 0.09, adjusted HR 4.37, 95% CI 3.30-5.71), they reported online in JAMA.
"Despite advances in secondary prevention, stroke risk after TIA remains higher compared with risk among TIA-free participants, even after accounting for confounding cardiovascular risk factors; the risk remained generally unchanged across most subgroups," the authors said.
Higher blood pressure was associated with subsequent early or delayed stroke, leading the investigators to conclude that "patients with TIA represent a particularly high-risk group in need of vigorous surveillance beyond the early, high-risk period and with special attention to hypertension monitoring and treatment."
Moreover, post-TIA strokes occurred at a median 1.64 years after the index TIA.
"Although early stroke risk is often highlighted, the subsequent stroke incidence continued to increase and diverge from that of TIA-free participants over the entire follow-up period in this study; 49% of strokes occurred more than 12 months from the index TIA, a finding in line with recent large longitudinal studies with similarly long follow-up periods, despite general adherence to prescribed preventive practices," Lioutas and colleagues noted.
Lioutas' group included Framing Heart Study participants who were enrolled in the original cohort, offspring cohort, or third-generation cohort and examined every few years. Eligible for the present analysis were the 14,059 people with no history of TIA or stroke at baseline.
People who stayed TIA-free were matched 5:1 to peers with incident TIA over a median 8.86 years of follow-up.
The study was not all bad news: data confirmed decades of progress in secondary prevention interventions after TIA given the falling rates of 90-day post-TIA stroke risk over the years (P=0.005 for trend):
- 1948-1985: 16.7%
- 1986-1999: 11.1% (HR 0.60, 95% CI 0.33-1.12)
- 2000-2017: 5.9% (HR 0.32, 95% CI 0.14-0.75)
However, Lioutas and colleagues cautioned that their study population was predominantly White.
"It is likely that the TIA incidence rates found in predominantly White populations are underestimates of the TIA incidence in the U.S. population, as it has been demonstrated that Black and Mexican American individuals have higher incidence rates than non-Hispanic White individuals; a similar pattern is true for risk of stroke after TIA," they said.
Other study limitations included possible recall and misclassification bias in TIA ascertainment, as well as insufficient information on medical and surgical treatments after the index TIA.
![author['full_name']](https://clf1.medpagetoday.com/media/images/author/nicoleLou_188.jpg)
Disclosures
Lioutas disclosed relevant relationships with Qmetis and Stroke.
Primary Source
JAMA
Source Reference: Lioutas V, et al "Incidence of transient ischemic attack and association with long-term risk of stroke" JAMA 2021; DOI: 10.1001/jama.2020.25071.
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