The importance of EXPRESS treatment for transient ischemic attack


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Abstract

SYNOPSISPatients with a transient ischemic attack (TIA) or minor stroke often do not receive urgent medical attention, even though the risk of stroke recurrence is substantially increased in the week after the index event.OBJECTIVETo assess the effect of rapid treatment after TIA or minor stroke in patients who are not admitted to hospital.DESIGN AND INTERVENTIONThe Early use of EXisting PREventive Strategies for Stroke (EXPRESS) study was a two-phased observational study in which collaborating primary care physicians were asked to refer all patients with a suspected TIA or minor stroke to a daily neurovascular clinic. In phase 1 (April 2002 to September 2004), referred patients had to wait for a clinic appointment, and treatment was initiated in primary care after assessment at the clinic. In phase 2 (October 2004 to March 2007), no appointments were necessary, and treatment was initiated immediately if the diagnosis of a minor stroke or TIA was confirmed. In both phases, treatment included a combination of antiplatelet therapy (aspirin or clopidogrel), simvastatin, blood-pressure-lowering medication, and anticoagulants, as required. The study was nested within a population-based study of the incidence of TIA and stroke in Oxfordshire, UK (Oxford Vascular Study, OXVASC). Owing to the nested design, case ascertainment, investigation, and follow-up were complete and identical in both phases of the EXPRESS study.OUTCOME MEASUREThe primary outcome measure was the proportion of patients with clinical and imaging evidence of a (recurrent) stroke within 90 days of first presentation.RESULTSDuring the study period, 1,278 patients presented with a TIA or minor stroke; 607 were referred or presented directly to hospital, 620 were referred for outpatient assessment, and 51 were not referred to secondary care. The majority of outpatient referrals were to the study clinic (310 in phase 1, 281 in phase 2). Among these patients, the baseline characteristics and delays in seeking medical attention were similar in both study periods. The median time to assessment in the study clinic was, however, significantly shorter in phase 2 (3 days in phase 1, <1 day in phase 2; P<0.0001), and the median time to first prescription of treatment was also reduced (20 days in phase 1, 1 day in phase 2; P<0.0001). Early treatment in phase 2 did not increase the 30-day risk of bleeding events requiring medical attention. The incidence of stroke within 90 days of presentation was 10.3% in phase 1 and 2.1% in phase 2 (adjusted hazard ratio 0.20, 95% CI 0.08-0.49; P = 0.0001). This reduction in risk was observed regardless of whether patients presented with a stroke or a TIA, and was independent of age and sex. The 90-day risk of recurrent stroke among patients who presented directly to emergency services remained the same throughout the study.CONCLUSIONRapid assessment and initiation of existing treatments can reduce the risk of early recurrent stroke after a TIA or minor stroke by 80%.

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