TIA

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TIA

• PACE events

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TIA - Definition

• A clinical syndrome characterised by an acute
  loss of focal cerebral or monocular function with
  symptoms lasting less than 24 hours, but
  typically less than 1 hour and is attributable to
  inadequate blood supply.

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TIA - Alternative definition

• Something strange that happens, usually
  involving feeling funny, falling down or
  tingling, that one cant immediately put a name
  to, but that resolves within 24 hours.

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Problems

• Under-reporting a third ignore symptoms
• Over-diagnosis
• Half incorrect
• Treatable conditions overlooked
• Iatrogenic risk

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Symptoms not acceptable as evidence of TIA in
isolation

• Loss of consciousness
• Falls
• Confusion
• Generalised weakness
• Dizziness
• Incontinence
• Amnesia
• Sensory symptoms confined to part of one limb or
  face

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Symptoms of TIA

• Sudden numbness or weakness of face, arm or leg
  esp. on one side of the body
• Sudden confusion ,trouble speaking or
  understanding
• Trouble seeing in one or both eyes
• Sudden trouble walking, loss of balance or
  coordination-

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Signs of TIA

• Flacid paralysis
• Reduced tone and reflexes
• Up going planters
• Hemianopia
• Expressive and receptive dysphasia

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Early risk of stroke after TIA or minor stroke

• Oxford vascular study
• Risk of stroke
• 8-12 at 7 days
• 11-15 at 1 month
• 17-19 at 3 months
• BMJ 2004 328 326-8

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Cumulative risk of stroke after TIA or minor
stroke
BMJ 2004 328 326-8
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TIA

• TIA is the most important forecaster of impending
  stroke
• 1707 patients presenting to AE with TIA
• within 3/12-10.5 Stroke
• -2.6 other CV event
• -2.6 Died
• JAMA 2000 2842901-6

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The ABCD Score

• Age 60 years 1
• Blood pressure 1 (Systolic 140mmHg and/or
  diastolic 90mmHg)
• Clinical features
• Unilateral weakness 2
• Speech disturbance/no weakness 1
• Other 0
• Duration of symptoms
• 60 minutes 2
• 10-59 minutes 1
• lt 10 minutes 0
• Lancet 200536629-36

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The ABCD Score

• ABCD 7 day Action
• Score stroke risk
• 6 31 Fax referral immediately to TIA
• clinic 01274 365252
• 5 12 Fax referral to TIA clinic
• 0-4 0.4 Fax/send referral to TIA clinic

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Aims of TIA clinic

• To see every patient with a new TIA in Bradford
• To avoid seeing any patients who have not had a
  TIA
• To see appropriate patients and get tests done as
  quickly as possible

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The mini-stroke clinic

• Patients seen within one week
• One-stop-shop
• Same day investigations
• Prompt carotid surgery opinion
• TIA referral letter
• Template letter to GP
• Stroke association leaflets

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What can be done?

• Anti-platelets
• Warfarin
• Anti-hypertensives
• Lipid-lowering therapy
• Carotid endarterectomy

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Trial Evidence

• PREVENTION INTERVENTION PATIENTS
  OUTCOME BENEFIT
• HOPE Ramipril
  VASC/DM/1 4.9 Stoke 0.68RR
• Progress Perindorpil/Indapamide
  CVA/TIA 13.7 0.57HR
• HPS Simvastatin
  Vas/DM 5.7 25 less
  incid
• LIPID Pravastatin
  IHDchol 6v5
• LIFE Losartan
  HT 6.7
  0.75RR
• NASCET Endarterecomy
  gt75stenosis 23 17ARR

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Heart Outcomes Prevention Evaluation Study

• A large, double blind, randomised trial of
  ramipril and vitamin E in patients at high risk
  for cardiovascular events
• NEJM 2000342(3)145-53

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Primary Event Rate
ramipril
placebo
()
()
RR
95 CI
P value
4645
4652
No.
Randomized

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Outcome
0.78
14.0
17.8
0.70-0.86
lt0.001
MI,Stroke,CV Death
0.74
6.1
8.1
0.64-0.87
lt0.001
CV Death
0.80
9.9
12.3
0.70-0.90
lt0.001
MI
0.68
3.4
4.9
0.56-0.84
lt0.001
Stroke
1.03
4.3
4.1
0.85-1.26
Non-CV Death
0.74
0.84
10.4
12.2
0.75-0.95
0.005
Mortality
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Randomised trial of a perindopril-based blood
pressure-lowering regimen among 6105individuals
with previous stroke or transient ischaemic
attack (PROGRESS trial)
Lancet 2001 358 1033-41
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PROGRESS trial - Results

• Outcome Perindopril/ Double RRR NNT
• indapamide placebo
• Stroke 8.5 14 43 17

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MRC/BHF Heart Protection Study of cholesterol
lowering with simvastatin in 20 536 high-risk
individuals a randomised placebo-controlled
trial
Lancet 2002 360 7-22
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Heart Protection Study

• Outcomes RRR NNT
• Major Coronary Event 27 33
• Stroke 25 73

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Carotid Endarterectomy

• Carotid endarterectomy significantly reduces the
  risk for patients who have had a carotid
  territory TIA in the preceding 6 months and who
  have a severe stenosis 70-99.
• Shown in North American symptomatic Carotid
  Endarterectomy Trial collaborators NASCET
• And the MRC European Carotid Surgery Trial
• NNT to prevent one disabling CVA21
• In clinical practice it is only appropriate for
  only 4 of patients with TIA