ischemic attack, transient

Importance: Data from randomized clinical trials on a long-term anticoagulation strategy for patients after catheter-based ablation for atrial fibrillation (AF) are lacking.

Objective: To evaluate whether discontinuing oral anticoagulant therapy provides superior clinical outcomes compared with continuing oral anticoagulant therapy in patients without documented atrial arrhythmia recurrence after catheter ablation for AF.

Design, setting, and participants: A randomized clinical trial including 840 adult patients (aged 19-80 years) who were enrolled and randomized from July 28, 2020, to March 9, 2023, at 18 hospitals in South Korea. Enrolled patients had at least 1 non-sex-related stroke risk factor (determined using the CHA2DS2-VASc score [range, 0-9]) and no documented recurrence of atrial arrhythmia for at least 1 year after catheter ablation for AF. The CHA2DS2-VASc score is used as an assessment of stroke risk among patients with AF (calculated using point values for congestive heart failure, hypertension, ≥75 years of age, diabetes, stroke or transient ischemic attack, vascular disease, between 65 and 74 years of age, and sex category). The date of final follow-up was June 4, 2025.

Interventions: The patients were randomly assigned in a 1:1 ratio to discontinue oral anticoagulant therapy (n = 417) or continue oral anticoagulant therapy (with direct oral anticoagulants; n = 423).

Main outcomes and measures: The primary outcome was the first occurrence of a composite of stroke, systemic embolism, and major bleeding at 2 years. Individual components of the primary outcome (such as ischemic stroke and major bleeding) were assessed as secondary outcomes.

Results: Of the 840 adults randomized, the mean age was 64 (SD, 8) years, 24.9% were women, the mean CHA2DS2-VASc score was 2.1 (SD, 1.0), and 67.6% had paroxysmal AF. At 2 years, the primary outcome occurred in 1 patient (0.3%) in the discontinue oral anticoagulant therapy group vs 8 patients (2.2%) in the continue oral anticoagulant therapy group (absolute difference, -1.9 percentage points [95% CI, -3.5 to -0.3]; P = .02). The 2-year cumulative incidence of ischemic stroke was 0.3% in the discontinue oral anticoagulant therapy group vs 0.8% in the continue oral anticoagulant therapy group (absolute difference, -0.5 percentage points [95% CI, -1.6 to 0.6]). Major bleeding occurred in 0 patients in the discontinue oral anticoagulant therapy group vs 5 patients (1.4%) in the continue oral anticoagulant therapy group (absolute difference, -1.4 percentage points [95% CI, -2.6 to -0.2]).

Conclusions and relevance: Among patients without documented atrial arrhythmia recurrence after catheter ablation for AF, discontinuing oral anticoagulant therapy resulted in a lower risk for the composite outcome of stroke, systemic embolism, and major bleeding vs continuing direct oral anticoagulant therapy.

Trial registration: ClinicalTrials.gov Identifier: NCT04432220.

Author/s:

Daehoon Kim, MD, Jaemin Shim, MD, Eue-Keun Choi, MD

Transient ischemic attack and minor stroke: diagnosis, risk stratification and management

Aubrey Delammermore — Sat, 28 Jan 2023 06:00:00 +0000

Date Added:

January 28, 2023

Journal/Publication:

CMAJ

Publisher:

CMA Impact

Publication Date:

October 11, 2022

Issue:

Volume:

194

Pages:

E1344-E1349

URL:

Transient ischemic attack and minor stroke: diagnosis, risk stratification and management

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.220344

Keywords

PMID (1):

36220167

MeSH

ischemic attack, transient

Hydroxymethylglutaryl-CoA Reductase Inhibitors

antihypertensive agents

Platelet Aggregation Inhibitors

anticoagulants

Evidence-based guidance for evaluation and management of patients with suspected transient ischemic attack. James W. Mold, MD, MPH

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Patients with suspected cerebral ischemia should be urgently assessed to distinguish between transient ischemic attack (TIA), minor stroke or mimics such as migraine, seizure, vertigo or syncope.

The Canadian TIA Score can be used to determine risk for early subsequent stroke in patients with a suspected TIA or minor stroke.

All patients with TIA or minor stroke should undergo urgent electrocardiography and computed tomography of the head.

Clinicians should order early vascular imaging for patients at moderate or high risk of subsequent stroke; urgent revascularization should be considered if there is more than 50% arterial stenosis congruent with symptom presentation.

Clinicians should prescribe dual antiplatelet drugs for high-risk patients, single antiplatelet agents for low-risk patients or direct oral anticoagulants for patients with atrial fibrillation.

All patients with TIA or minor stroke should be counselled about modifiable lifestyle factors (including smoking cessation), be treated with statins and take steps toward optimizing blood pressure, including treatment with antihypertensive drugs, if necessary.

Author/s:

Perry, J. J., Yadav, K., Syed, S., Shamy, M.

Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review

Devin Evans — Fri, 19 Mar 2021 05:00:00 +0000

Date Added:

March 19, 2021

Journal/Publication:

Journal of the American Medical Association

Publication Date:

March 16, 2021

Issue:

Volume:

325

Pages:

1088-1098

URL:

Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2020.26867

Keywords

blood pressure

stroke

transient ischemic attack

Acute Ischemic Stroke

PMID (1):

33724327

MeSH

Tissue Plasminogen Activator

Platelet Aggregation Inhibitors

ischemic attack, transient

blood pressure

stroke

A non-systematic review of the diagnosis and management of patients with transient ischemic attack and acute stroke. James W. Mold, MD, MPH

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Importance: Stroke is the fifth leading cause of death and a leading cause of disability in the United States, affecting nearly 800 000 individuals annually.

Observations: Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA). An estimated 7.5% to 17.4% of patients with TIA will have a stroke in the next 3 months. Patients presenting with nondisabling AIS or high-risk TIA (defined as a score ≥4 on the age, blood pressure, clinical symptoms, duration, diabetes [ABCD2] instrument; range, 0-7 [7 indicating worst stroke risk]), who do not have severe carotid stenosis or atrial fibrillation, should receive dual antiplatelet therapy with aspirin and clopidigrel within 24 hours of presentation. Subsequently, combined aspirin and clopidigrel for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% (hazard ratio, 0.66 [95% CI, 0.56-0.77]). Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation. In patients presenting with AIS and disabling deficits interfering with activities of daily living, intravenous alteplase improves the likelihood of minimal or no disability by 39% with intravenous recombinant tissue plasminogen activator (IV rtPA) vs 26% with placebo (odds ratio [OR], 1.6 [95% CI, 1.1-2.6]) when administered within 3 hours of presentation and by 35.3% with IV rtPA vs 30.1% with placebo (OR, 1.3 [95% CI, 1.1-1.5]) when administered within 3 to 4.5 hours of presentation. Patients with disabling AIS due to anterior circulation large-vessel occlusions are more likely to be functionally independent when treated with mechanical thrombectomy within 6 hours of presentation vs medical therapy alone (46.0% vs 26.5%; OR, 2.49 [95% CI, 1.76-3.53]) or when treated within 6 to 24 hours after symptom onset if they have a large ratio of ischemic to infarcted tissue on brain magnetic resonance diffusion or computed tomography perfusion imaging (modified Rankin Scale score 0-2: 53% vs 18%; OR, 4.92 [95% CI, 2.87-8.44]).

Conclusions and relevance: Dual antiplatelet therapy initiated within 24 hours of symptom onset and continued for 3 weeks reduces stroke risk in select patients with high-risk TIA and minor stroke. For select patients with disabling AIS, thrombolysis within 4.5 hours and mechanical thrombectomy within 24 hours after symptom onset improves functional outcomes.

Author/s:

Mendelson, Scott J., Prabhakaran, Shyam

Screening for Asymptomatic Carotid Artery Stenosis US Preventive Services Task Force Recommendation Statement

Devin Evans — Thu, 04 Feb 2021 06:00:00 +0000

Date Added:

February 4, 2021

Journal/Publication:

Journal of the American medical Association

Publication Date:

February 2, 2021

Issue:

Volume:

325

Pages:

476-481

URL:

Screening for Asymptomatic Carotid Artery Stenosis US Preventive Services Task Force Recommendation Statement

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2020.26988

Keywords

stroke

US Preventive Services Task Force

Asymptomatic Carotid Artery Stenosis

PMID (1):

33528542

MeSH

Carotid Stenosis

ischemic attack, transient

Constriction, Pathologic

Brain Ischemia

stroke

The U.S. Preventive Services Task Force continues to recommend against screening for asymptomatic carotid stenosis finding that it causes more harm than good. That includes not listening for carotid bruits in asymptomatic patients. James W. Mold, MD, MPH

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Importance: Carotid artery stenosis is atherosclerotic disease that affects extracranial carotid arteries. Asymptomatic carotid artery stenosis refers to stenosis in persons without a history of ischemic stroke, transient ischemic attack, or other neurologic symptoms referable to the carotid arteries. The prevalence of asymptomatic carotid artery stenosis is low in the general population but increases with age.

Objective: To determine if its 2014 recommendation should be reaffirmed, the US Preventive Services Task Force (USPSTF) commissioned a reaffirmation evidence review. The reaffirmation update focused on the targeted key questions on the potential benefits and harms of screening and interventions, including revascularization procedures designed to improve carotid artery blood flow, in persons with asymptomatic carotid artery stenosis.

Population: This recommendation statement applies to adults without a history of transient ischemic attack, stroke, or other neurologic signs or symptoms referable to the carotid arteries.

Evidence assessment: The USPSTF found no new substantial evidence that could change its recommendation and therefore concludes with moderate certainty that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits.

Recommendation: The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population. (

Author/s:

US Preventive Services Task Force

Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline

Tracy Ashby — Sun, 06 Jan 2019 06:00:00 +0000

Date Added:

January 6, 2019

Journal/Publication:

BMJ

Publisher:

BMJ Publishing Group Ltd

Publication Date:

December 18, 2018

URL:

Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline

Type:

Meta-analyses, Reviews, and Guidelines, Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1136/bmj.k5130

Keywords

transient ischemic attack

PMID (1):

30563885

MeSH

ischemic attack, transient

This expert panel has issued a strong recommendation for initiating dual antiplatelet therapy (e.g. aspirin plus clopidogrel) within 24 hours of the onset of symptoms of a high-risk TIA or minor ischemic stroke based upon evidence from a recent large meta-analysis.

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What is the role of dual antiplatelet therapy after high risk transient ischaemic attack or minor stroke? Specifically, does dual antiplatelet therapy with a combination of aspirin and clopidogrel lead to a greater reduction in recurrent stroke and death over the use of aspirin alone when given in the first 24 hours after a high risk transient ischaemic attack or minor ischaemic stroke? An expert panel produced a strong recommendation for initiating dual antiplatelet therapy within 24 hours of the onset of symptoms, and for continuing it for 10-21 days. Current practice is typically to use a single drug.

Author/s:

Reed A.C., Hao, Qiukui, Guyatt, Gordon H., O’Donnell, Martin, Lytvyn, Lyubov, Heen, Anja Fog, Agoritsas, Thomas, Vandvik, Per O., Gorthi, Sankar P., Fisch, Loraine, Jusufovic, Mirza, Muller, Jennifer, Booth, Brenda, Horton, Eleanor, Fraiz, Auxiliadora, Siemieniuk, Jillian, Fobuzi, Awah C., Katragunta, Neelima, Rochwerg, Bram, Prasad, Kameshwar