Background: Rapid management can reduce the short stroke risk after transient ischaemic attack (TIA), but the long-term effect is still little known. We evaluated 3-year vascular outcomes in patients with TIA after urgent care. Methods: We prospectively enrolled all consecutive patients with TIA diagnosed by a vascular neurologist and referred to our emergency department (ED). Expedited assessment and best secondary prevention was within 24 h. Endpoints were stroke within 90 days, and stroke, myocardial infarction, and vascular death at 12, 24 and 36 months. Results: Between August 2010 and July 2013, we evaluated 686 patients with suspected TIA; 433 (63%) patients had confirmed TIA. Stroke at 90 days was 2.07% (95% confidence interval (CI), 1.1-3.9) compared with the ABCD2-predicted risk of 9.1%. The long-term stroke risk was 2.6% (95% CI, 1.1-4.2), 3.7% (95% CI, 1.6-5.9) and 4.4% (95% CI, 1.9-6.8) at 12, 24 and 36 months, respectively. The composite outcome of stroke, myocardial infarction, and vascular death was 3.5% (95% CI, 1.7-5.1), 4.9% (95% CI, 2.5-7.4), and 5.6% (95% CI, 2.8-8.3) at 12, 24, and 36 months, respectively. Conclusions: TIA expedited management driven by vascular neurologists was associated with a marked reduction in the expected early stroke risk and low long-term risk of stroke and other vascular events.

Keywords:
Transient ischaemic attack, Stroke, Cerebrovascular disease, TIA care models, Long-term vascular outcomes
1.
Wu CM, McLaughlin K, Lorenzetti DL, Hill MD, Manns BJ, Ghali WA: Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis. Arch Intern Med 2007;167:2417-2422.
2.
Lavallée PC, Meseguer E, Abboud H, Cabrejo L, Olivot JM, Simon O, Mazighi M, Nifle C, Niclot P, Lapergue B, Klein IF, Brochet E, Steg PG, Lesèche G, Labreuche J, Touboul PJ, Amarenco P: A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007;6:953-960.
3.
Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O, Redgrave JN, Lovelock CE, Binney LE, Bull LM, Cuthbertson FC, Welch SJ, Bosch S, Alexander FC, Silver LE, Gutnikov SA, Mehta Z: Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007;370:1432-1442.
4.
Montassier E, Lim TX, Goffinet N, Guillon B, Segard J, Martinage A, Potel G, Le Conte P: Results of an outpatient transient ischemic attack evaluation: a 90-day follow-up study. J Emerg Med 2013;44:970-975.
5.
Olivot JM, Wolford C, Castle J, Mlynash M, Schwartz NE, Lansberg MG, Kemp S, Albers GW: Two aces: transient ischemic attack work-up as outpatient assessment of clinical evaluation and safety. Stroke 2011;42:1839-1843.
6.
Stead LG, Bellolio MF, Suravaram S, Brown RD Jr, Bhagra A, Gilmore RM, Boie ET, Decker WW: Evaluation of transient ischemic attack in an emergency department observation unit. Neurocrit Care 2009;10:204-208.
7.
Sanders LM, Srikanth VK, Jolley DJ, Sundararajan V, Psihogios H, Wong K, Ramsay D, Phan TG: Monash transient ischemic attack triaging treatment: safety of a transient ischemic attack mechanism-based outpatient model of care. Stroke 2012;43:2936-2941.
8.
Hörer S, Schulte-Altedorneburg G, Haberl RL: Management of patients with transient ischemic attack is safe in an outpatient clinic based on rapid diagnosis and risk stratification. Cerebrovasc Dis 2011;32:504-510.
9.
Wasserman J, Perry J, Dowlatshahi D, Stotts G, Stiell I, Sutherland J, Symington C, Sharma M: Stratified, urgent care for transient ischemic attack results in low stroke rates. Stroke 2010;41:2601-2605.
10.
Von Weitzel-Mudersbach P, Johnsen SP, Andersen G: Low risk of vascular events following urgent treatment of transient ischaemic attack: the Aarhus TIA study. Eur J Neurol 2011;18:1285-1290.
11.
Benavente L, Calleja S, Larrosa D, Vega J, Mauri G, Pascual J, Lahoz CH: Long term evolution of patients treated in a TIA unit. Int Arch Med 2013;6:19.
12.
Tari Capone F, Cavallari M, Casolla B, Caselli G, Pieroni A, Di Lazzaro V, Napolitano S, Stanzione P, Puca E, Toni D, Rasura M, Orzi F: Stroke prediction after transient ischemic attacks in patients admitted to a stroke unit. Eur Neurol 2012;67:34-38.
13.
Prabhakaran S, Silver AJ, Warrior L, McClenathan B, Lee VH: Misdiagnosis of transient ischemic attacks in the emergency room. Cerebrovasc Dis 2008;26:630-635.
14.
Amarenco P, Labreuche J, Lavallée PC, Meseguer E, Cabrejo L, Slaoui T, Guidoux C, Olivot JM, Abboud H, Lapergue B, Klein IF, Mazighi M, Touboul PJ: Does ABCD2 score below 4 allow more time to evaluate patients with a transient ischemic attack? Stroke 2009;40:3091-3095.
15.
Amarenco P, Labreuche J, Lavallée PC: Patients with transient ischemic attack with ABCD2 <4 can have similar 90-day stroke risk as patients with transient ischemic attack with ABCD2 ≥4. Stroke 2012;43:863-865.
16.
The World Health Organization MONICA project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. WHO MONICA project principal investigators. J Clin Epidemiol 1988;41:105-114.
17.
SPREAD, SPREAD VI Edizione, Ictus Cerebrale: Linee Guide Italiane di Prevenzione e Trattamento. Stroke Prevention and Educational Awareness Diffusion, 2010. http://www.spread.it/files/SPREAD_ext.pdf (accessed August 1, 2010).
18.
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd: Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute stroke treatment. Stroke 1993;24:35-41.
19.
Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S: Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007;369:283-292.
20.
Cancelli I, Janes F, Gigli GL, Perelli A, Zanchettin B, Canal G, D'Anna L, Russo V, Barbone F, Valente M: Incidence of transient ischemic attack and early stroke risk: validation of the ABCD2 score in an Italian population-based study. Stroke 2011;42:2751-2757.
21.
Lauria G, Gentile M, Fassetta G, Casetta I, Agnoli F, Andreotta G, Barp C, Caneve G, Cavallaro A, Cielo R, Mongillo D, Mosca M, Olivieri P: Incidence of transient ischemic attacks in the Belluno Province, Italy. First-year results of a community-based study. Acta Neurol Scand 1996;93:291-296.
22.
Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN, Warlow CP, Mehta Z: A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet 2005;366:29-36.
23.
Johnston SC, Gress DR, Browner WS, Sidney S: Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000;284:2901-2906.
24.
Sheehan OC, Kyne L, Kelly LA, Hannon N, Marnane M, Merwick A, McCormack PM, Duggan J, Moore A, Moroney J, Daly L, Harris D, Horgan G, Williams EB, Kelly PJ: Population-based study of ABCD2 score, carotid stenosis, and atrial fibrillation for early stroke prediction after transient ischemic attack: the North Dublin TIA study. Stroke 2010;41:844-845.
25.
Purroy F, Jiménez Caballero PE, Gorospe A, Torres MJ, Alvarez-Sabin J, Santamarina E, Martínez-Sánchez P, Cánovas D, Freijo MM, Egido JA, Girón JM, Ramírez-Moreno JM, Alonso A, Rodríguez-Campello A, Casado I, Delgado-Medeiros R, Martí-Fàbregas J, Fuentes B, Silva Y, Quesada H, Cardona P, Morales A, de la Ossa N, García-Pastor A, Arenillas JF, Segura T, Jiménez C, Masjuán J; Stroke Project of the Spanish Cerebrovascular Diseases Study Group: Prediction of early stroke recurrence in transient ischemic attack patients from the PROMAPA study: a comparison of prognostic risk scores. Cerebrovasc Dis 2012;33:182-189.
26.
Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) study group. Lancet 1993;342:1255-1262.
27.
Wu CM, Manns BJ, Hill MD, Ghali WA, Donaldson C, Buchan AM: Rapid evaluation after high-risk TIA is associated with lower stroke risk. Can J Neurol Sci 2009;36:450-455.
28.
van Wijk I, Kappelle LJ, van Gijn J, Koudstaal PJ, Franke CL, Vermeulen M, Gorter JW, Algra A; LiLAC study group: Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study. Lancet 2005;365:2098-2104.
29.
Kehdi EE, Cordato DJ, Thomas PR, Beran RG, Cappelen-Smith C, Griffith NC, Hanna IY, McDougall AJ, Worthington JM, Hodgkinson SJ: Outcomes of patients with transient ischaemic attack after hospital admission or discharge from the emergency department. Med J Aust 2008;7:9-12.
30.
Nguyen-Huynh MN, Johnston SC: Is hospitalization after TIA cost-effective on the basis of treatment with tPA? Neurology 2005;65:1799-1801.
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2015
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