Published online before print July 3, 2008, doi: 10.1161/STROKEAHA.108.514166
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(Stroke. 2008;39:2400.)
© 2008 American Heart Association, Inc.
Emerging Therapies |
EXPRESS Transient Ischemic Attack Study
Speed the Process!
From INSERM U-698 and Denis Diderot University–Paris VII (P.A.), France; and the University of Texas (O.B.), San Antonio, Texas.
Correspondence to Pierre Amarenco, Department of Neurology and Stroke Center, Bichat Hospital, 46 rue Henri Huchard, 75018 Paris, France. E-mail pierre.amarenco{at}bch.aphp.fr
Marc Fisher MD Kennedy Lees MD Section Editors:
Key Words: TIA • emerging therapies
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Introduction |
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 Top Introduction References |
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Retinal and cerebral transient ischemic attacks (TIAs) are a falsely benign form of brain attack. After a TIA, the risk of completed stroke is up to 8% within the first 8 to 15 days.1,2 TIAs precede a completed stroke in as many as 25% of patients with stroke.3 Because diffusion-weighted imaging shows a small amount of brain tissue damage in most cases of TIA, TIAs often represent ministrokes4 and hence should be considered an emergency.5 Since their description in the 1950s, TIAs were considered as giving to clinicians the best opportunity to avoid a completed stroke and its devastating personal, social, or sometimes fatal consequences.6
However, this is only true provided TIAs are detected and treated. Awareness and rapid management are the real challenges of TIAs. It is striking how quickly the concept of a stroke unit and a stroke team was developed and implemented in the past 2 decades for the treatment of morbidity and comorbidities of patients with a completed stroke and then to speed the pre- and intrahospital delay of tissue plasminogen activator therapy within 3 hours of symptom onset.7 Although the concept of TIA arose in the 1950s and effective therapies for stroke prevention post-TIA had been well established,6 the first publication of the effectiveness of round-the-clock access (SOS-TIA) to diagnose and treat TIA without delay only appeared in 2007.8 Simultaneously, the EXPRESS study brought convincing evidence that the combination of proven therapies given to patients within 24 hours of symptom onset dramatically reduced the risk of subsequent stroke at 3 months.9
The EXPRESS Study
The EXPRESS study (Effect of urgent treatment of transient ischemic attack and minor stroke on early recurrent stroke) compared in a population-based prospective cohort (Oxford Vascular Study) 2 different modalities of management of patients with TIAs and minor stroke. Patients referred to a specialized clinic (EXPRESS clinic) between April 2002 and September 2004 (Phase 1) were compared with those referred between the period of October 2004 and March 2007 (Phase 2). During Phase 2, patients received a more urgent assessment and initiation of treatment. Of the 1287 patients (634 in Phase 1 and 644 in Phase 2), 607 were evaluated and treated at the hospital and 620 in an outpatient facility. Of the latter, 591 were assessed in the EXPRESS clinic. There were no significant differences in baseline characteristics among patients assessed during both phases. The only difference was the proportion of patients using statins in Phase 2 (20% versus 32%). Patients in both phases received similar treatment protocols for stroke prevention, the only difference being time elapsed between symptom onset and clinic assessment. During Phase 2, patients were seen immediately and treatment was initiated. All patients were followed up to 2 years and the primary outcome was recurrent stroke within 90 days of presentation.
The delay of assessment in the study clinic fell from 3 days in Phase 1 to <1 day in Phase 2 and median delay to first prescription fell from 20 days to 1 day (P<0.0001). In addition, the proportion of patients seen within the first 6 hours was significantly greater in Phase 2 than in Phase 1 (P<0.0001). The risk of stroke at 90 days was significantly lower in patients referred to the EXPRESS clinic during Phase 2 than in Phase 1 (2% versus 10%; hazard ratio: 0.20; 95% CI: 0.08 to 0.49; P=0.0001). There were no differences in stroke recurrence when both periods were compared for those patients assessed in the hospital.
Next Step: Develop Public Awareness and Transient Ischemic Attack Clinics With Round-the-Clock Access
Public education on TIA symptoms and the need for urgent management have been proposed.10 Symptoms of TIA are frequently ignored or minimized by patients and their relatives or underdiagnosed and not prioritized as an emergency by doctors. Even after a diagnosis of TIA, a patient can be reluctant to be admitted to the hospital because the symptoms often last for only a few minutes, and the patient subsequently feels completely recovered. Once a patient agrees to be admitted to the hospital, comprehensive testing for diagnosis often cannot be organized quickly or in the same hospital, particularly after 5:00 pm, which can delay the start of assessment substantially. Mean hospital length of stay for TIA is 6.8 days in France and 7.7 days in Germany.11 With experiences such as SOS-TIA in Paris, we know that it is feasible and effective to provide urgent care, including intense treatment for patients with TIA, 24 hours a day, with a median length of stay of 1 day and a 1.2% 3-month stroke event rate, although ABCD2 score predicted 6%.8 With the results of the EXPRESS study9 showing a 80% reduction in the 3-month stroke risk with similar early, intense treatment, we now should aim at developing dedicated TIA clinics accessible 24 hours a day as part of a comprehensive stroke center, similarly as stroke units were implemented in the past 2 decades. In addition, a systematic review assessing the early stroke risk post-TIA convincingly showed that early management of patients with TIA lowers significantly the stroke risk at 8 and 90 days.12 The message from both studies is that the workup of a patient with TIA should no longer be performed within days by appointment(s) to a TIA clinic or to various specialists. Evaluation and intense treatment need to be completed within hours after symptom onset. Despite the inherent limitations of both studies8,9 related to the lack of controls, the observed stroke reduction supports the premise that TIAs are indeed a true medical emergency.
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Acknowledgments |
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Disclosures
None.
Received January 4, 2008; accepted January 10, 2008.
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References |
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TopIntroductionReferences |
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