Aggressively treating mini strokes
could reduce subsequent massive strokes by a whopping
80%. That's the conclusion of a pair of studies in The Lancet and Lancet Neurology.
Time is brain, they say in stroke
medicine. Patients are ceaselessly nagged to waste not
a moment, but to present themselves at hospital upon
the first sign of stroke symptoms. But stroke physicians
don't always heed their own advice.
In massive strokes priority care
is an undisputed necessity, but there's been a growing
awareness that transient ischemic attacks (TIAs) and
minor strokes do not merely indicate that patients are
at high risk for a real stroke, they are quite often
an immediate precursor of one. Without treatment, about
7-10% of patients who suffer a TIA or minor stroke will
go on to face a full-blown stroke in the next 90 days.
Almost half of these could occur in the first two days.
FASTER,
FASTER
In The Lancet study, Oxford researchers looked at 1,278
patients who had a stroke or a mini stroke. They were
divided into two groups: phase I patients underwent
standard care, typical procedure. Phase II patients
were given expedited care. The basic treatment in both
groups consisted of 300mg loading doses of aspirin and
clopidogrel followed by 75mg daily doses of both, with
the clopidogrel stopped after 30 days. High-risk patients
were also given simvastatin, and antihypertensives if
indicated. Anticoagulation and carotid endarterectomy
were applied at need.
What differed between the two groups
was the waiting period. Patients in phase I averaged
a three-day wait for their first proper assessment,
and a 20-day wait to begin drug therapy. Patients in
phase II averaged a one-day wait for both assessment
and prescription.
The results speak for themselves.
The 90-day risk for recurrent stroke in phase I patients
was 10.3%, while in phase II it fell to 2.1% —
an 80% reduction. This reduction was seen across the
board for age and sex. Importantly, there was no evidence
that early treatment increased the risk of intracerebral
hemorrhage or other bleeding.
"Extrapolated across the UK population,
this equates to the prevention of nearly 10,000 strokes
per year," the researchers conclude. "Follow-up treatment
is required to determine long-term outcome, but these
results have immediate implications for the service
provision and public education about TIA and minor stroke."
Many in the stroke business seem
to agree. Two Canadian specialists who wrote an accompanying
editorial in The Lancet, Drs Naeem Dean and Ashfaq Shuaib,
called the findings "very important," adding that they
"should promote renewed attention to urgent care of
patients with TIAs and minor strokes."
FRENCH
CONNECTION
Corroboration comes in the form of remarkably similar
treatment effects seen in a French study published in
Lancet Neurology. The study follows the results
of the SOS-TIA program run by a group of French teaching
hospitals, which aims to provide rapid assessment and
treatment of stroke and TIA victims in a specialized
clinic.
Of 1,085 patients with suspected
TIA who presented at the SOS-TIA clinic, more than half
had completed assessments within 24 hours. The 643 with
confirmed TIAs immediately entered the stroke prevention
program, which in 43 cases meant urgent carotid revascularization.
Again, it was not the treatments that were novel, but
the waiting times.
There was no placebo group, but
the clinic achieved a 90-day stroke risk in TIA patients
of 1.24% compared to the 5.96% that had been expected
from calculating risk scores. That reduction, if real,
is almost identical to the proportion of strokes the
British team believes it avoided.
Two Yale specialists commenting
in Lancet Neurology on the SOS-TIA program argue
that it represents a new paradigm in stroke care. "We
believe that the time is right to accept this new standard
and to begin use of rapid access as a platform for rigorous
testing of innovative strategies for TIA care," write
Drs Walter Kernan and Joseph Schindler.
Rigorous testing is already underway.
The ongoing FASTER (in Calgary) and CASTIA trials are
looking at exactly these questions, and many experts
believe they will produce a new approach to the management
of 'minor' strokes.
|
