Elsevier

The Lancet

Volume 365, Issue 9477, 18–24 June 2005, Pages 2098-2104
The Lancet

Articles
Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study

https://doi.org/10.1016/S0140-6736(05)66734-7Get rights and content

Summary

Background

Determinants of survival and of risk of vascular events after transient ischaemic attack (TIA) or minor ischaemic stroke are not well defined in the long term. We aimed to restudy these risks in a prospective cohort of patients after TIA or minor ischaemic stroke (Rankin grade≤3), after 10 years or more.

Methods

We assessed the survival status and occurrence of vascular events in 2473 participants of the Dutch TIA Trial (recruitment in 1986–89; arterial cause of cerebral ischaemia). We included 24 hospitals in the Netherlands that recruited at least 50 patients. Primary outcomes were all-cause mortality and the composite event of death from all vascular causes, non-fatal stroke, and non-fatal myocardial infarction. We assessed cumulative risks by Kaplan-Meier analysis and prognostic factors with Cox univariate and multivariate analysis.

Findings

Follow-up was complete in 2447 (99%) patients. After a mean follow-up of 10·1 years, 1489 (60%) patients had died and 1336 (54%) had had at least one vascular event. 10-year risk of death was 42·7% (95% CI 40·8–44·7). Age and sex-adjusted hazard ratios were 3·33 (2·97–3·73) for age over 65 years, 2·10 (1·79–2·48) for diabetes, 1·77 (1·45–2·15) for claudication, 1·94 (1·42–2·65) for previous peripheral vascular surgery, and 1·50 (1·31–1·71) for pathological Q waves on baseline electrocardiogram. 10-year risk of a vascular event was 44·1% (42·0–46·1). After falling in the first 3 years, yearly risk of a vascular event increased over time. Predictive factors for risk of vascular events were similar to those for risk of death.

Interpretation

Long-term secondary prevention in patients with cerebral ischaemia still has room for further improvement.

Introduction

Although worldwide fatality rates from cerebrovascular disease have fallen, stroke remains one of the most serious neurological problems, which leaves most patients with chronic disability.1, 2 Secondary stroke prevention is standard practice in patients with a transient ischaemic attack (TIA) or minor ischaemic stroke, but many of these individuals have a recurrent stroke or other vascular complications.

In clinical studies so far, the follow-up of patients with TIA or stroke has lasted no longer than 3–5 years for the assessment of the incidence of recurrent stroke, myocardial infarction, and vascular death. 5-year cumulative risk of a recurrent stroke was 22·5%; major determinants of recurrence were advanced age, haemorrhagic index stroke, and diabetes mellitus.3 In cohorts from clinical trials, the yearly risk of vascular events ranged from 4 to 11% if the presumed cause of the cerebral ischaemia was arterial disease.4, 5 The corresponding estimate for population-based studies is 9% per year.6 Observational studies report a wide range of incidence rates for cerebral ischaemia of miscellaneous severity (TIA vs stroke) and type (arterial vs cardiac), with various outcome measures and lengths of follow-up (most up to a mean of 5 years).7, 8, 9, 10, 11, 12, 13 Much of the variation between studies on the prognosis of patients after TIA is due to the fact that many did not fulfil six important principles in their methods: description of diagnostic criteria, description of outcome events, study of an inception cohort, description of outcome surveillance, report and analysis of censored patients, and multivariate analysis for predictive variables.14

Only a few hospital-based studies have had follow-up periods of 10 years or more after stroke.15, 16, 17, 18 Apart from one study,18 the inclusion period of these studies was between 1977 and 1986, during which secondary prevention was not routinely prescribed. The numbers of participants in most studies were small (n=178–339), and none of the studies fulfilled all six criteria mentioned above. The few community-based studies with extended follow-up focused on mortality only and did not study prognostic factors.19, 20, 21 We aimed to assess the long-term risk of death and vascular events in patients with TIA or minor stroke of arterial origin. We also studied any changes in risk over time and identified any independent predictors of mortality and vascular events.

Section snippets

Study design

The LiLAC (Life Long After Cerebral ischaemia) cohort study was based on the Dutch TIA Trial (DTT).22 Patients who had had a TIA or minor stroke were randomly assigned (after consent was given) to 30 mg or 283 mg of aspirin in this trial between February, 1986, and March, 1989. The diagnosis was made by a neurologist from one of the participating hospitals. For logistical reasons, in the present study we included only patients from the 24 hospitals that had enrolled at least 50 patients in the

Results

Basic characteristics of the 2473 participants are shown in table 1. The mean age at study entry was 65 years (SD 10·1). Follow-up was complete for all participants until close-out of the DTT. 26 patients were completely lost to follow-up after close-out from the DTT (mean follow-up up to 1993). Seven patients were lost because they moved abroad and 19 because of unknown reasons. In 495 (20%) patients, some information was missing (eg, on cause of death or on number of events that preceded

Discussion

Our study shows that, roughly 10 years after a presentation of TIA or minor ischaemic stroke, about 60% of patients had died and 54% had experienced at least one new vascular event. Event-free survival after 10 years was 48%. The risk of a vascular event was highest shortly after the ischaemic event, reached its lowest point at about 3 years, and gradually rose afterwards. The same pattern was recorded for the risk of stroke during the first 3 years, whereas the risk for mortality gradually

References (36)

  • C Warlow

    Secondary prevention of stroke

    Lancet

    (1992)
  • S Yusuf et al.

    Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study

    Lancet

    (2004)
  • M Peltonen et al.

    Time trends in long-term survival after stroke

    Stroke

    (1998)
  • JB Reitsma et al.

    Cardiovascular disease in the Netherlands, 1975 to 1995: decline in mortality, but increasing numbers of patients with chronic conditions

    Heart

    (1999)
  • GJ Hankey et al.

    Long-term risk of first recurrent stroke in the Perth Community Stroke Study

    Stroke

    (1998)
  • Collaborative overview of randomised trials of antiplatelet therapy—I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients

    BMJ

    (1994)
  • A Algra et al.

    Aspirin at any dose above 30 mg offers only modest protection after cerebral ischaemia

    J Neurol Neurosurg Psychiatry

    (1996)
  • S Saeki et al.

    Return to work after stroke. A follow-up study

    Stroke

    (1995)
  • HS Jorgensen et al.

    Stroke recurrence: predictors, severity, and prognosis. The Copenhagen Stroke Study

    Neurology

    (1997)
  • GJ Hankey et al.

    Transient ischaemic attacks: which patients are at high (and low) risk of serious vascular events?

    J Neurol Neurosurg Psychiatry

    (1992)
  • WN Kernan et al.

    A prognostic system for transient ischemia or minor stroke

    Ann Intern Med

    (1991)
  • J Burn et al.

    Long-term risk of recurrent stroke after a first-ever stroke. The Oxfordshire Community Stroke Project

    Stroke

    (1994)
  • PR Wilkinson et al.

    A long-term follow-up of stroke patients

    Stroke

    (1997)
  • P Sandercock et al.

    Atrial fibrillation and stroke: prevalence in different types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project)

    BMJ

    (1992)
  • WN Kernan et al.

    A methodological appraisal of research on prognosis after transient ischemic attacks

    Stroke

    (1991)
  • TG Clark et al.

    Long term risk of stroke, myocardial infarction, and vascular death in “low risk” patients with a non-recent transient ischaemic attack

    J Neurol Neurosurg Psychiatry

    (2003)
  • M Prencipe et al.

    Long-term prognosis after a minor stroke. 10-year mortality and major stroke recurrence rates in a hospital-based cohort

    Stroke

    (1998)
  • G Staaf et al.

    Pure motor stroke from presumed lacunar infarct. Long-term prognosis for survival and risk of recurrent stroke

    Stroke

    (2001)
  • Cited by (255)

    • Predicting transient ischemic attack after carotid endarterectomy: The role of intraoperative neurophysiological monitoring

      2022, Clinical Neurophysiology
      Citation Excerpt :

      We intend to evaluate this hypothesis under the secondary aim that patients who had changes in IONM during the procedure (indicative of hypoperfusion) are at an increased risk of TIA. Finally, we intend to explore the mortality rate of our patient population to determine if postoperative TIA increases mortality akin to the risk of TIA in the general population (Amarenco and Project, 2018; van Wijk et al., 2005). We hypothesize CEA patients with postoperative TIA will have an increased long-term mortality risk.

    • e-Health solution for home patient telemonitoring in early post-acute TIA/Minor stroke during COVID-19 pandemic

      2021, International Journal of Medical Informatics
      Citation Excerpt :

      In particular, the cumulative risk in stroke patients is increasing from 3% during the first month to 40 % at 10 years after the event [9]. TIA patients are also at high risk for stroke recurrence, with a cumulative stroke risk of 3% during the first month [10], and 18 % at 10 years [11]. Alteration of vital signs such as blood pressure, heart rate, body temperature, saturation and respiration rate may be correlated with cerebrovascular risk factors and may thus be useful to assess patient condition, titrate therapy, and prevent adverse outcomes.

    • Prognosis After Stroke

      2021, Stroke: Pathophysiology, Diagnosis, and Management
    View all citing articles on Scopus

    Investigators (neurologists of centres with >50 patients) listed in appendix of reference 22

    View full text