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Incidence of Transient Ischemic Attack and Association With Long-term Risk of Stroke

Educational Objective
To understand the risk of stroke after transient ischemic attack (TIA).
1 Credit CME
Key Points

Question  What is the incidence of first transient ischemic attack (TIA) and how is TIA associated with subsequent stroke risk?

Findings  In this population-based cohort study from 1948-2017, the estimated crude TIA incidence was 1.19/1000 person-years, the risk of stroke was significantly greater after TIA compared with matched control participants who did not have a TIA (adjusted hazard ratio, 4.37), and the risk of stroke within 90 days after TIA was significantly lower in the most recent epoch from 2000-2017 compared with an earlier period from 1948-1985 (hazard ratio, 0.32).

Meaning  Among participants in the Framingham Heart Study from 1948-2017, TIA was associated with greater risk of subsequent stroke compared with matched control participants without TIA, and the risk of stroke after a TIA was lower in more recent periods.

Abstract

Importance  Accurate estimation of the association between transient ischemic attack (TIA) and risk of subsequent stroke can help to improve preventive efforts and limit the burden of stroke in the population.

Objective  To determine population-based incidence of TIA and the timing and long-term trends of stroke risk after TIA.

Design, Setting, and Participants  Retrospective cohort study (Framingham Heart Study) of prospectively collected data of 14 059 participants with no history of TIA or stroke at baseline, followed up from 1948-December 31, 2017. A sample of TIA-free participants was matched to participants with first incident TIA on age and sex (ratio, 5:1).

Exposures  Calendar time (TIA incidence calculation, time-trends analyses), TIA (matched longitudinal cohort).

Main Outcomes and Measures  The main outcomes were TIA incidence rates; proportion of stroke occurring after TIA in the short term (7, 30, and 90 days) vs the long term (>1-10 years); stroke after TIA vs stroke among matched control participants without TIA; and time trends of stroke risk at 90 days after TIA assessed in 3 epochs: 1954-1985, 1986-1999, and 2000-2017.

Results  Among 14 059 participants during 66 years of follow-up (366 209 person-years), 435 experienced TIA (229 women; mean age, 73.47 [SD, 11.48] years and 206 men; mean age, 70.10 [SD, 10.64] years) and were matched to 2175 control participants without TIA. The estimated incidence rate of TIA was 1.19/1000 person-years. Over a median of 8.86 years of follow-up after TIA, 130 participants (29.5%) had a stroke; 28 strokes (21.5%) occurred within 7 days, 40 (30.8%) occurred within 30 days, 51 (39.2%) occurred within 90 days, and 63 (48.5%) occurred more than 1 year after the index TIA; median time to stroke was 1.64 (interquartile range, 0.07-6.6) years. The age- and sex-adjusted cumulative 10-year hazard of incident stroke for patients with TIA (130 strokes among 435 cases) was 0.46 (95% CI, 0.39-0.55) and for matched control participants without TIA (165 strokes among 2175) was 0.09 (95% CI, 0.08-0.11); fully adjusted hazard ratio [HR], 4.37 (95% CI, 3.30-5.71; P < .001). Compared with the 90-day stroke risk after TIA in 1948-1985 (16.7%; 26 strokes among 155 patients with TIA), the risk between 1986-1999 was 11.1% (18 strokes among 162 patients) and between 2000-2017 was 5.9% (7 strokes among 118 patients). Compared with the first epoch, the HR for 90-day risk of stroke in the second epoch was 0.60 (95% CI, 0.33-1.12) and in the third epoch was 0.32 (95% CI, 0.14-0.75) (P = .005 for trend).

Conclusions and Relevance  In this population-based cohort study from 1948-2017, the estimated crude TIA incidence was 1.19/1000 person-years, the risk of stroke was significantly greater after TIA compared with matched control participants who did not have TIA, and the risk of stroke after TIA was significantly lower in the most recent epoch from 2000-2017 compared with an earlier period from 1948-1985.

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Article Information

Corresponding Author: Vasileios-Arsenios Lioutas, MD, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 (vlioutas@bidmc.harvard.edu).

Accepted for Publication: December 3, 2020.

Author Contributions: Dr Himali had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Lioutas, Ivan, Beiser, and Seshadri contributed equally.

Concept and design: Lioutas, Ivan, Romero, Beiser, Seshadri.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Lioutas, Ivan, Seshadri.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Lioutas, Himali, Beiser.

Obtained funding: Seshadri.

Administrative, technical, or material support: Aparicio, Leveille, Romero.

Supervision: Romero, Beiser, Seshadri.

Conflict of Interest Disclosures: Dr Lioutas reported receiving personal fees from Qmetis and serving as the Continuing Medical Education editor for Stroke (American Heart Association). No other disclosures were reported.

Funding/Support: This study was supported by grants from the National Institute on Aging (R01 AG054076, R01 AG049607, R01 AG033040, R01 AG063507, R01 AG059725, RF1 AG052409, RF1 AG061872, U01 AG049505, AG058589), grants from the National Institute of Neurological Disorders and Stroke (NS017950 and UH2 NS100605), and the National Heart, Blood, and Lung Institute contract for the Framingham Heart Study (N01-HC-25195, HHSN268201500001I, and 75N92019D00031).

Role of the Funder/Sponsor: The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Dennis  M , Bamford  J , Sandercock  P , Warlow  C .  Prognosis of transient ischemic attacks in the Oxfordshire Community Stroke Project.   Stroke. 1990;21(6):848-853. doi:10.1161/01.STR.21.6.848PubMedGoogle ScholarCrossref
2.
Kleindorfer  D , Panagos  P , Pancioli  A ,  et al.  Incidence and short-term prognosis of transient ischemic attack in a population-based study.   Stroke. 2005;36(4):720-723. doi:10.1161/01.STR.0000158917.59233.b7PubMedGoogle ScholarCrossref
3.
Johnston  SC , Easton  JD , Farrant  M ,  et al; Clinical Research Collaboration, Neurological Emergencies Treatment Trials Network, and the POINT Investigators.  Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA.   N Engl J Med. 2018;379(3):215-225. doi:10.1056/NEJMoa1800410PubMedGoogle ScholarCrossref
4.
Johnston  SC , Gress  DR , Browner  WS , Sidney  S .  Short-term prognosis after emergency department diagnosis of TIA.   JAMA. 2000;284(22):2901-2906. doi:10.1001/jama.284.22.2901PubMedGoogle ScholarCrossref
5.
Hill  MD , Yiannakoulias  N , Jeerakathil  T , Tu  JV , Svenson  LW , Schopflocher  DP .  The high risk of stroke immediately after transient ischemic attack: a population-based study.   Neurology. 2004;62(11):2015-2020. doi:10.1212/01.WNL.0000129482.70315.2FPubMedGoogle ScholarCrossref
6.
Johnston  SC , Rothwell  PM , Nguyen-Huynh  MN ,  et al.  Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack.   Lancet. 2007;369(9558):283-292. doi:10.1016/S0140-6736(07)60150-0PubMedGoogle ScholarCrossref
7.
Amarenco  P , Lavallée  PC , Monteiro Tavares  L ,  et al; TIAregistry.org Investigators.  Five-year risk of stroke after TIA or minor ischemic stroke.   N Engl J Med. 2018;378(23):2182-2190. doi:10.1056/NEJMoa1802712PubMedGoogle ScholarCrossref
8.
Tsao  CW , Vasan  RS .  Cohort profile: the Framingham Heart Study (FHS): overview of milestones in cardiovascular epidemiology.   Int J Epidemiol. 2015;44(6):1800-1813. doi:10.1093/ije/dyv337PubMedGoogle ScholarCrossref
9.
Kannel  WB , Feinleib  M , McNamara  PM , Garrison  RJ , Castelli  WP .  An investigation of coronary heart disease in families: the Framingham Offspring Study.   Am J Epidemiol. 1979;110(3):281-290. doi:10.1093/oxfordjournals.aje.a112813PubMedGoogle ScholarCrossref
10.
 An investigation of coronary heart disease in families: the Framingham Offspring Study.   Am J Epidemiol. 2017;185(11):1093-1102. doi:10.1093/aje/kwx110PubMedGoogle ScholarCrossref
11.
Andersson  C , Johnson  AD , Benjamin  EJ , Levy  D , Vasan  RS .  70-year legacy of the Framingham Heart Study.   Nat Rev Cardiol. 2019;16(11):687-698. doi:10.1038/s41569-019-0202-5PubMedGoogle ScholarCrossref
12.
 The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V).   Arch Intern Med. 1993;153(2):154-183. doi:10.1001/archinte.1993.00410020010002PubMedGoogle ScholarCrossref
13.
IPPPSH Collaborative Group.  Cardiovascular risk and risk factors in a randomized trial of treatment based on the beta-blocker oxprenolol: the International Prospective Primary Prevention Study in Hypertension (IPPPSH).   J Hypertens. 1985;3(4):379-392. doi:10.1097/00004872-198508000-00011PubMedGoogle ScholarCrossref
14.
Medical Research Council Working Party.  MRC trial of treatment of mild hypertension: principal results.   Br Med J (Clin Res Ed). 1985;291(6488):97-104. doi:10.1136/bmj.291.6488.97PubMedGoogle ScholarCrossref
15.
Dennis  MS , Bamford  JM , Sandercock  PA , Warlow  CP .  Incidence of transient ischemic attacks in Oxfordshire, England.   Stroke. 1989;20(3):333-339. doi:10.1161/01.STR.20.3.333PubMedGoogle ScholarCrossref
16.
Brown  RD  Jr , Petty  GW , O’Fallon  WM , Wiebers  DO , Whisnant  JP .  Incidence of transient ischemic attack in Rochester, Minnesota, 1985-1989.   Stroke. 1998;29(10):2109-2113. doi:10.1161/01.STR.29.10.2109PubMedGoogle ScholarCrossref
17.
Tavosian  A , Ström  JO , Appelros  P .  Incidence of transient ischemic attacks in Sweden.   Neuroepidemiology. 2016;47(1):20-25. doi:10.1159/000447240PubMedGoogle ScholarCrossref
18.
Madsen  TE , Khoury  JC , Alwell  K ,  et al.  Temporal trends of sex differences in transient ischemic attack incidence within a population.   J Stroke Cerebrovasc Dis. 2019;28(9):2468-2474. doi:10.1016/j.jstrokecerebrovasdis.2019.06.020PubMedGoogle ScholarCrossref
19.
Howard  VJ , McClure  LA , Meschia  JF , Pulley  L , Orr  SC , Friday  GH .  High prevalence of stroke symptoms among persons without a diagnosis of stroke or transient ischemic attack in a general population: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.   Arch Intern Med. 2006;166(18):1952-1958. doi:10.1001/archinte.166.18.1952PubMedGoogle ScholarCrossref
20.
Chandratheva  A , Lasserson  DS , Geraghty  OC , Rothwell  PM ; Oxford Vascular Study.  Population-based study of behavior immediately after transient ischemic attack and minor stroke in 1000 consecutive patients: lessons for public education.   Stroke. 2010;41(6):1108-1114. doi:10.1161/STROKEAHA.109.576611PubMedGoogle ScholarCrossref
21.
 TIA/Mini Strokes: Public Knowledge and Experience—Roper Starch Worldwide Survey. National Stroke Association, 2000.
22.
Amarenco  P , Lavallée  PC , Labreuche  J ,  et al; TIAregistry.org Investigators.  One-year risk of stroke after transient ischemic attack or minor stroke.   N Engl J Med. 2016;374(16):1533-1542. doi:10.1056/NEJMoa1412981PubMedGoogle ScholarCrossref
23.
Sundararajan  V , Thrift  AG , Phan  TG , Choi  PM , Clissold  B , Srikanth  VK .  Trends over time in the risk of stroke after an incident transient ischemic attack.   Stroke. 2014;45(11):3214-3218. doi:10.1161/STROKEAHA.114.006575PubMedGoogle ScholarCrossref
24.
Rothwell  PM , Giles  MF , Flossmann  E ,  et al.  A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack.   Lancet. 2005;366(9479):29-36. doi:10.1016/S0140-6736(05)66702-5PubMedGoogle ScholarCrossref
25.
Morgenstern  LB , Smith  MA , Lisabeth  LD ,  et al.  Excess stroke in Mexican Americans compared with non-Hispanic Whites: the Brain Attack Surveillance in Corpus Christi Project.   Am J Epidemiol. 2004;160(4):376-383. doi:10.1093/aje/kwh225PubMedGoogle ScholarCrossref
26.
Prabhakaran  S , Chong  JY , Sacco  RL .  Impact of abnormal diffusion-weighted imaging results on short-term outcome following transient ischemic attack.   Arch Neurol. 2007;64(8):1105-1109. doi:10.1001/archneur.64.8.1105PubMedGoogle ScholarCrossref
27.
Arsava  EM , Furie  KL , Schwamm  LH , Sorensen  AG , Ay  H .  Prediction of early stroke risk in transient symptoms with infarction: relevance to the new tissue-based definition.   Stroke. 2011;42(8):2186-2190. doi:10.1161/STROKEAHA.110.604280PubMedGoogle ScholarCrossref
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