Abstract
The fact that transient ischaemic attacks are a harbinger for the possible development of ischaemic stroke has been recognised for several decades. However, within the past decade, our concepts regarding transient ischaemic attacks as a distinct entity from stroke and the prognosis for transient ischaemic attack patients have been challenged. In addition, clinical trials have clarified that modem transient ischaemic attack management is more complex than in the past, with the addition of newer pharmacological options to the stroke prevention armamentarium.
Recent information regarding newer antiplatelet agents is reviewed in this article, along with results of clinical trials pertaining to warfarin in stroke prevention. The evolving role of statins, ACE inhibitors and estrogen replacement is reviewed. Finally, the appropriate use of surgery following transient ischaemic ttacks is outlined. Recent studies have shown that many patients will benefit from a multimodal pharmacological approach following transient cerebral ischaemia, and the potential for combination therapy is highlighted.
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References
Feinberg WM, Albers GW, Barnett HJM, et al. Guidelines for the management of transient ischemic attacks. Stroke 1994; 25: 1320–35
Levy DE. How transient are transient ischemic attacks? Neurology 1988; 38: 674–7
Futty DE, Conneally M, Dyken ML, et al. Cooperative study of hospital frequency and character of transient ischemic attacks. V: symptom analysis. JAMA 1977; 238(22): 2386–90
Kelly J, Hunt BJ, Lewis RR, et al. Transient ischemic attacks: under-reported, over-diagnosed, under-treated. Age Ageing 2001; 30: 379–81
Rauch U, Osende JI, Fuster V, et al. Thrombus formation on atherosclerotic plaques: pathogenesis and clinical consequences. Ann Intern Med 2001; 134(3): 224–38
Albers GW, Hart RG, Lutsep HL, et al. AHA Scientific Statement: supplement to the guidelines for the management of transient ischemic attacks: a statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. Stroke 1999; 30(11): 2502–11
Goldstein LB, Adams R, Becker K, et al. Primary prevention of ischemic stroke. Stroke 2001; 32: 280–99
Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension: the Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997; 350: 757–64
Collins R, Peto R, MacMahon S, et al. Blood pressure, stroke, and coronary heart disease, part 2. Short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet 1990; 335: 827–38
Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38: UK Prospective Diabetes Study Group. BMJ 1998; 317(7160): 703–13
Shinton R, Beevers G. Meta-analysis of relation between cigarette smoking and stroke. BMJ 1989; 298: 789–94
Wolf PA, D’Agostino RB, Kannel WB, et al. Cigarette smokingas a risk factor for stroke: the Framingham study. JAMA 1988; 259: 1025–9
Expert panel on detection, evaluation, and treatment of high blood cholesterol in adults: executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001; 285: 2486–97
Byington RP, Davis BR, Plehn JF, et al. Reduction of stroke events with pravastatin. Circulation 2001; 103: 387–92
Reynolds K, Lewis LB, Nolen JDL, et al. Alcohol consumption and risk of stroke. JAMA 2003; 289: 579–88
Albers GW. Atrial fibrillation and stroke. Arch Int Med 1994; 154: 1443–8
Sacco RL, Ellenberg JH, Mohr JP, et al. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol 1989; 25(4): 382–90
Markus HS, Ali N, Swaminathan R, et al. A common polymorphism in the methylenetetrahydrofolate reductase gene, homocysteine, and ischemic cerebrovascular disease. Stroke 1997; 28(9): 1739–43
Giles WH, Croft JB, Greenlund KJ, et al. Total homocyst(e)ine concentration and the likelihood of nonfatal stroke: results from the Third National Health and Nutrition Examination Survey 1988–1994. Stroke 1998; 29(12): 2473–7
Kidwell C, Saver JL. CT and MRI in transient ischemic attacks. In: Chaturvedi S, Levine SR, editors. Transient ischemic attacks. Boston (MA): Blackwell Science. In press
Kidwell CS, Alger JR, Di Salle F, et al. Diffusion MRI in patients with transient ischemic attacks. Stroke 1999; 30(6): 1174–80
Kittner SJ, Sharkness CM, Price TR, et al. Infarcts with a cardiac source of embolism in the NINCDS Stroke Data Bank: historical features. Neurology 1990; 40(2): 281–4
Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988; 318(18): 1148–52
Di Tullio MR, Sacco RL, Homma S. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke: the French Study of Aortic Plaques in Stroke Group. N Engl J Med 1996; 334(19): 1216–21
Swedish Aspirin Low-Dose Trial (SALT) of 75mg aspirin as secondary prophylaxis after cerebrovascular ischaemic events: the SALT Collaborative Group. Lancet 1991; 338(8779): 1345–9
A comparison of two doses of aspirin (30mg vs 283mg a day) in patients after a transient ischemic attack or minor ischemic stroke: the Dutch transient ischaemic attack Trial Study Group. N Engl J Med 1991; 325(18): 1261–6
Taylor DW, Barnett HJ, Haynes RB, et al. Low-dose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: a randomised controlled trial: ASA and Carotid Endarterectomy (ACE) Trial Collaborators. Lancet 1999; 353(9171): 2179–84
Diener HC, Cunha L, Forbes C, et al. European Stroke Prevention Study. 2: dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996; 143(1-2): 1–13
Hass WK, Easton JD, Adams HP, et al. A randomized trial comparing ticlopidine hydrochloride with aspirin for the prevention of stroke in high-risk patients: Ticlopidine Aspirin Stroke Study Group. N Engl J Med 1989; 321(8): 501–7
Gent M, Blakely JA, Easton JD, et al. The Canadian American Ticlopidine Study (CATS) in thromboembolic stroke. Lancet 1989; I(8649): 1215–20
A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE): CAPRIE Steering Committee. Lancet 1996; 348(9038): 1329–39
Mohr JP, Thompson JL, Lazar RM, et al. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001; 345(20): 1444–51
Bennett CL, Connors JM, Carwile JM, et al. Thrombotic thrombocytopenic purpura associated with clopidogrel. N Engl J Med 2000; 342(24): 1773–7
Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345(7): 494–502
Albers GW, Amarenco P, Easton JD, et al. Antithrombotic and thrombolytic therapy for ischemic stroke. Chest 2001; 119(1 Suppl.): 300S–20S
Hirsh JL, Dalen JE, Deykin D, et al. Oral anticoagulants: mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest 1995; 108 Suppl.: 231S–46S
Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke: EAFT (European Atrial Fibrillation Trial) Study Group. Lancet 1993; 342(8882): 1255–62
Homma S, Sacco RL, DiTullio MR, et al. Effect of medical treatment in stroke patients with patent foramen ovale. Circulation 2002; 105: 2625–31
A random trial of anticoagulants versus aspirin after cerebral ischemia of presumed arterial origin: The Stroke Prevention in Reversible Ischemia Trial (SPIRIT) Study Group. Ann Neurol 1997; 42: 857–65
Chimowitz MI, Kokkinos J, Strong J, et al. The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology 1995; 45(8): 1488–93
Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels: the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. N Engl J Med 1998; 339(19): 1349–57
Cohn JN. ACE inhibition and vascular remodeling of resistance vessels: vascular compliance and cardiovascular implications. Heart Dis 2000; 2(2): S2–6
Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensinconverting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients: the Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000; 342(3): 145–53
Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358(9287): 1033–41
Viscoli CM, Brass LM, Kernan WN, et al. A clinical trial of estrogen-replacement therapy after ischemic stroke. N Engl J Med 2001; 345(17): 1243–9
Wise PM, Dubal DB, Wilson ME, et al. Minireview: neuroprotective effects of estrogen-new insights into mechanisms of action. Endocrinology 2001; 142(3): 969–73
MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis: European Carotid Surgery Trialists’ Collaborative Group. Lancet 1991; 337(8752): 235–43
Mayberg MR, Wilson SE, Yatsu F, et al. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis: Veterans Affairs Cooperative Studies Program 309 Trialist Group. JAMA 1991; 266(23): 3289–94
Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis: North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1991; 325: 445–53
Biller J, Feinberg WM, Castaldo JE, et al. Guidelines for carotid endarterectomy. Stroke 1998; 29: 554–62
Barnett HJ, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis: North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339(20): 1415–25
Goldstein LB, Moore WS, Robertson JT, et al. Complication rates for carotid endarterectomy: a call to action. Stroke 1997; 28(5): 889–90
Chaturvedi S, Femino L. Are carotid endarterectomy complication rates being monitored? Neurology 1998; 50(6): 1927–8
Johnston SC, Gress DR, Browner WS, et al. Short-term prognosis after emergency department diagnosis of transient ischaemic attack. JAMA 2000; 284(22): 2901–6
Acknowledgements
Dr Chaturvedi has received honoraria in the past from Sanofi, Boehringer Ingelheim, Pfizer and Wyeth. Dr Chaturvedi also received a research grant from Pfizer. No other sources of funding were used in the preparation of this manuscript.
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Madhavan, R., Chaturvedi, S. Transient Ischaemic Attacks. CNS Drugs 17, 293–305 (2003). https://doi.org/10.2165/00023210-200317050-00001
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DOI: https://doi.org/10.2165/00023210-200317050-00001