Risk of subsequent stroke following Transient Ischemic Attack varies based on receipt of follow-up care

1. A systematic review and meta-analysis including data from more than 200,000 patients having had a transient ischemic attack (TIA) found that inpatient versus outpatient care did not significantly affect the risk of experiencing a subsequent stroke.

2. Patients who received care only in the ED were at a higher risk of suffering subsequent stroke.

Level of Evidence: 1 (Excellent)

Study Rundown: Transient Ischemic Attacks (TIAs) are a well-known risk factor for experiencing a subsequent stroke, although there is currently no standardized post-TIA management strategy in North America designed to investigate the etiology of TIA and minimize risk of subsequent vascular events. Several proposed approaches to post-TIA care have been evaluated in the literature, although the optimal approach is unknown. The present study is a systematic review and meta-analysis seeking to assess the risk of subsequent ischemic stroke following TIA managed in various care settings. A total of 71 studies were included. The included studies described data from 226,683 patients recruited between 1981 and 2018. Patients were divided into cohorts for the purpose of this study based on the post-TIA care they received. Stroke risk at 90 days after TIA was estimated to be 2.1% amongst patients treated at a TIA clinic, 2.8% amongst patients treated as hospital inpatients and 3.5% amongst those who received care at the ED only. Patients treated at the ED were considered to have higher stroke risk than those treated as inpatients at 2 and 7 days after TIA, and at 2, 7 and 90 days after TIA compared to those treated at a TIA clinic. No significant differences in stroke risk were found between patients treated as inpatients and outpatients. The risk of publication bias in this study was estimated as low, as was the risk of bias amongst 90.6% of individual studies. This systematic review and meta-analysis by Shahjouei et al concluded that inpatient hospital care or outpatient clinic care following TIA are advantageous in preventing subsequent stroke within a 90 day time frame. Notably, they also concluded that outpatient care is noninferior to inpatient care, a finding important for resource management in TIA care. A primary advantage of this study is the large number of prospective and retrospective studies included, as well as the thoroughness of the statistical analysis. Given that nonrandomized studies were included, there remains some potential for confounding bias. Additionally, synthesis of such a large number of studies may rely on several assumptions and reduce the external validity of the reported findings.

Click to read this study in JAMA Network Open

Relevant Reading: Performance of the ABCD2 score for stroke risk post TIA: meta-analysis and probability modeling

In Depth [systematic review & meta-analysis]: A systematic search of several databases (Medline, Web of Science, Scopus, Embase, International Clinical Trials Registry Platform, ClinicalTrials.gov, Trip Medical Database, CINAHL, and all Evidence-Based Medicine databases) from their respective inception date to October 1, 2020 was conducted. Additionally, peer-reviewed publications, unpublished studies and gray literature sources were evaluated. Studies providing information on TIA and post-TIA care in adult patients were included. Exposure to care setting was defined as follows: TIA clinic, inpatient hospitalization, Emergency Department (ED) or unspecified setting. Studies were reviewed by two independent reviewers; risk of bias was assessed using the Risk of Bias in Nonrandomized Studies of Exposures tool. The risk of subsequent stroke for patients treated at a TIA clinic was as follows: was 0.3% (95% confidence interval [CI], 0.0%-1.2%) within 2 days, 1.0% (95% CI, 0.3%-2.0%) within 7 days, 1.3% (95% CI, 0.4%-2.6%) within 30 days, and 2.1% (95% CI, 1.4%-2.8%) within 90 days. Among inpatients, stroke risk was: was 0.5% (95% CI, 0.1%-1.1%) within 2 days, 1.2% (95% CI, 0.4%-2.2%) within 7 days, 1.6% (95% CI, 0.6%-3.1%) within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. Patients treated in an ED had the following stroke risk: was 1.9% (95% CI, 1.2%-2.7%) within 2 days, 3.4% (95% CI, 2.3%-4.7%) within 7 days, 3.5% (95% CI, 1.5%-6.3%) within 30 days, and 3.5% (95% CI, 2.5%-4.5%) within 90 days. A sensitivity analysis of patients in prospective studies conducted after the year 2000 found no difference in stroke risk for patients treated at TIA clinics versus in hospital at 2 days (0.2% [95% CI, 0-1.0%] vs 0.3% [95% CI, 0-0.8%] among inpatients; P = 0.94), (7 days (0.8% [95% CI, 0.2%-1.8%] vs 0.7% [95% CI, 0.3%-1.3%] among inpatients; P = 0.81), 30 days (1.3% [95% CI, 0.4%-2.5%] vs 1.3% [0.3%-2.7%] among inpatients; P>0.99), and 90 days (2.2% [95% CI, 1.5%-3.0%] vs 2.6% [95% CI, 1.9%-3.3%] among inpatients; P = .46).

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