暂时性脑缺血发作的专门单位与极低的事件比率有关


【24drs.com】根据一篇新研究,在专门的TIA单位治疗暂时性脑缺血发作(TIA)或轻微中风的患者,由中风专家提供紧急的实证照护,之后一年,中风与其它心血管事件的比率相当低。
  
  法国巴黎Bichat医院Pierre Amarenco医师等人进行的这篇研究,发表于4月21日的新英格兰医学期刊。
  
  研究结果来自「TIAregistry.org project」这项计画,目的是说明TIA或轻微中风患者的当前资料,以及短期和长期结果的风险因素,并定义风险评估。
  
  作者们结论指出,在「TIAregistry.org project」计画中,我们观察到,发生TIA或轻微中风后的心血管事件比率比以往的历史资料低,我们的研究结果或许反映出,就诊于TIA门诊、接受风险因素控制与根据当前指引之建议,进行抗血栓治疗之TIA或轻微中风患者之复发心血管事件的当今风险情况。
  
  他们指出,虽然我们发现ABCD2分数是不错的风险预测因子,但我们的研究结果认为,对于分数4分以上患者,有限的紧急评估,可能会错过约20%的初期复发中风。神经影像学发现多发性梗塞与大动脉粥样硬化性疾病,也是复发血管事件的强烈独立预测因子,这些结果可能有助于设计和诠释未来的随机试验。
  
  在编辑评论中,佛罗里达州迈阿密大学米勒医学院的Ralph L. Sacco医师和Tatjana Rundek博士表示,研究结果支持采用有组织的单位照护TIA或轻微中风患者的价值,在该单位由中风专家迅速诊断评估且适当采用有实证的预防治疗,减少中风的初期和后期风险。
  
  研究者报告了来自61个城市、4,789名患者的资料,都适用于「TIAregistry.org」的其中21国的TIA患者紧急评估。
  
  这些患者中,78.4%是在症状发生的24小时内由中风专家评估,在计算机断层或MRI发现急性梗塞比率为33%、新发生的心房颤动为5%(其中67%在出院前接受抗凝血剂治疗)、颈动脉狭窄比率将近16%(其中27%在出院前进行了颈动脉血管重建)。
  
  各种心血管预后(中风、急性冠状动脉症状、心血管原因死亡)的一年事件发生率为6.2%,第2、7、30、90和365天时的中风比率分别是1.5%、2.1%、2.8%、3.7%与5.1%— 远低于之前的研究报告。
  
  作者们表示,这篇研究的低事件发生率并不是因为低风险对象,研究对象有三分之二以上是ABCD2分数4分以上,在每个分数级距观察到的风险都偏低。
  
  反之,他们认为,良好结果的核心原因可能是,更好更快速地执行次级中风预防策略,包括立即给予抗血小板药物、心房颤动者给予口服抗凝血剂、危急颈动脉狭窄者进行紧急血管重建、以及其它次级预防措施(例如:使用statins类药物和降血压药物治疗)。
  
  Sacco医师和Rundek博士在编辑评论中强调,轻微中风或TIA患者的失能程度最小,但他们发生中风时的损失程度最严重,然而,他们常常因为延迟就医或者医师评估不需要紧急治疗,而错过发现急性中风的机会。
  
  他们表示,监于初级和次级中风预防质量的大幅改善,错失这个机会更是令人担忧。
  
  这篇注册研究报告的结果,比以前的研究报告低了至少50% ,显示不论是在TIA门诊或专门的保健服务单位由中风专家对TIA或轻微中风患者紧急照护,无疑地是有用的。
  
  他们指出,「TIAregistry.org project」这项计画的另一个重要成功之处是,在3个月和12个月时,极佳的自我报告用药遵医嘱率,与出院时相当。
  
  该研究在患者的风险评估也发现一些有趣结果,特别的是,脑部影像检查、大动脉粥样硬化、ABCD2分数6分或7分,都和中风风险增加1倍以上有关,不过,ABCD2分数4分以上患者的有限紧急评估可能会错过约20%的初期复发中风。
  
  Sacco医师和Rundek博士指出,多发性梗塞的观察代表著一个新结果,纳入风险预测模式后可能会有帮助。
  
  他们结论表示,这篇研究应可促使卫生保健提供者和决策者对中风照护系统进行必要修改,目的是为急性中风患者与TIA或轻微中风患者提供最有效的照护。
  
  资料来源:http://www.24drs.com/
  
  Native link:Specialized TIA Clinics Linked to Very Low Event Rates
  

Specialized TIA Clinics Linked to Very Low Event Rates

By Sue Hughes
Medscape Medical News

Patients treated for a transient ischemic attack (TIA) or minor stroke at specialized TIA units in which urgent evidence-based care is delivered by stroke specialists had a very low risk for stroke and other cardiovascular events over the following year, according to a new study.

The study, published in the April 21 issue of the New England Journal of Medicine, was conducted by a team led by Pierre Amarenco, MD, Bichat Hospital, Paris, France.

The findings come from a program called the TIAregistry.org project, designed to describe the current profile of patients with TIA or minor stroke, as well as risk factors and short- and long-term outcomes and to "refine risk assessment," they write.

"In the TIAregistry.org project, we observed a lower rate of cardiovascular events after a TIA or minor stroke than that in historical cohorts," the authors conclude. "Our findings probably reflect the contemporary risk of recurrent cardiovascular events among patients with a TIA or minor stroke who are admitted to TIA clinics and who receive risk-factor control and antithrombotic treatment as recommended by current guidelines.

"Although we found that the ABCD2 score was a good predictor of risk, our findings suggest that limiting urgent assessment to patients with a score of 4 or more would miss approximately 20% of those with early recurrent strokes. Multiple infarctions on neuroimaging and large-artery atherosclerotic disease were also strong independent predictors of recurrent vascular events," they add. "These results may help in the design and interpretation of future randomized trials."

In an accompanying editorial, Ralph L. Sacco, MD, and Tatjana Rundek, MD, PhD, Miller School of Medicine, University of Miami, Florida, say the study results "support the value of organizing specialized units for the care of patients with a TIA or minor stroke where rapid diagnostic evaluations and evidence-based preventive treatments by stroke specialists can be initiated promptly and lead to reduced early and late risks of stroke."

The researchers report data on 4789 patients from 61 sites, all dedicated to urgent evaluation of patients with TIA in 21 countries as part of the TIAregistry.org.

Of these patients, 78.4% were evaluated by stroke specialists within 24 hours of symptom onset. Acute infarction was found on computed tomography or MRI in 33%, new-onset atrial fibrillation in 5% (67% of whom received anticoagulant therapy before discharge), and carotid stenosis in approximately 16% (27% of whom underwent carotid revascularization before discharge).

The 1-year event rate for composite cardiovascular outcome (stroke, an acute coronary syndrome, or death from cardiovascular causes) was 6.2%. The stroke rates at days 2, 7, 30, 90, and 365 were 1.5%, 2.1%, 2.8%, 3.7%, and 5.1%, respectively — much lower than rates reported in previous studies.

The authors say the low event rates in this study were not explained by a low-risk population. More than two thirds of the cohort had an ABCD2 score of 4 or more, and the risk observed was low in each stratum of the score.

Rather, they suggest that the good outcomes core may be explained by better and faster implementation of secondary stroke prevention strategies, including immediate initiation of antiplatelet drugs, oral anticoagulation in the event of atrial fibrillation, urgent revascularization in patients with critical carotid stenosis, and other secondary prevention measures (such as treatment with statins and blood pressure–lowering drugs).

In their editorial, Dr Sacco and Dr Rundek emphasize that patients with minor stroke or TIA have the least amount of disability and the most to lose should they have a stroke, but they often slip through systems for detecting acute stroke owing either to delay in seeking medical attention or clinicians' assessments that urgent treatment is not needed.

"This lost opportunity is even more worrisome given the tremendous improvements in the quality of primary and secondary stroke prevention," they say.

Urgent Care "Undoubtedly Works"

They note that the outcomes reported in this registry study were at least 50% lower than those reported in previous studies, showing that "urgent care for patients with a TIA or minor stroke either in specialized TIA clinics or dedicated care delivery units with stroke specialists undoubtedly works."

They point out that another important success of the TIAregistry.org project was the excellent adherence rates of self-reported medication use at 3 months and 12 months, which were similar to the rates at discharge.

The study also found some interesting results on risk assessment of patients. In particular, multiple infarctions on brain imaging, large-artery atherosclerosis, and an ABCD2 score of 6 or 7 were each associated with more than a doubling of the risk for stroke. However, limiting urgent assessment to patients with an ABCD2 score of 4 or more would miss approximately 20% of those with early recurrent strokes.

Dr Sacco and Dr Rundek point out that the multiple infarctions observation represent a new finding and may be useful for inclusion in risk-prediction models.

"This study should prompt health care providers and policymakers to make necessary changes in systems of stroke care in order to deliver the most effective care not only to patients with acute stroke, but also to those with a TIA or minor stroke," they conclude.

The study was supported by an unrestricted grant from Sanofi and Bristol-Myers Squibb. Dr Amarenco reports grant support and personal fees from Sanofi and Bristol Myers-Squibb during the conduct of the study; grant support and personal fees from Pfizer; and personal fees from Bayer, Daiichi-Sankyo, Boehringer Ingelheim, Boston Scientific, Medtronic, GlaxoSmithKline, and the Kowa Company outside the submitted work.

N Engl J Med. Published online April 21, 2016.

    
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