by American Heart Association
Dallas - Stroke symptoms that disappear in under an hour, known as a transient ischemic attack (TIA), need emergency assessment to help prevent a full-blown stroke, according to a new American Heart Association scientific statement published today in the Association’s journal
Stroke. The statement offers a standardized approach to evaluating people with suspected TIA, with guidance specifically for hospitals in rural areas that may not have access to advanced imaging or an on-site neurologist.
Photo courtesy American Heart Assoc.
TIA is a temporary blockage of blood flow to the brain. Each year, about 240,000 people in the U.S. experience a TIA, although this estimate may represent underreporting of TIA because symptoms tend to go away within an hour. While the TIA itself doesn’t cause permanent damage, nearly 1 in 5 of those who have a TIA will have a full-blown stroke within three months after the TIA, almost half of which will happen within two days. For this reason, a TIA is more accurately described as a warning stroke rather than a “mini-stroke,” as it’s often called.
TIA symptoms are the same as stroke symptoms, only temporary. They begin suddenly and may have any or all of these characteristics:
- Symptoms begin strong then fade;
- Symptoms typically last less than an hour;
- Facial droop;
- Weakness on one side of the body;
- Numbness on one side of the body;
- Trouble finding the right words/slurred speech; or
- Dizziness, vision loss or trouble walking.
The F.A.S.T. acronym for stroke symptoms can be used to identify a TIA: F ― Face drooping or numbness; A ― Arm weakness; S ― Speech difficulty; T ― Time to call 9-1-1, even if the symptoms go away.
“Confidently diagnosing a TIA is difficult since most patients are back to normal function by the time they arrive at the emergency room,” said Hardik P. Amin, M.D., chair of the scientific statement writing committee and associate professor of neurology and medical stroke director at Yale New Haven Hospital, St. Raphael Campus in New Haven, Connecticut. “There also is variability across the country in the workup that TIA patients may receive. This may be due to geographic factors, limited resources at health care centers or varying levels of comfort and experience among medical professionals.”
For example, Amin said, “Someone with a TIA who goes to an emergency room with limited resources may not get the same evaluation that they would at a certified stroke center. This statement was written with those emergency room physicians or internists in mind – professionals in resource-limited areas who may not have immediate access to a vascular neurologist and must make challenging evaluation and treatment decisions.”
The statement also includes guidance to help health care professionals tell the difference between a TIA and a “TIA mimic” – a condition that shares some signs with TIA but is due to other medical conditions such as low blood sugar, a seizure or a migraine. Symptoms of a TIA mimic tend to spread to other parts of the body and build in intensity over time.
Who is at risk for a TIA?
People with cardiovascular risk factors, such as high blood pressure, diabetes, obesity, high cholesterol and smoking, are at high risk for stroke and TIA. Other conditions that increase risk of a TIA include peripheral artery disease, atrial fibrillation, obstructive sleep apnea and coronary artery disease. In addition, a person who has had a prior stroke is at high risk for TIA.
Which tests come first once in the emergency room?
Blood work should be completed in the emergency department to rule out other conditions
After assessing for symptoms and medical history, imaging of the blood vessels in the head and neck is an important first assessment. A non-contrast head CT should be done initially in the emergency department to rule out intracerebral hemorrhage and TIA mimics. CT angiography may be done as well to look for signs of narrowing in the arteries leading to the brain. Nearly half of people with TIA symptoms have narrowing of the large arteries that lead to the brain.
A magnetic resonance imaging (MRI) scan is the preferred way to rule out brain injury (i.e., a stroke), ideally done within 24 hours of when symptoms began. About 40% of patients presenting in the ER with TIA symptoms will actually be diagnosed with a stroke based on MRI results. Some emergency rooms may not have access to an MRI scanner, and they may admit the patient to the hospital for MRI or transfer them to a center with rapid access to one.
Blood work should be completed in the emergency department to rule out other conditions that may cause TIA-like symptoms, such as low blood sugar or infection, and to check for cardiovascular risk factors like diabetes and high cholesterol.
Once TIA is diagnosed, a cardiac work-up is advised due to the potential for heart-related factors to cause a TIA. Ideally, this assessment is done in the emergency department, however, it could be coordinated as a follow-up visit with the appropriate specialist, preferably within a week of having a TIA. An electrocardiogram to assess heart rhythm is suggested to screen for atrial fibrillation, which is detected in up to 7% of people with a stroke or TIA. The American Heart Association recommends that long-term heart monitoring within six months of a TIA is reasonable if the initial evaluation suggests a heart rhythm-related issue as the cause of a TIA or stroke.
Early neurology consultation, either in-person or via telemedicine, is associated with lower death rates after a TIA. If consultation isn’t possible during the emergency visit, the statement suggests following up with a neurologist ideally within 48 hours but not longer than one week after a TIA, given the high risk of stroke in the days after a TIA. The statement cites research that about 43% of people who had an ischemic stroke (caused by a blood clot) had a TIA within the week before their stroke.
Assessing stroke risk after TIA
A rapid way to assess a patient’s risk of future stroke after TIA is the 7-point ABCD2 score, which stratifies patients into low, medium and high risk based on Age, Blood pressure, Clinical features (symptoms), Duration of symptoms (less than or greater than 60 minutes) and Diabetes. A score of 0-3 indicates low risk, 4-5 is moderate risk and 6-7 is high risk. Patients with moderate to high ABCD2 scores may be considered for hospitalization.
Collaboration among emergency room professionals, neurologists and primary care professionals is critical to ensure the patient receives a comprehensive evaluation and a well-communicated outpatient plan for future stroke prevention at discharge.
“Incorporating these steps for people with suspected TIA may help identify which patients would benefit from hospital admission, versus those who might be safely discharged from the emergency room with close follow-up,” Amin said. “This guidance empowers physicians at both rural and urban academic settings with information to help reduce the risk of future stroke.”
DALLAS — Having a stroke may significantly increase the risk of developing dementia. The risk of dementia was the highest in the first year after a stroke and remained elevated over a period of twenty years, according to preliminary research to be presented at the American Stroke Association’s International Stroke Conference 2024. The meeting will be held in Phoenix, Feb. 7-9, and is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.
“Our findings show that stroke survivors are uniquely susceptible to dementia, and the risk can be up to 3 times higher in the first year after a stroke. While the risk decreases over time, it remains elevated over the long-term,” said lead study author Raed Joundi, M.D., D.Phil., an assistant professor at McMaster University in Hamilton, Ontario, Canada, and an investigator at the Population Health Research Institute, a joint institute of McMaster University and Hamilton Health Sciences.
To evaluate dementia risk after stroke, the researchers used databases at the Institute for Clinical Evaluative Sciences (University of Toronto, Canada), which includes more than 15 million people in the Canadian province of Ontario. They identified 180,940 people who had suffered a recent stroke — either an ischemic stroke (clot-caused) or intracerebral hemorrhage (bleeding within the brain) — and matched those stroke survivors to two control groups — people in the general population (who had not had a heart attack or stroke) and those who had had a heart attack and not a stroke. Researchers evaluated the rate of new cases of dementia starting at 90 days after stroke over an average follow-up of 5.5 years. In addition, they analyzed the risk of developing dementia in the first year after the stroke and over time, up to 20 years.
The study found:
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DALLAS — The combination of soaring heat and smothering fine particulate pollution may double the risk of heart attack death, according to a new study of more than 202,000 heart attack deaths in China. The study published today in the American Heart Association’s flagship journal Circulation.
"Extreme temperature events are becoming more frequent, longer and more intense, and their adverse health effects have drawn growing concern. Another environmental issue worldwide is the presence of fine particulate matter in the air, which may interact synergistically with extreme temperatures to adversely affect cardiovascular health," said senior author Yuewei Liu, M.D., Ph.D., an associate professor of epidemiology in the School of Public Health at Sun Yat-sen University in Guangzhou, China. "However, it remains unknown if and how co-exposure to extreme temperatures and fine particulate pollution might interact to trigger a greater risk of death from heart attack, which is an acute response potentially brought on by an acute scenario and a great public health challenge due to its substantial disease burden worldwide."
To examine the impact of extreme temperatures with and without high levels of fine particulate pollution, the researchers analyzed 202,678 heart attack deaths between 2015-2020 that occurred in Jiangsu province, a region with four distinct seasons and a wide range of temperatures and fine particulate pollution levels. The deaths were among older adults with an average age of 77.6 years; 52% were older than age 80; and 52% were male. Particulate exposure on the day of each death and one day before death were included in the analysis.
Extreme temperatures were gauged according to the daily heat index (also referred to as apparent temperature) for an area, which captures the combined effect of both heat and humidity. Both the length and extremeness of heat waves and cold snaps were evaluated. Heart attack deaths, or case days, during these periods were compared with control days on the same day of the week in the same month — meaning that if a death occurred on a Wednesday, all other Wednesdays in the same month would be considered control days. Particulate levels were considered high on any day with an average level of fine particulate matter above 37.5 micrograms per cubic meter.
"Our findings provide evidence that reducing exposure to both extreme temperatures and fine particulate pollution may be useful to prevent premature deaths from heart attack, especially for women and older adults," Liu said.
Compared with control days, the risk of a fatal heart attack was observed at the following levels:
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