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Hypertension and Stroke Special Report

Nothing Minor About Ministrokes

Johns Hopkins Health Alerts Hypertension (High Blood Pressure) and Stroke Ministrokes

A transient ischemic attack (TIA), sometimes called a ministroke, warrants the same immediate medical attention that a full-blown stroke does.

A transient ischemic attack (TIA) may not seem like an emergency. The symptoms—although nearly identical to a stroke — are by definition temporary, lasting no longer than 24 hours and often subsiding within 20 minutes. These so-called ministrokes are rarely painful, and people often put off seeking medical care or never consult a doctor at all about their symptoms.

But transient ischemic attacks are not as benign as they may appear. Emerging evidence presented at the American Stroke Association’s 27th International Stroke Conference in 2004 demonstrated that the risk of subsequent stroke and death is high among transient ischemic attack patients and that hospitalization for 24 hours after a transient ischemic attack may be the best course of action.

How Risky Are Transient Ischemic Attacks?

Two presentations at the conference looked at the risk of stroke and death after a transient ischemic attack. The first study compared the risk of stroke, dependency, and death in transient ischemic attack and stroke patients in Germany. Although stroke patients were at a higher risk in each category, patients who had a transient ischemic attack still had a high likelihood of having a stroke (6%), becoming dependent on others for daily care (22%), and dying (2%) within six months of the transient ischemic attack. The researchers concluded that transient ischemic attacks “merit the same attention” as strokes.

The second study, conducted in California, found that nearly 6% of transient ischemic attack patients experienced a stroke within 48 hours of their TIA. By three months, this percentage increased to 16%. Three years later, 30% of transient ischemic attack patients had gone on to have a stroke, showing that the risk of stroke is high after a transient ischemic attack, especially in the first few hours. Older patients, those with diabetes, and those with hypertension were at a higher risk for stroke after a transient ischemic attack.

Should Transient Ischemic Attack Patients Be Hospitalized?

Knowing the risks of transient ischemic attacks, the California researchers conducted another study that looked at the cost-effectiveness of hospitalizing transient ischemic attack patients for the first 24 hours after the event. The rationale was simple: Because transient ischemic attack patients have such a high risk of stroke immediately after a transient ischemic attack, if they are already in the hospital they can be given the emergency stroke drug t-PA immediately if they have a stroke. Otherwise, they may be far from medical help when a stroke occurs and not likely to receive t-PA during the short window of opportunity in which this treatment is effective.

The researchers found that 2.9% of transient ischemic attack patients would have a stroke and receive t-PA if they were hospitalized compared with only 0.5% of patients not hospitalized. Hospitalizing all transient ischemic attack patients for 24 hours would be cost-effective, the researchers concluded. The strategy would cost about $44,300 per quality-adjusted life-years saved. (Any intervention that costs less than $50,000 per quality-adjusted life-years saved is considered cost-effective.)

Although routine hospitalization of transient ischemic attack patients is not recommended at this time, it could become standard practice if further studies bear out the result of this one. In the meantime, Rafael H. Llinas, M.D., director of cerebrovascular neurology at Johns Hopkins Bayview Medical Center, recommends people receive an inpatient or outpatient workup soon after a transient ischemic attack because of the small but elevated risk of stroke within the next 48 hours.

Evaluating and Treating Transient Ischemic Attacks

Because transient ischemic attacks are short-lived, they often aren’t treated as emergencies—but they should be. If you experience transient ischemic attack symptoms, which are similar to stroke symptoms, call 911 or have someone drive you to the hospital, even if the symptoms go away.

At the hospital, someone will take your medical history, and you will undergo blood tests, electrocardiography, and imaging studies of the head and, possibly, carotid arteries. You can also expect to receive treatments that include those used for strokes themselves—including medications to prevent blood clots and future strokes, such as aspirin, Plavix (clopidogrel), Aggrenox (aspirin plus dipyridamole), Coumadin (warfarin), and occasionally, in specific situations, heparin.

Patients should view a transient ischemic attack as a warning sign that they need to control any modifiable stroke risk factors they have. Lifestyle changes should include improving one’s diet and exercising regularly, quitting smoking if you smoke, and drinking only in moderation (no more than two drinks daily for men, one for women).

Patients may also need additional medications to lower levels of blood pressure or low-density lipoprotein (LDL, or “bad”) cholesterol. Those with diabetes may need medication to lower blood glucose levels. Patients with heart conditions that increase their risk of another transient ischemic attack or stroke—including coronary heart disease, an abnormal heart rhythm such as atrial fibrillation, heart failure, and valvular heart disease—should receive appropriate treatment for these conditions.

Finally, for patients whose evaluation reveals a significant blockage of the carotid arteries, a surgical procedure called carotid endarterectomy may be done to improve the flow of blood to the brain.

  • For more Hypertension & Stroke articles, please visit the Hypertension & Stroke Topic Page

    Posted in Hypertension and Stroke on April 6, 2006

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