scholarly journals European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack

2021 ◽  
Vol 6 (2) ◽  
pp. V-V
Author(s):  
Ana Catarina Fonseca ◽  
Áine Merwick ◽  
Martin Dennis ◽  
Julia Ferrari ◽  
José M Ferro ◽  
...  
Keyword(s):  
High Risk ◽  
Secondary Prevention ◽  
Transient Ischaemic Attack ◽  
Randomised Controlled Trials ◽  
Controlled Trials ◽  
Large Artery ◽  
Guideline Document ◽  
Ischaemic Attack ◽  
Abcd2 Score ◽  
Randomised Controlled

The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.

scholarly journals European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack

2021 ◽  
pp. 239698732199290
Author(s):  
Ana Catarina Fonseca ◽  
Áine Merwick ◽  
Martin Dennis ◽  
Julia Ferrari ◽  
José M Ferro ◽  
...  
Keyword(s):  
High Risk ◽  
Secondary Prevention ◽  
Transient Ischaemic Attack ◽  
Randomised Controlled Trials ◽  
Controlled Trials ◽  
Large Artery ◽  
Guideline Document ◽  
Ischaemic Attack ◽  
Abcd2 Score ◽  
Randomised Controlled

The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score of 4 or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score of 4 or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.

scholarly journals Effectiveness of a gentamicin impregnated collagen sponge on reducing sternal wound infections following cardiac surgery: a meta-analysis of randomised controlled trials

2012 ◽  
Vol 94 (4) ◽  
pp. 227-231 ◽  
Author(s):  
S Creanor ◽  
A Barton ◽  
A Marchbank
Keyword(s):  
Cardiac Surgery ◽  
High Risk ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Current Evidence ◽  
Controlled Trials ◽  
Wound Infections ◽  
Insufficient Evidence ◽  
Sternal Wound Infections ◽  
Randomised Controlled

INTRODUCTION Gentamicin impregnated collagen sponges are licensed for use after cardiac surgery in over 50 countries but their effectiveness at preventing sternal wound infections (SWIs) remains uncertain. The aim of this meta-analysis was to assess the current evidence for effectiveness of such sponges at preventing SWIs in patients after cardiac surgery. METHODS A systematic search of the literature was undertaken and meta-analyses were performed on the results of the identified, eligible studies. Using random effects models, odds ratios (OR) and corresponding 95% confidence intervals (Cl) were calculated for all SWIs and deep SWIs for: a) all participants, and b) participants deemed as high risk. RESULTS Three unique randomised controlled trials (published between 2005 and 2010) involving 3,994 participants met the inclusion criteria. There was insufficient evidence of a significant difference between intervention and control groups for all SWIs (all participants: OR: 0.66, 95% Cl: 0.39–1.14; high risk participants: OR: 0.60, 95% Cl: 0.24–1.52). There was insufficient evidence of a significant benefit of the sponge in deep SWIs across all participants (OR: 0.72, 95% Cl: 0.47–1.10) but some evidence of benefit in terms of reducing the incidence of deep SWIs in high risk participants (OR: 0.62, 95% Cl: 0.39–0.98). CONCLUSIONS There is insufficient evidence of the effectiveness (or otherwise) of gentamicin impregnated sponges in preventing SWIs following cardiac surgery. However, some evidence does exist that such sponges can reduce the incidence of deep infections in high risk patients.

scholarly journals Transient Ischaemic Attack Rarely Precedes Stroke in a Cohort with Low Proportions of Large Artery Atherosclerosis: A Population-Based Study

2018 ◽  
Vol 8 (2) ◽  
pp. 101-105
Author(s):  
Blake F. Giarola ◽  
James Leyden ◽  
Sally Castle ◽  
Jim Jannes ◽  
Craig Anderson ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Transient Ischaemic Attack ◽  
Population Based ◽  
Medical Attention ◽  
Large Artery ◽  
Population Based Study ◽  
Stroke Incidence ◽  
Ischaemic Attack ◽  
Abcd2 Score ◽  
Toast Criteria

Background: Ischaemic stroke is reportedly preceded by transient ischaemic attack (TIA) in 15–30% of all cases. The risk of stroke following TIA is highest in the presence of unstable atherosclerotic plaques in large arteries. The recent population-based Adelaide Stroke Incidence Study describes a population with a low proportion (16%) of stroke attributable to large artery atherosclerosis (LAA). We hypothesized that this population-based ischaemic stroke cohort would have a lower rate of preceding TIA than previously reported. Methods: This paper is a prospective ascertainment of all suspected TIAs and strokes in a 12-month period from 2009 to 2010. Ischaemic stroke pathogenesis was classified by the TOAST criteria. Details of preceding TIA events were scrutinised. Results: In this 12-month period, 318 stroke events in 301 individuals were recorded. Of the total 258 ischaemic strokes, 16% (95% confidence interval [CI] 12–22) were from LAA. Of 258 ischaemic stroke patients, only 11 (4%; 95% CI 2–7) reported symptoms in the preceding 90 days consistent with TIA. Nine (82%) sought medical attention. The median ABCD2 score in this group was 4.5 (IQR: 3–7), and the median time of event prior to stroke was 20 days (IQR: 4–32). Conclusion: In our population-based cohort, rates of TIA preceding ischaemic stroke were much lower than previously reported, probably reflective of effective secondary prevention (active TIA clinics) and primary prevention (limiting LAA prevalence). In our population, further enhancements in TIA care will be of limited yield.

Hit or miss: the new cholesterol targets

2020 ◽  
pp. bmjebm-2020-111413
Author(s):  
Robert DuBroff ◽  
Aseem Malhotra ◽  
Michel de Lorgeril
Keyword(s):  
Cardiovascular Risk ◽  
High Risk ◽  
Randomised Controlled Trials ◽  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Lipoprotein Cholesterol ◽  
Controlled Trials ◽  
Low Density ◽  
Low Density Lipoprotein Cholesterol ◽  
Randomised Controlled

Drug treatment to reduce cholesterol to new target levels is now recommended in four moderate- to high-risk patient populations: patients who have already sustained a cardiovascular event, adult diabetic patients, individuals with low density lipoprotein cholesterol levels ≥190 mg/dL and individuals with an estimated 10-year cardiovascular risk ≥7.5%. Achieving these cholesterol target levels did not confer any additional benefit in a systematic review of 35 randomised controlled trials. Recommending cholesterol lowering treatment based on estimated cardiovascular risk fails to identify many high-risk patients and may lead to unnecessary treatment of low-risk individuals. The negative results of numerous cholesterol lowering randomised controlled trials call into question the validity of using low density lipoprotein cholesterol as a surrogate target for the prevention of cardiovascular disease.

scholarly journals Dual versus mono antiplatelet therapy for acute non-cardioembolic ischaemic stroke or transient ischaemic attack: a systematic review and meta-analysis

2018 ◽  
Vol 3 (2) ◽  
pp. 107-116 ◽  
Author(s):  
Yingying Yang ◽  
Mengyuan Zhou ◽  
Xi Zhong ◽  
Yongjun Wang ◽  
Xingquan Zhao ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Major Bleeding ◽  
Randomised Controlled Trials ◽  
Dual Antiplatelet Therapy ◽  
Meta Analysis ◽  
Stroke Recurrence ◽  
Controlled Trials ◽  
Vascular Events ◽  
Ischaemic Attack ◽  
Randomised Controlled

ObjectiveRecent years have seen new evidence on the efficacy and safety of dual antiplatelet therapy for secondary stroke prevention. We updated a meta-analysis of randomised controlled trials evaluating dual antiplatelet versus monotherapy for patients with acute non-cardioembolic ischaemic stroke (IS) or transient ischaemic attack (TIA).MethodsWe searched PubMed and identified randomised controlled trials evaluating dual antiplatelet versus monotherapy for acute non-cardioembolic IS or TIA within 3 days of ictus up to May 2018. Risk ratio (RR) with 95% CI were calculated using random effects models. Clinical endpoints included stroke recurrence, composite vascular events and major bleeding.Results18 randomised controlled trials including 15 515 patients were pooled in the meta-analysis. When compared with monotherapy among patients with acute IS or TIA, dual antiplatelet therapy reduced the risk of stroke recurrence (RR 0.69; 95% CI 0.61 to 0.78; p<0.001) and composite vascular events (RR 0.72; 95% CI 0.64 to 0.80; p<0.001). Dual therapy was associated with a significant increase in the risk of major bleeding (RR 1.77; 95% CI 1.09 to 2.87; p=0.02) when all trial data were combined. However, when all previous trials before the completion of the POINT trial were analysed, dual antiplatelet versus monotherapy was not associated with a significant increase in the risk of major bleeding (RR 1.46; 95% CI 0.77 to 2.75; p=0.25).ConclusionsAmong patients with acute non-cardioembolic IS or TIA within 3 days of ictus, dual antiplatelet therapy was associated with a reduction in stroke recurrence, and composite vascular events, when compared with monotherapy. However, a significant increase in the risk of major bleeding was observed.

scholarly journals Completeness of reporting of randomised controlled trials including people with transient ischaemic attack or stroke: A systematic review

2018 ◽  
Vol 3 (4) ◽  
pp. 337-346 ◽  
Author(s):  
Blair Wilson ◽  
Peter Burnett ◽  
David Moher ◽  
Douglas G Altman ◽  
Rustam Al-Shahi Salman
Keyword(s):  
Systematic Review ◽  
Randomised Controlled Trial ◽  
Randomised Controlled Trials ◽  
Controlled Trial ◽  
Reporting Guidelines ◽  
Controlled Trials ◽  
Ischaemic Attack ◽  
Randomised Controlled ◽  
Over Time ◽  
Completeness Of Reporting

Purpose To assess the adherence of stroke randomised controlled trials to Consolidated Standards Of Reporting Trials reporting guidelines and investigate the factors that are associated with completeness of reporting. Method We took a random sample from the Cochrane Stroke Group's Trial Register of transient ischaemic attack or stroke randomised controlled trials, published in English in 1997–2016 inclusive. Two reviewers assessed the published report of the final primary results of stroke randomised controlled trials with a 10-point truncated Consolidated Standards Of Reporting Trials reporting checklist to investigate adherence over time, univariable associations and independent associations with total Consolidated Standards Of Reporting Trials reporting score in a multiple linear regression model. Findings In this random sample of 177 stroke randomised controlled trials, the mean score on the truncated Consolidated Standards Of Reporting Trials checklist was 5.8 (SD 2.2); reporting improved from 1997–2000 (4.9 SD 2.0) to 2001–2009 (5.8 SD 2.1) and to 2010–2016 (6.8 SD 2.1). A higher Consolidated Standards Of Reporting Trials score was independently associated with publication during epochs following a revision of Consolidated Standards Of Reporting Trials reporting guidelines (p < 0.001), journal endorsement of the Consolidated Standards Of Reporting Trials reporting guideline at the time of randomised controlled trial publication (p < 0.001) and modified journal impact factor using median citation distribution (p = 0.012). Discussion Stroke randomised controlled trial reporting to Consolidated Standards Of Reporting Trials standards has improved over time, but could be better. Conclusion Journal endorsement and enforcement of Consolidated Standards Of Reporting Trials reporting guidelines could further improve the reporting of stroke randomised controlled trials. Systematic review registration: Registered with PROSPERO (CRD42017072193).

scholarly journals Pharmacological interventions for the prevention of contrast-induced acute kidney injury in high-risk adult patients undergoing coronary angiography: a systematic review and meta-analysis of randomised controlled trials

Open Heart ◽  
2019 ◽  
Vol 6 (1) ◽  
pp. e000864 ◽  
Author(s):  
Alexander J Sharp ◽  
Nishith Patel ◽  
Barney C Reeves ◽  
Gianni D Angelini ◽  
Francesca Fiorentino
Keyword(s):  
Systematic Review ◽  
Acute Kidney Injury ◽  
High Risk ◽  
Coronary Angiography ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Kidney Injury ◽  
Controlled Trials ◽  
High Dose ◽  
Randomised Controlled

ObjectiveQuantify the efficacy of strategies to prevent contrast-induced acute kidney injury (CI-AKI) in high-risk patients undergoing coronary angiography (CAG) with or without percutaneous coronary intervention (PCI).BackgroundCI-AKI remains a common problem. The renoprotective efficacy of existing pharmacological agents remains uncertain in high-risk populations.MethodsSystematic review and meta-analysis of randomised controlled trials (RCTs) to compare different strategies versus hydration in patients with chronic kidney disease (CKD) undergoing CAG±PCI. Primary outcome was incident CI-AKI. Fixed-effects meta-analyses estimated ORs, 95% CIs and heterogeneity.ResultsForty-eight RCTs were included. Seven pharmacological strategies were evaluated by multiple RCTs and 10 by one RCT each. These had varying risk of bias; >25% of trials were at high risk of performance bias. Five strategies significantly reduced the odds of CI-AKI: N-acetylcysteine (NAC) (27 trials, 5694 participants; OR=0.77, 95% CI 0.65 to 0.91, p=0.002, I2=36%), ascorbic acid (four trials, 759 participants; OR=0.59, 95% CI 0.39 to 0.89, p=0.01, I2=0%), statin (two trials, 3234 participants; OR=0.59, 95% CI 0.39 to 0.89, p=0.75, I2=0%), trimetazidine (two trials, 214 participants; OR=0.27, 95% CI 0.10 to 0.71, p=0.01, I2=0%) and nicorandil (two trials, 389 participants; OR=0.47, 95% CI 0.23 to 0.94, p=0.03, I2=52%). Theophylline had a similar, but non-significant, effect. A subgroup analysis found that the benefit of NAC was highest in patients requiring a high-contrast dose.ConclusionsSeveral drugs are renoprotective in patients with CKD undergoing CAG±PCI. The evidence is strongest for NAC. We recommend that NAC should be used when a high dose of contrast is anticipated.Trial registration numberPROSPERO registration CRD42014014704.Open Science Framework link: https://osf.io/vxg7d/?view_only=62bad0404b18405abd39ff2ead2575a8

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