Journal Mobile Options
Table of Contents
Vol. 25, No. 3, 2008
Issue release date: March 2008
Cerebrovasc Dis 2008;25:225–233

Major Vascular Events after Transient Ischaemic Attack and Minor Ischaemic Stroke: Post Hoc Modelling of Incidence Dynamics

Atanassova P.A. · Chalakova N.T. · Dimitrov B.D.
aDepartment of Neurology, Medical University, and bInformation Services Section, Medical University Hospital St. George, Plovdiv, Bulgaria

Individual Users: Register with Karger Login Information

Please create your User ID & Password

Contact Information

I have read the Karger Terms and Conditions and agree.

To view the fulltext, please log in

To view the pdf, please log in


Background: Only few follow-up studies have compared the long-term risk of such major vascular events (MVE) as myocardial infarction (MI) and/or stroke following transient ischaemic attack (TIA) or minor ischaemic stroke (MIS). Estimates of relative risk and cumulative long-term occurrence of MVE may provide better information and contribute to the optimization of treatment decisions. Methods: In the current post hoc modelling study with unique data from Bulgaria, we analysed 183 consecutive patients with TIA (n = 89) or MIS (n = 94), aged >40 years, who were prospectively followed over 36 months for non-fatal or fatal MVE. The cumulative survival, hazard and risks (with 95% confidence intervals) for MVE (combined or by stratification) were calculated by Kaplan-Meier analysis and adjusted (age, sex) by multivariate Cox proportional hazard models. A set of regression models was then applied to MVE incidence (per 100 patients; 4-month intervals). Results: Median follow-up was 36 months (interquartile range 30.8–36.0); no differences by age or sex were found (p > 0.05). The risk of non-fatal or fatal MVE was approximately 28% (stroke 19.7%, MI 8.2%). The adjusted cumulative risk of stroke was 0.21 versus 0.10 for MI. The odds ratio of TIA versus MIS was 0.75 (95% CI 0.43–1.32), i.e. lower for stroke (0.63, 0.31–1.25) than for MI (1.12, 0.40–3.14). The risk of non-fatal MVE was higher in MIS than in TIA (pBreslow = 0.0497), especially for non-fatal stroke (p = 0.0325). Time series regression models provided best estimates of the different outcome dynamics in TIA versus MIS (R2TIA = 0.969 with bpower = 1.04 vs. R2MIS = 0.989 with blinear = 0.84; p1-tailed = 0.04) over the study period. Conclusions: The age- and sex-adjusted cumulative 36-month hazard of MVE is higher after MIS than after TIA, but MVE fatality was higher after TIA than after MIS. Although stroke incidence was higher (up to 3 times that of MI), with the highest difference between months 8 and 18, MI fatality was always higher in absolute, relative or adjusted terms. The above alarming patterns and increasing, diverging tendencies for MVE indicate a higher long-term cumulative risk after MIS compared with TIA. These results confirm our hypothesis of a differential risk of TIA versus MIS and, at least, point toward equal importance of therapies aimed at preventing MVE in both types of preceding conditions (TIA or MIS) and the increased fatality after MI, in particular in patients with TIA.

Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.


  1. De Reuck J, De Groote L, Van Maele G: Delayed transient worsening of neurological deficits after ischaemic stroke. Cerebrovasc Dis 2006;22:27–32.
  2. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486–2497.
  3. Grundy SM, Cleeman JI, Merz CN, et al: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:227–239.
  4. Ross GW, Petrovitch H, White LR, et al: Characterization of risk factors for vascular dementia: the Honolulu-Asia Aging Study. Neurology 1999;53:337–343.
  5. Tatemichi TK, Desmond DW, Paik M, et al: Clinical determinants of dementia related to stroke. Ann Neurol 1993;33:568–575.
  6. Albers GW: Choice of endpoints in antiplatelet trials: which outcomes are most relevant to stroke patients? Neurology 2000;54:1022–1028.
  7. Atanassova P, Semerdjieva M, Naydenov V, et al: Transient ischaemic attacks and minor strokes (analyses and clinically significant comparisons). Folia Medica 2006;48:30–36.

    External Resources

  8. Atanassova P, Hadjipetrova E, Zachariev Z: One-year clinical follow-up study of patients with reversible ischaemic neurological deficit. Folia Medica 1998;40:56–61.
  9. Atanassova P: Clinical and Electrophysiological Study of Patients with Minor Stroke; DM thesis, Medical University, Plovdiv, 1998.
  10. Bamford J, Sandercock P, Dennis M, et al: A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981–1986. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoidal haemorrhage. J Neurol Neurosurg Psychiatry 1990;53:16–22.
  11. De Reuck J, Helleputte T, et al: Transient ischaemic attack. Patient Care 2005;28:27–29.
  12. Dimitrov BD, et al: Cyclic variations in the frequency of spread of cerebro-vascular disease in Stara Zagora for the period 1985–1988. Annuaire de l’Institut Supérieur de Médecine de Stara Zagora 1996;5:23–24.
  13. Dimitrov BD: Cyclic patterns of incidence variations for stomach cancer in the North-Western Region of England. Croat Med J 2000;41:197–202.
  14. Dimitrov BD: Assessment of the dynamics in the spread of some malignant neoplasms in Bulgaria: nonlinear prognostic models; DM thesis, Medical University, Plovdiv, 2006.
  15. Foulkes MA, Wolf PA, Price TR, et al: The Stroke Data Bank: design, methods, and baseline characteristics. Stroke 1988;19:547–554.
  16. Bronnum-Hansen H, Davidsen M, Thorvaldsen P: Long-term survival and causes of death after stroke. Stroke 2001;32:2131–2136.
  17. Peltonen M, Stegmayr B, Asplund K: Time trends in long-term survival after stroke: the Northern Sweden Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study, 1985–1994. Stroke 1998;29:1358–1365.
  18. Dennis M, Burn J, Sandercock P, et al: Long-term survival after first-ever stroke: the Oxfordshire Community Stroke Project. Stroke 1993;24:796–800.
  19. Bamford J, Dennis M, Sandercock P, et al: The frequency, causes and timing of death within 18 months of a TIA or MIS: the Oxfordshire Community Stroke Project. J Neurol Neurosurg Psychiatry 1990;53:824–829.
  20. Hardie K, Jamrozik K, Hankey GJ, et al: Trends in five-year survival and risk of recurrent stroke after first-ever stroke in the Perth Community Stroke Study. Cerebrovasc Dis 2005;19:179–185.
  21. Clark TG, Murphy MF, Rothwell PM: Long term risks of stroke, myocardial infarction, and vascular death in ‘low risk’ patients with a non-recent transient ischaemic attack. J Neurol Neurosurg Psychiatry 2003;74:577–580.
  22. Van Wijk I, Kappelle LJ, van Gijn J, Koudstaal PJ, Franke CL, Vermeulen M, Gorter JW, Algra A, LiLAC study group: Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study. Lancet 2005;365:2098–2104.
  23. Brown DL, Lisabeth LD, Roychoudhury C, et al: Stroke risk is higher than cardiac event risk after initial stroke/transient ischemic attack. Stroke 2005;36:1285–1287.
  24. Petty GW, Brown RD Jr, Whisnant JP, et al: Survival and recurrence after first cerebral infarction: a population-based study in Rochester, Minnesota, 1975 through 1989. Neurology 1998;50:208–216.
  25. Donnan GA, Davis SM, Chambers BR, et al: Streptokinase for acute ischemic stroke with relationship to time of administration: Australian Streptokinase (ASK) Trial Study Group. JAMA 1996;276:961–966.
  26. Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. The Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. JAMA 1998;279:1265–1272.
  27. Diener HC, Cortens M, Ford G, et al: Lubeluzole in acute ischemic stroke treatment: a double-blind study with an 8-hour inclusion window comparing a 10-mg daily dose of lubeluzole with placebo. Stroke 2000;31:2543–2551.
  28. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19,435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet 1997;349:1569–1581.
  29. CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group. Lancet 1997;349:1641–1649.
  30. Berge E, Abdelnoor M, Nakstad PH, et al: Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial. Lancet 2000;355:1205–1210.
  31. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996;348:1329–1339.
  32. Dutch TIA Trial Study Group. A comparison of two doses of aspirin (30 vs 283 mg a day) in patients after a transient ischemic attack or minor ischemic stroke. N Engl J Med 1991;325:1261–1266.
  33. Trial of secondary prevention with atenolol after transient ischemic attack or nondisabling ischemic stroke. The Dutch TIA Trial Study Group. Stroke 1993;24:543–548.
  34. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) Study Group. Lancet 1993;342:1255–1262.
  35. High-dose acetylsalicylic acid after cerebral infarction. A Swedish Cooperative Study. Stroke 1987;18:325–334.
  36. Hass WK, Easton JD, Adams HP Jr, et al: A randomized trial comparing ticlopidine hydrochloride with aspirin for the prevention of stroke in high-risk patients. Ticlopidine Aspirin Stroke Study Group. N Engl J Med 1989;321:501–507.
  37. Viscoli CM, Brass LM, Kernan WN, et al: A clinical trial of estrogen-replacement therapy after ischemic stroke. N Engl J Med 2001;345:1243–1249.
  38. Swedish Aspirin Low-Dose Trial (SALT) of 75 mg aspirin as secondary prophylaxis after cerebrovascular ischaemic events. The SALT Collaborative Group. Lancet 1991;338:1345–1349.

    External Resources

  39. Gent M, Blakely JA, Easton JD, et al: The Canadian American Ticlopidine Study (CATS) in thromboembolic stroke. Lancet 1989;i: 1215–1220.
  40. Farrell B, Godwin J, Richards S, et al: The United Kingdom Transient Ischaemic Attack (UK-TIA) Aspirin Trial: final results. J Neurol Neurosurg Psychiatry 1991;54:1044–1054.
  41. European Stroke Prevention Study. ESPS Group. Stroke 1990;21:1122–1130.
  42. Kwiatkowski TG, Libman RB, Frankel M, et al: Effects of tissue plasminogen activator for acute ischemic stroke at one year. National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group. N Engl J Med 1999;340:1781–1787.
  43. Bath PM, Lindenstrom E, Boysen G, et al: Tinzaparin in acute ischaemic stroke (TAIST): a randomised aspirin-controlled trial. Lancet 2001;358:702–710.
  44. Appelros P, Samuelsson M, Lindell D: Lacunar infarcts: functional and cognitive outcomes at five years in relation to MRI findings. Cerebrovasc Dis 2005;20:34–40.
  45. PROGRESS Collaborative Group: Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001;358:1033–1041.
  46. Diener HC, Cunha L, Forbes C, et al: European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996;143:1–13.

Pay-per-View Options
Direct payment This item at the regular price: USD 38.00
Payment from account With a Karger Pay-per-View account (down payment USD 150) you profit from a special rate for this and other single items.
This item at the discounted price: USD 26.50