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Transient ischemic attacks: an update
1Department of Neurology, University of Miami School of Medicine, FL.
Insights
Transient ischemic attacks (TIAs) are linked to coronary artery disease. Aspirin (ASA) effectively reduces stroke and heart attack risk in TIA patients, while carotid endarterectomy lacks proven indications.
Area of Science:
- Neurology
- Cardiology
- Vascular Surgery
Background:
- Transient ischemic attacks (TIAs) require clear definitions and understanding of their prognostic significance.
- Established associations exist between TIAs and coronary artery disease.
- Pathogenesis of TIAs can be complex, with emerging mechanisms beyond traditional perfusion impairment or embolization.
Purpose of the Study:
- To review current concepts of TIAs, including definitions, prognosis, pathogenesis, physiology, and management.
- To evaluate the evidence for current TIA management strategies.
- To highlight the need for controlled trials in TIA research.
Main Methods:
- Review of extant literature on transient ischemic attacks (TIAs).
- Analysis of definitions, prognostic significance, pathogenesis, physiology, and management.
- Evaluation of therapeutic trial methodologies and existing data on interventions.
Main Results:
- A strong association between TIAs and coronary artery disease is established.
- Carotid endarterectomy lacks proven indications, despite historical overuse.
- Aspirin (ASA) is supported by data for reducing stroke and myocardial infarction incidence in TIA patients.
Conclusions:
- Therapeutic trials for TIAs must be controlled and randomized, not relying on historical natural history data.
- Current evidence does not support long-term anticoagulation for TIAs.
- Ongoing multi-center studies are expected to clarify the role of carotid endarterectomy.
Abstract:
This is a review of extant concepts of transient ischemic attacks (TIAs), their definitions, prognostic significance, pathogenesis, physiology, and management. The natural history of TIAs depends upon the risk factors of the population group studied, so that therapeutic trials should be controlled and randomized and not dependent upon published natural history data. A strong association between TIAs and coronary artery disease has now been established. It may be difficult to establish the cause or pathogenesis of TIAs in any given patient in view of the relatively poor correlation between the patient's symptoms and location of arterial plaques. Recent studies have suggested mechanisms aside from impaired perfusion or embolization from carotid plaques or vertebral basilar disease. There are no proven indications for carotid endarterectomy, a procedure which has been excessively used in the United States, but presently ongoing prospective, randomized, controlled multi-center studies will likely resolve this important issue. Neither is there scientific validation for the use of long-term anticoagulants, but data support the efficacy of ASA in reducing the incidence of stroke and myocardial infarction in patients with TIAs.