Transient Ischemic Attack as a Marker of Coronary Heart Disease: A Population-Based Study

The association between transient ischemic attack (TIA) and stroke is well-established but the association with coronary heart disease (CHD) is incompletely characterized. Studying the association between TIA and CHD can also help improve risk stratification and personalized treatment strategies for patients with TIA. We undertook this analysis to determine the incidence, timing and long-term trends of post-TIA CHD and congestive heart failure (CHF) risk.

Prospective longitudinal cohort study design within the Framingham Heart Study. TIA- and CHD- free participants were matched on age and sex (ratio 3:1) to CHD-free participants with first incident TIA. The main outcomes were: 10-year risk of CHD, major CHD, CHF, and stroke comparing TIA cases with matched controls; and time trends of cardiac outcomes and stroke risk assessed in 3 epochs: 1948-1985, 1986-1999 and 2000-2019.

286 participants with TIA (116 (41%) men, mean age 73.1±10.8 years) were matched to 858 controls without TIA. 54 (19%) participants had CHD, 35 (12%) major CHD, 37 (13%) CHF, 83 (29%) stroke. Participants with TIA had significantly higher risk of CHD (adjusted Hazard Ratio 1.55, 95% CI (1.06-2.28 p=0.03) and stroke (adjusted HR 4.01 (2.73-5.87), p<0.0001), but not of major CHD or CHF. 35 strokes (42%) occurred within 3 months; 44 (81.5%) CHD events occurred >12 months. CHD (HR 0.64, 95% CI (0.52-0.80), p<0.0001) incidence showed a significant decline over time between 1948-2019 driven by controls; it did not decline significantly among TIA cases (HR 0.80 (0.56-1.15), p=0.22.

We found that among patients with TIA CHD events are concentrated beyond the first year, a temporal pattern distinct from the early clustering of post-TIA stroke risk and not well captured in current post-TIA management frameworks. These findings support the need for sustained cardiovascular prevention strategies after TIA that extend beyond current pathways focused on short-term stroke risk reduction.