暫時性腦缺血發作的專門單位與極低的事件比率有關


【24drs.com】根據一篇新研究,在專門的TIA單位治療暫時性腦缺血發作(TIA)或輕微中風的患者,由中風專家提供緊急的實證照護,之後一年,中風與其他心血管事件的比率相當低。
  
  法國巴黎Bichat醫院Pierre Amarenco醫師等人進行的這篇研究,發表於4月21日的新英格蘭醫學期刊。
  
  研究結果來自「TIAregistry.org project」這項計畫,目的是說明TIA或輕微中風患者的當前資料,以及短期和長期結果的風險因素,並定義風險評估。
  
  作者們結論指出,在「TIAregistry.org project」計畫中,我們觀察到,發生TIA或輕微中風後的心血管事件比率比以往的歷史資料低,我們的研究結果或許反映出,就診於TIA門診、接受風險因素控制與根據當前指引之建議,進行抗血栓治療之TIA或輕微中風患者之復發心血管事件的當今風險情況。
  
  他們指出,雖然我們發現ABCD2分數是不錯的風險預測因子,但我們的研究結果認為,對於分數4分以上患者,有限的緊急評估,可能會錯過約20%的初期復發中風。神經影像學發現多發性梗塞與大動脈粥樣硬化性疾病,也是復發血管事件的強烈獨立預測因子,這些結果可能有助於設計和詮釋未來的隨機試驗。
  
  在編輯評論中,佛羅里達州邁阿密大學米勒醫學院的Ralph L. Sacco醫師和Tatjana Rundek博士表示,研究結果支持採用有組織的單位照護TIA或輕微中風患者的價值,在該單位由中風專家迅速診斷評估且適當採用有實證的預防治療,減少中風的初期和後期風險。
  
  研究者報告了來自61個城市、4,789名患者的資料,都適用於「TIAregistry.org」的其中21國的TIA患者緊急評估。
  
  這些患者中,78.4%是在症狀發生的24小時內由中風專家評估,在電腦斷層或MRI發現急性梗塞比率為33%、新發生的心房顫動為5%(其中67%在出院前接受抗凝血劑治療)、頸動脈狹窄比率將近16%(其中27%在出院前進行了頸動脈血管重建)。
  
  各種心血管預後(中風、急性冠狀動脈症狀、心血管原因死亡)的一年事件發生率為6.2%,第2、7、30、90和365天時的中風比率分別是1.5%、2.1%、2.8%、3.7%與5.1%— 遠低於之前的研究報告。
  
  作者們表示,這篇研究的低事件發生率並不是因為低風險對象,研究對象有三分之二以上是ABCD2分數4分以上,在每個分數級距觀察到的風險都偏低。
  
  反之,他們認為,良好結果的核心原因可能是,更好更快速地執行次級中風預防策略,包括立即給予抗血小板藥物、心房顫動者給予口服抗凝血劑、危急頸動脈狹窄者進行緊急血管重建、以及其他次級預防措施(例如:使用statins類藥物和降血壓藥物治療)。
  
  Sacco醫師和Rundek博士在編輯評論中強調,輕微中風或TIA患者的失能程度最小,但他們發生中風時的損失程度最嚴重,然而,他們常常因為延遲就醫或者醫師評估不需要緊急治療,而錯過發現急性中風的機會。
  
  他們表示,鑑於初級和次級中風預防品質的大幅改善,錯失這個機會更是令人擔憂。
  
  這篇註冊研究報告的結果,比以前的研究報告低了至少50% ,顯示不論是在TIA門診或專門的保健服務單位由中風專家對TIA或輕微中風患者緊急照護,無疑地是有用的。
  
  他們指出,「TIAregistry.org project」這項計畫的另一個重要成功之處是,在3個月和12個月時,極佳的自我報告用藥遵醫囑率,與出院時相當。
  
  該研究在患者的風險評估也發現一些有趣結果,特別的是,腦部影像檢查、大動脈粥樣硬化、ABCD2分數6分或7分,都和中風風險增加1倍以上有關,不過,ABCD2分數4分以上患者的有限緊急評估可能會錯過約20%的初期復發中風。
  
  Sacco醫師和Rundek博士指出,多發性梗塞的觀察代表著一個新結果,納入風險預測模式後可能會有幫助。
  
  他們結論表示,這篇研究應可促使衛生保健提供者和決策者對中風照護系統進行必要修改,目的是為急性中風患者與TIA或輕微中風患者提供最有效的照護。
  
  資料來源:http://www.24drs.com/
  
  Native link:Specialized TIA Clinics Linked to Very Low Event Rates
  

Specialized TIA Clinics Linked to Very Low Event Rates

By Sue Hughes
Medscape Medical News

Patients treated for a transient ischemic attack (TIA) or minor stroke at specialized TIA units in which urgent evidence-based care is delivered by stroke specialists had a very low risk for stroke and other cardiovascular events over the following year, according to a new study.

The study, published in the April 21 issue of the New England Journal of Medicine, was conducted by a team led by Pierre Amarenco, MD, Bichat Hospital, Paris, France.

The findings come from a program called the TIAregistry.org project, designed to describe the current profile of patients with TIA or minor stroke, as well as risk factors and short- and long-term outcomes and to "refine risk assessment," they write.

"In the TIAregistry.org project, we observed a lower rate of cardiovascular events after a TIA or minor stroke than that in historical cohorts," the authors conclude. "Our findings probably reflect the contemporary risk of recurrent cardiovascular events among patients with a TIA or minor stroke who are admitted to TIA clinics and who receive risk-factor control and antithrombotic treatment as recommended by current guidelines.

"Although we found that the ABCD2 score was a good predictor of risk, our findings suggest that limiting urgent assessment to patients with a score of 4 or more would miss approximately 20% of those with early recurrent strokes. Multiple infarctions on neuroimaging and large-artery atherosclerotic disease were also strong independent predictors of recurrent vascular events," they add. "These results may help in the design and interpretation of future randomized trials."

In an accompanying editorial, Ralph L. Sacco, MD, and Tatjana Rundek, MD, PhD, Miller School of Medicine, University of Miami, Florida, say the study results "support the value of organizing specialized units for the care of patients with a TIA or minor stroke where rapid diagnostic evaluations and evidence-based preventive treatments by stroke specialists can be initiated promptly and lead to reduced early and late risks of stroke."

The researchers report data on 4789 patients from 61 sites, all dedicated to urgent evaluation of patients with TIA in 21 countries as part of the TIAregistry.org.

Of these patients, 78.4% were evaluated by stroke specialists within 24 hours of symptom onset. Acute infarction was found on computed tomography or MRI in 33%, new-onset atrial fibrillation in 5% (67% of whom received anticoagulant therapy before discharge), and carotid stenosis in approximately 16% (27% of whom underwent carotid revascularization before discharge).

The 1-year event rate for composite cardiovascular outcome (stroke, an acute coronary syndrome, or death from cardiovascular causes) was 6.2%. The stroke rates at days 2, 7, 30, 90, and 365 were 1.5%, 2.1%, 2.8%, 3.7%, and 5.1%, respectively — much lower than rates reported in previous studies.

The authors say the low event rates in this study were not explained by a low-risk population. More than two thirds of the cohort had an ABCD2 score of 4 or more, and the risk observed was low in each stratum of the score.

Rather, they suggest that the good outcomes core may be explained by better and faster implementation of secondary stroke prevention strategies, including immediate initiation of antiplatelet drugs, oral anticoagulation in the event of atrial fibrillation, urgent revascularization in patients with critical carotid stenosis, and other secondary prevention measures (such as treatment with statins and blood pressure–lowering drugs).

In their editorial, Dr Sacco and Dr Rundek emphasize that patients with minor stroke or TIA have the least amount of disability and the most to lose should they have a stroke, but they often slip through systems for detecting acute stroke owing either to delay in seeking medical attention or clinicians' assessments that urgent treatment is not needed.

"This lost opportunity is even more worrisome given the tremendous improvements in the quality of primary and secondary stroke prevention," they say.

Urgent Care "Undoubtedly Works"

They note that the outcomes reported in this registry study were at least 50% lower than those reported in previous studies, showing that "urgent care for patients with a TIA or minor stroke either in specialized TIA clinics or dedicated care delivery units with stroke specialists undoubtedly works."

They point out that another important success of the TIAregistry.org project was the excellent adherence rates of self-reported medication use at 3 months and 12 months, which were similar to the rates at discharge.

The study also found some interesting results on risk assessment of patients. In particular, multiple infarctions on brain imaging, large-artery atherosclerosis, and an ABCD2 score of 6 or 7 were each associated with more than a doubling of the risk for stroke. However, limiting urgent assessment to patients with an ABCD2 score of 4 or more would miss approximately 20% of those with early recurrent strokes.

Dr Sacco and Dr Rundek point out that the multiple infarctions observation represent a new finding and may be useful for inclusion in risk-prediction models.

"This study should prompt health care providers and policymakers to make necessary changes in systems of stroke care in order to deliver the most effective care not only to patients with acute stroke, but also to those with a TIA or minor stroke," they conclude.

The study was supported by an unrestricted grant from Sanofi and Bristol-Myers Squibb. Dr Amarenco reports grant support and personal fees from Sanofi and Bristol Myers-Squibb during the conduct of the study; grant support and personal fees from Pfizer; and personal fees from Bayer, Daiichi-Sankyo, Boehringer Ingelheim, Boston Scientific, Medtronic, GlaxoSmithKline, and the Kowa Company outside the submitted work.

N Engl J Med. Published online April 21, 2016.

    
相關報導
中風發生率與空氣品質不佳有關
2016/3/2 下午 06:32:37
偏頭痛會增加抽菸者的中風風險
2015/8/13 下午 04:06:04
體育補充品中的刺激物與運動誘發的中風有關
2015/5/27 下午 03:21:34

上一頁
   1   2   3   4   5   6   7   8   9   10  




回上一頁