New findings from the University of Birmingham (Birmingham, UK) challenge the ‘transient’ nature of mini-strokes and provide insight into the long-term impact of an under-recognised condition. Transient ischaemic attack patients in the study consulted their general practitioners more frequently than similarly-aged patients for fatigue, cognitive impairment and anxiety or depression.
Primary care follow-ups with transient ischaemic attack patients found that they had a 43% increased risk of fatigue, 26% increased risk of psychological impairment, such as anxiety or depression, and a 45% increased risk of cognitive impairment.
The research, published in the European Journal of Neurology, recommends that clinical guidelines for transient ischaemic attack need to be revised to acknowledge the likelihood of residual impairments and support rehabilitation for patients that can improve their quality of life.
Guidelines for transient ischaemic attack are centred on rapid evaluation of people with suspected transient ischaemic attack, and focus on diagnosis. Follow-up for transient ischaemic attack patients is focused on management of stroke risk factors through medical, surgical and lifestyle interventions. Though clinical guidelines recognise that stroke patients may experience ongoing impairments which require rehabilitation; these guidelines do no extend to transient ischaemic attack.
The long-term impact of transient ischaemic attack has been unclear for some time, and the UK’s leading stroke charity, Stroke Association, recommended this as a research priority in their transient ischaemic attack campaign report in 2014.
The Birmingham study, funded by National Institute for Health Research (NIHR) School for Primary Care Research (SPCR), used anonymised electronic primary care records from The Health Improvement Network (THIN) database, which covers approximately 6% of the UK population.
The team designed a retrospective matched cohort study of 9,419 transient ischaemic attack patients, and 46,511 controls were included. The median age of those in the study was 74, and 48% were male.
When compared to the control group, which were the same age and sex, transient ischaemic attack patients reported an increased risk of consulting for fatigue (43%), psychological impairment (26%) and cognitive impairment (45%).
Grace Turner, from the University of Birmingham, explains “There have been a number of small studies which suggest long term impacts of transient ischaemic attack, but nothing on this scale, and nothing that included a control group for comparison. It is further evidence of how we can use electronic patient records to further our knowledge and improve patient care.”
The study design addressed limitations of previous studies by not only including the control group, but also excluding patients with previous impairments from the analysis and controlling for other confounding variables.
Turner adds, “These findings present an urgent need to revisit clinical guidelines for transient ischaemic attack. They can no longer be considered ‘transient’ or ‘temporary’, there is a potential long term impact which could affect quality of life. In some cases people may not be able to return to work, or participate in social activities, and there is a very real impact on their quality of life.”
“Future research should focus on improving care for transient ischaemic attack patients presenting signs of fatigue, anxiety, depression, or other impairments.”
The team acknowledge that there is a possibility of misdiagnosis or underreporting of symptoms in follow-ups, either by the patient or general practitioner, but note that it is more likely that risk levels are higher than reported in the study.