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PubMed1993

Racial variations in the rates of carotid angiography and endarterectomy in patients with stroke and transient ischemic attack.

BACKGROUND: Carotid endarterectomy is emerging as the treatment of choice for patients with symptomatic carotid artery stenosis at low operative risk. We sought to determine if racial variations in the rate of carotid angiography and endarterectomy exist in the Veteran Affairs health care system among patients who are insulated from the cost of their care. METHODS: From a national database of all hospitalizations at Veterans Affairs medical centers, we identified a cohort of patients with diagnoses of stroke or transient ischemic attack who were likely to be candidates for carotid angiography and endarterectomy. We used logistic regression to determine if the patient's race was associated with receiving carotid angiography and endarterectomy, after adjusting for patient's age, degree of eligibility for Veterans Affairs care, socioeconomic status, comorbidities associated with hospital admission, and geographic region of the hospital. RESULTS: Of the 35 922 veterans in the cohort, 3535 (9.8%) underwent angiography during the study period and 1249 (3.5%) had carotid endarterectomy. Blacks constituted 18.2% of the patients with a history of stroke or transient ischemic attack, 9.8% of the patients having angiography, but only 4.2% of the patients undergoing carotid endarterectomy. Whites constituted 77.1% of the patients with a history of stroke or transient ischemic attack, 86.1% of the patients receiving angiography, and 93.0% of those having carotid endarterectomies. After adjusting for confounding variables, black patients continued to have a significantly lower likelihood than white patients of undergoing angiography (risk ratio = 0.47; 95% confidence interval = 0.42, 0.53) and subsequent endarterectomy (risk ratio = 0.28; 95% confidence interval = 0.20, 0.38). CONCLUSIONS: Socioeconomic status and access to care within a large managed health care system do not fully explain racial differences in the rate of carotid angiography and endarterectomy. Either referral bias for evaluation for carotid endarterectomy or racial differences in the extent and location of cerebrovascular disease are more important explanations for the observed racial variations.

Aged↗
PubMed1987

Life history of patients with transient ischemic attacks and essentially normal angiograms.

Eighty-three patients, 43 women and 40 men, with hemispheric transient ischemic attacks (TIAs) and normal angiograms were studied. Fifty-two of the patients had a single episode of transient ischemia, whereas 31 had multiple episodes prompting initial evaluation. Follow-up ranging from 3 to 132 months was obtained for all patients. In this period, six patients suffered a cerebrovascular accident and five had further hemispheric TIAs. These results are in contrast to our earlier data, which suggested a benign prognosis in this group of patients. Results of this updated study show that the prognosis of patients with hemispheric TIAs and normal angiograms is not so benign as originally reported. Those patients with multiple events before initial evaluation are at increased risk of subsequent cerebrovascular accident or TIA. Close observation of this group of patients is recommended.

Adult↗
PubMed2006

Quality of hospital and outpatient care after stroke or transient ischemic attack: insights from a stroke survey in the Netherlands.

BACKGROUND AND PURPOSE: Limited data are available on management of outpatients with stroke or transient ischemic attack (TIA) and on clinicians' reasons for withholding procedures recommended by guidelines. We assessed to what extent guidelines are appropriately applied after ischemic stroke or TIA, in admitted patients as well as outpatients. METHODS: A survey was conducted in 11 centers in the Netherlands, which prospectively enrolled 579 admitted patients and 393 outpatients. Data were collected by trained research assistants. Duplicate assessment in 10% of patients showed good agreement with neurologists (median kappa=0.86). Treating neurologists were asked to provide arguments for withholding recommended procedures in eligible patients. RESULTS: Recommended acute procedures were provided in the majority of admitted patients, but less often in outpatients: brain imaging (98% and 93%, respectively), 12-lead ECG (96% and 81%), laboratory tests (97% and 86%), aspirin within 48 hours (90% and 68% of eligible patients). Secondary preventive measures were not always taken in both eligible inpatients and eligible outpatients: carotid endarterectomy (provided in 31% and 30% of patients), antiplatelet agents (93% and 90%), oral anticoagulants (60% and 48%), antihypertensive agents (57% and 44%), and cholesterol-lowering therapy (71% and 52%). Reasons for withholding recommended procedures were plausible for almost all admitted patients, but were unclear in the majority of outpatients. CONCLUSIONS: Compared with other national stroke surveys, we found high-quality acute care in admitted ischemic stroke patients, whereas secondary prevention was comparably poor. Although the majority of our centers have rapid-access TIA clinics, there is still substantial potential to improve quality of stroke care in outpatients.

Aged↗
PubMedDate not supplied

The patient with transient ischemic attacks--is this the time for a new therapeutic approach?

Current and future improvements in treatment to prevent cerebral infarction among patients with transient ischemic attacks may reduce neurological morbidity but may not lead to a proportional improvement in life expectancy. Because the long-term primary cause of death in these patients is myocardial infarction, it is most likely that the most important way to prolong survival may be the vigorous investigation of their cardiac status and the treatment of their coronary artery disease, even if asymptomatic.

Angiography↗
PubMed1992

Cardiovascular disease in male patients with carotid transient ischemic attacks or minor strokes.

The authors tested the hypothesis that coronary heart disease and lower extremity atherosclerosis occur more frequently in patients with transient ischemic attacks (TIA) than in patients with minor stroke. Thirty-three consecutive male patients with TIA and 36 with minor stroke from the carotid artery territory were examined with ultrasonography of the cardiac, iliac, and femoral arteries; echocardiography (UCG); electrocardiogram (ECG); thallium scintigraphy (TS) of the myocardium; and assessment of the ankle/arm index (A/AI). TS showed myocardial infarctions to be more common among TIA patients than among minor stroke patients, 54% vs 19%, p = 0.019. UCG showed the frequency of left ventricular and atrial dilatation to be higher in the TIA group than in the minor stroke group, 64% vs 27%, p = 0.0084. Significant artery stenosis (greater than or equal to 50%) was not, however, more frequent in the TIA group than in the minor stroke group, nor was there any significant difference between the groups in A/AI. The frequency of TS-verified myocardial infarction (MI) was higher in the subgroup with greater than or equal to 50% carotid artery stenosis than in that with less than 50% stenosis, 61% vs 25%, p = 0.022, and also higher in the pathological UCG subgroup than in the normal UCG subgroup, 50% vs 15%, p = 0.025. Thus, there was a greater incidence both of TS-verified MI and of UCG-verified cardiac dilatation in the TIA group than in the minor stroke group but no difference between the groups in the degree of atherosclerosis either in the carotid or lower extremity regions.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1997

[Transient ischemic attacks in Chilean patients and their relationship with the country's pattern of cerebrovascular disease].

BACKGROUND: It has been postulated that in Chile, transient ischemic attacks (TIA) are much less frequent than in Caucasian populations. A lesser frequency of these attacks would be due to a higher frequency of intracranial atheromas, whereas an abundance of TIA would be a result of a higher prevalence of extracranial atheromas. AIM: To study the history of TIA in a group of Chilean patients with an acute episode of cerebrovascular disease. PATIENTS AND METHODS: One hundred forty nine patients admitted to a Neurology service of a public hospital in Santiago, with an acute stroke, were studied. Patients and close relatives were interrogated about previous symptoms of TIA using a structured questionnaire. RESULTS: One hundred nine patients had an ischemic and 40 patients a hemorrhagic stroke. Twenty patients with ischemic stroke had a history of TIA (18%). Fifteen out of 74 patients without a cardiac source of emboli (20%) and five out of 35 cases with an embolic source (14%) had a TIA preceding their stroke. Three out of 40 patients (8%) with hemorrhagic stroke had a history of TIA. CONCLUSIONS: This study does not support nor reject the hypothesis of a Chilean pattern of cerebrovascular disease unlike that found in Northern Caucasians.

Acute Disease↗
PubMed1985

Vertebrobasilar transient ischemic attacks in internal carotid artery occlusion or tight stenosis.

We studied 12 patients with internal carotid artery (ICA) occlusion or tight stenosis but without vertebrobasilar and subclavian atherosclerosis who suffered vertebrobasilar insufficiency (VBI). The patients with ICA occlusion were compared with a sex- and age-matched control group that had ICA occlusion but no VBI. Visible infarct on computed tomographic scan, greater size of visible infarct, weak collateral circulation, and bilateral atherosclerosis of the ICA significantly correlated with the occurrence of VBI. No significant difference was demonstrated for emboligenic lesions, but posterior to anterior flow through the posterior communicating arteries was demonstrated only in the patients with VBI. These facts suggested hemodynamic disturbances with "steal VBI." In ICA tight stenosis, VBI symptoms disappeared after endarterectomy but persisted in patients with more than 50% stenosis; this was also suggestive of hemodynamic VBI. Vertebrobasilar insufficiency had a prognostic significance, being associated with an increased occurrence of delayed stroke.

Arterial Occlusive Diseases↗