Title: The Prognostic Markers of TIA Evolution Study
Funder: Department of Health (England)

Abstract: Stroke is the biggest cause of adult-onset disability in the UK, therefore identifying those at risk and providing improved risk stratification and preventative strategies are of paramount importance. The biggest risk factor for stroke remains recent transient ischaemic attack (TIA) or minor stroke, indeed nearly half of all completed strokes suffered either a TIA or minor stroke over the previous 3 months. Therefore, TIA and minor stroke survivors represent a high-risk group in need of further assessment and intervention. Progression to a completed stroke, however, only occurs in between 8-10% of TIA presentations. Intensive intervention for all TIA patients can reduce this to between 2-3%, however this requires hospitalization of all TIA patients to a 24-hour a day consultant led stroke service. In addition to the lack of feasibility due to insufficient numbers of trained consultants, this type of intervention would consume the entire NHS budget, for relatively little gain, given that is will have no impact on over 90% of admissions. Clearly, a good risk prediction tool that can accurately predict those at greatest risk would allow appropriate targeting of resources to prevent completed strokes, whilst reducing unnecessary admissions and providing reassurance to those at lower risk. An increased urinary albumin:creatinine ratio (ACR) is used clinically in diabetes to indicate individuals who are at risk of diabetic nephropathy and cardiovascular disease. In these patients drugs affecting the renin angiotensin aldosterone system have been demonstrated to reduce ACR and commensurately reduce progression of diabetic nephropathy and cardiovascular disease. We have demonstrated that ACR predicts rehabilitation potential, prognosis and mortality after a completed stroke. In pilot work for this study, we have demonstrated ACR is two fold higher in TIA victims who go on to have a recurrent cerebrovascular event within 90 days. Further, an ACR >3mg/mmol identified 27% of the population who were at a 3.2 fold increased risk of a further event within 90 days. This appeared to be independent of currently used risk stratification tools such as ABCD2 however, this pilot information from 150 patients is not sufficient to determine whether ACR provides sufficient additional prognostic information to existing risk stratification tools. The proposed study will examine whether ACR obtained from a single spot test after a TIA or minor stroke is able to identify patients at risk of future stroke or TIA. We will obtain this information in 2,400 attendees of the rapid access daily TIA & stroke clinics across the Peninsula Stroke Research Network. Participants will be followed up by telephone after 7 days, 1 and 3 months. Improving risk stratification will allow appropriate targeting of high-risk patients with expensive interventions in order to reduce their stroke risk, whilst reassuring and avoiding unnecessary admissions amongst lower risk individuals. It will also support projects exploring the possibility of ACR as a therapeutic target


Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health categories: STROKE