Underlying Causes of TIA and Minor Ischemic Stroke and Risk of Major Vascular Events
Authors: Lavallée Philippa C. , Charles Hugo , Albers Gregory W. , Caplan Louis R. , Donnan Geoffrey A. , Ferro José M. , Hennerici Michael G. , Labreuche Julien , Molina Carlos , Rothwell Peter M. , Steg Philippe Gabriel , Touboul Pierre-Jean , Uchiyama Shinichiro , Vicaut Éric , Wong Lawrence K. S. , Amarenco Pierre ,   TIAregistry.org Investigators, Ameriso Sebastian , Nora Gandolfo Claudia , Povedano Guillermo , Sagesse Javier , Pavon Heman , Cancino Jorge , Toledo Walter , Huang Yinin , Gong Xiping , Martin Yeato , Mi Donghu , Song Tian , Wang Yilong , Wang Yongjun , Chandgfend Fran , Contago Guo , Hongyun Jiao , Intao Heman , Jixing Wu , Liquing Song , Liwen Tai , Ran Liu , Shujuan Tian , Wenhong Liu , Hong Soi Tak , Wong Lawrence , Roxanna Liu , Flasar Roman , Ziktova Bedriska , Reif Michael , Goldemund Daniel Sanak , Neumann Jiri , Svakov Dagmar , Sanak Daniel , Kral Michael , Skoloudik David , Vaclavik Daniel , Kuhila Martin , Amarenco Pierre , Cabrejo Lucie , Guidoux Céline , Hobeanu Cristina Maria , Lavallée Philippa , Meseguer Elena , Audebert Henrich , Menger Daniel , Heide Wofgang , Lipp Saskia , Ozalp Huriye , Sctzmann Christine , Weimar Christian , Platzbecker Katharina , Ringleb Peter , Hennerici Michel G , Griebe Martin , Knoll Olaf Katrin , Willmann Olaf , Harmut Faiss Juergen , Dilan Susan , Kobersteein Anja , Krimmer Katarina , Tietz Sandra , Wienecke Peter , Hamann Gerhard , Burkhardt Nico , Liebetrau Martin , Mueller Nadine , Wagner Michaela , Strivastava Dr , Kelly Peter , Tanne Hashomer David , Cavazzuti Milena , Anticoli Sabrina , Toni Danilo , Nagata Ken , Okada Yasushi , Yamagami Hiroshi , Minematsu Kazuo , Nakagawara Jojo , Uchiyama Shinchiro , Chui Lee Byung , Woo Yoon Byung , Hoe Ji , Moo Park Jong , Abboud Halim , Koussa Salam , Awada Adnan , Sin Tan Kay , Arauz Antonio , Gongora Frnando , Valenzuela Adrian Infante , Esamilla Juan M. , Canhao Patricia , Ferro ******- , Fonseca Ana Catarina , Correia Manuel , Tuna Assuncao , Sternic Nada , Mijajlovic Milija , Dupejova Beata , Szedelyova Jana , Smirkova Renata , Segura Tomas , Molina Carlos , Rodriguez Ana , Silva Yolanda , Tejada Javier , Purroy Francisco , Masjuan Jaime , Vivancos Jose , Palomeras Ernest , Gamemro Miguel Angel , Arenillas JF , Calleja Anna , Rojo Esther , Buchan Alastair , Rothwell Peter , Hai Lee Tsong , Chang Ku Chou , Huang Yu-Ching , Lin Ruey-Tay , Timkao Somsak 
Published: October 2023

Importance

The coexistence of underlying causes in patients with transient ischemic attack (TIA) or minor ischemic stroke as well as their associated 5-year risks are not well known.

Objective

To apply the ASCOD (atherosclerosis, small vessel disease, cardiac pathology, other cause, or dissection) grading system to assess coexistence of underlying causes of TIA and minor ischemic stroke and the 5-year risk for major vascular events.

Design, Setting, and Participants

This international registry cohort (TIAregistry.org) study enrolled 4789 patients from June 1, 2009, to December 31, 2011, with 1- to 5-year follow-up at 61 sites in 21 countries. Eligible patients had a TIA or minor stroke (with modified Rankin Scale score of 0 or 1) within the last 7 days. Among these, 3847 patients completed the 5-year follow-up by December 31, 2016. Data were analyzed from October 1, 2022, to June 15, 2023.

Exposure

Five-year follow-up.

Main Outcomes and Measures

Estimated 5-year risk of the composite outcome of stroke, acute coronary syndrome, or cardiovascular death.

Results

A total of 3847 patients (mean [SD] age, 66.4 [13.2] years; 2295 men [59.7%]) in 42 sites were enrolled and participated in the 5-year follow-up cohort (median percentage of 5-year follow-up per center was 92.3% [IQR, 83.4%-97.8%]). In 998 patients with probable or possible causal atherosclerotic disease, 489 (49.0%) had some form of small vessel disease (SVD), including 110 (11.0%) in whom a lacunar stroke was also probably or possibly causal, and 504 (50.5%) had no SVD; 275 (27.6%) had some cardiac findings, including 225 (22.6%) in whom cardiac pathology was also probably or possibly causal, and 702 (70.3%) had no cardiac findings. Compared with patients with none of the 5 ASCOD categories of disease (n = 484), the 5-year rate of major vascular events was almost 5 times higher (hazard ratio [HR], 4.86 [95% CI, 3.07-7.72]; P &amp;lt; .001) in patients with causal atherosclerosis, 2.5 times higher (HR, 2.57 [95% CI, 1.58-4.20]; P &amp;lt; .001) in patients with causal lacunar stroke or lacunar syndrome, and 4 times higher (HR, 4.01 [95% CI, 2.50-6.44]; P &amp;lt; .001) in patients with causal cardiac pathology.

Conclusion and Relevance

The findings of this cohort study suggest that in patients with TIA and minor ischemic stroke, the coexistence of atherosclerosis, SVD, cardiac pathology, dissection, or other causes is substantial, and the 5-year risk of a major vascular event varies considerably across the 5 categories of underlying diseases. These findings further suggest the need for secondary prevention strategies based on pathophysiology rather than a one-size-fits-all approach.