Urgent Secondary Prevention of TIA or Minor Stroke Has Long-Term Positive Effect

The long-term benefits observed were due to maintenance of the early effect, rather than any additional benefit accrued after 90 days of the initial event, with no evidence either of rebound or loss of benefit.

Findings from a 10-year follow-up analysis of the EXPRESS study suggest that urgent assessment and treatment of transient ischemic attack (TIA) or minor stroke have long-term benefits, with reductions in recurrent strokes and improved outcomes irrespective of age. Additionally, patients demonstrated an increased disability-free and quality-adjusted life expectancy, making urgent acute prevention highly cost-effective.

EXPRESS was a prospective population-based before (phase 1: April 2002-September 2004; n = 310) versus after (phase 2: October 2004-March 2007; = 281) study that assessed the effects of early assessment and treatment of TIA or minor stroke through outpatient clinics. Previously reported results showed that this method of care reduced 90-day stroke risk by 80%.

In this 10-year analysis, senior investigator Peter M. Rothwell, MD, PhD, clinical neurologist, University of Oxford, and colleagues found the number of recurrent strokes to be significantly lower in the phase 2 population compared with phase 1 (55 [20%] vs 82 [26%]; P = .048). Additionally, the 10-year risk of disabling/fatal recurrent stroke was also significantly lower in those patients treated in the phase 2 clinic (17 [6%] vs 32 [10%]; HR, 0.54 [95% CI, 0.30-0.97]; P = .036). Notably, after 90 days, neither phase group differed in terms of recurrent or disabling stroke (phase 2: HR, 0.88 [95% CI, 0.65-1.44]; P = .88; and phase 1: 0.83 [95% CI, 0.42-1.65]; P = .59).

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Further, these new data show that recurrent stroke risk was directly impacted by maintenance of early benefit, rather than any additional benefit post-90 days. The study investigators also concluded that the results "suggest that other new acute treatment approaches in TIA and minor stroke that are effective in the short-term will also have the potential to have long-term benefit."

The proportions of patients alive at 10 years were similar between the 2 phases (phase 1: 158 of 310 [51%]; vs phase 2: 158 of 281 [56%]; P = .20), with the risk of death nonsignificantly reduced for those in phase 2 (HR, 0.84 [95% CI, 0.66-1.07]; P = .15). The discounted life expectancy was 5.58 years in those attending phase 1 clinic compared to 5.87 years for those in phase 2 (mean difference, 0.29 [95% CI, –0.06 to 0.66]; P = .08).

In total, 27% of those in phase 2 were disabled at 10 years compared with 36% of those in phase 1 clinic. These patients also had significantly lower risk of time to disability or death (HR, 0.74 [95% CI, 0.60-0.91]; P = .004), which remained consistent after multiple imputation for cases in which disability information was missing (HR, 0.74 [95% CI, 0.60-0.90]; P = .003). Again, investigators concluded that this benefit was attributable to the early effect of intervention, with no additional benefit after 90 days and with risk of death or disability after 90 days being similar across phases (HR, 0.94 [95% CI, 0.73-1.20]; P = .62).

Ten-year discounted disability-free life expectancy was significantly higher in those attending the phase 2 clinic (4.02 years) than those attending the phase 1 clinic (3.49 years; mean difference 0.53 [95% CI, 0.03-1.04]; P = .043).

As for cost, there was no significant differences in discounted costs between the 2 clinic populations, over the short- or long-term. At 10 years, overall costs were nonsignificantly higher in the phase 2 clinic population ($20,399 versus $19,846; P = .80); however, a separate analysis showed significantly higher vascular disease costs in the phase 2 clinic up until 1 year following index event ($1480 vs $3141 in phase 1; P = .04). By 10 years, costs were similar across phases ($4619 in phase 2 vs $5478 in phase 1; P = .49). The additional cost per quality-adjusted life year gained in phase 2 versus phase 1 was $2103, well below current cost-effectiveness thresholds.

Luengo-Fernandez R, Li L, Silver L, et al. Long-term impact of urgent secondary prevention after transient ischemic attack and minor stroke: ten-year follow-up of the EXPRESS study. Stroke. Published online October 28, 2021. doi:10.1161/STROKEAHA.121.034279