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S. Claiborne Johnston, MD, MPH; Daryl R. Gress, MD; Warren S. Browner, MD, MPH; Stephen Sidney, MD, MPH

JAMA. 2000;284:2901-2906.

Context  Management of patients with acute transient ischemic attack (TIA) varies widely, with some institutions admitting all patients and others proceeding with outpatient evaluations. Defining the short-term prognosis and risk factors for stroke after TIA may provide guidance in determining which patients need rapid evaluation.

Objective  To determine the short-term risk of stroke and other adverse events after emergency department (ED) diagnosis of TIA.

Design and Setting  Cohort study conducted from March 1997 through February 1998 in 16 hospitals in a health maintenance organization in northern California.

Patients  A total of 1707 patients (mean age, 72 years) identified by ED physicians as having presented with TIA.

Main Outcome Measures  Risk of stroke during the 90 days after index TIA; other events, including death, recurrent TIA, and hospitalization for cardiovascular events.

Results  During the 90 days after index TIA, 180 patients (10.5%) returned to the ED with a stroke, 91 of which occurred in the first 2 days. Five factors were independently associated with stroke: age greater than 60 years (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-2.7; P = .01), diabetes mellitus (OR, 2.0; 95% CI, 1.4-2.9; P<.001), symptom duration longer than 10 minutes (OR, 2.3; 95% CI, 1.3-4.2; P = .005), weakness (OR, 1.9; 95% CI, 1.4-2.6; P<.001), and speech impairment (OR, 1.5; 95% CI, 1.1-2.1; P = .01). Stroke or other adverse events occurred in 428 patients (25.1%) in the 90 days after the TIA and included 44 hospitalizations for cardiovascular events (2.6%), 45 deaths (2.6%), and 216 recurrent TIAs (12.7%).

Conclusions  Our results indicate that the short-term risk of stroke and other adverse events among patients who present to an ED with a TIA is substantial. Characteristics of the patient and the TIA may be useful for identifying patients who may benefit from expeditious evaluation and treatment.

Author Affiliations: Neurovascular Service, Department of Neurology, University of California, San Francisco (Drs Johnston and Gress); General Internal Medicine Section, San Francisco VA Medical Center, and Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco (Dr Browner); and the Division of Research, Kaiser-Permanente Northern California, Oakland (Drs Johnston and Sidney).

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