Transient ischemic attacks, treatment

Coronary artery disease Due to the vasodilatory effect of dipyridamole, use with caution in patients with severe coronary artery disease (eg, unstable angina, recently sustained Ml). Chest pain may be aggravated in patients with underlying coronary artery disease who are receiving dipyridamole. For stroke or transient ischemic attack patients for whom aspirin is indicated to prevent recurrent Ml or angina pectoris, the aspirin in this product may not provide adequate treatment for the cardiac indications. 

Unlabeled Uses Prevention of myocardial infarction, recurrent cerebral embolism treatment adjunct in transient ischemic attacks... 

Activation of platelets is considered an essential process for arterial thrombosis. Thus, treatment with platelet-inhibiting drugs such as aspirin and ticlopidine or clopidogrel is indicated in patients with transient ischemic attacks and strokes or unstable angina and acute myocardial infarction. In angina and infarction, these drugs are often used in conjunction with -blockers, calcium channel blockers, and fibrinolytic drugs. 

Correct answer = C. Among the NSAIDs, aspirin is among the worst for causing gastric irritation. Aspirin is an effective analgesic and is used to reduce muscle pain. It also has antipyretic actions so that it can be used to treat fever. Because of its anti-inflammatory properties, aspirin is used to treat pain related to the inflammatory process, for example, in the treatment of rheumatoid arthritis. Low doses of aspirin also decrease the incidence of transient ischemic attacks. 

In order to understand the clinical management of transient ischemic attacks (TIAs) and stroke, to plan clinical services or to design randomized controlled trials, and to measure the overall impact of treatments, it is important to understand the epidemiology of stroke. 

Homocysteine-lowering treatment with folic acid, cobalamin and pyridoxine does not reduce blood markers of inflammation, endothelial dysfunction or hypercoagulability in patients with previous transient ischemic attack or stroke a randomized substudy of the VITATOPS trial. Stroke 36 144-146... 

Fig. 27.8. A risk table for the five-year risk of ipsilateral ischemic stroke in patients with recently symptomatic carotid stenosis on medical treatment derived from the ECST model, European Carotid Surgery Trial (ECST) method. TIA, transient ischemic attack.

Fig. 18.1. The evolution of the estimates of treatment effect in the UKTIA-Aspirin Trial (Farrell et at. 1991) of high-dose aspirin versus low-dose aspirin versus placebo in patients with transient ischemic attack or minor stroke. The treatment effect (odds ratio) calculated at each point was based on the outcomes at final follow-up for patients randomized to that point (PM Rothwell, unpublished data). The dashed lines represent the level at which the apparent treatment effect approached statistical significance at the p = 0,05 level.

I Acute treatment of transient ischemic attack and minor stroke... 

Fig. 19.2. The 90-day risk of recurrent stroke after first seeking medical attention in all patients with transient ischemic attack or stroke referred to the study clinic in the non-randomized Early Use of Existing Preventive Strategies for Stroke (EXPRESS) study (Rothwell et a . 2007), The continuous line represents phase 1 of the study (standard treatment) and the dotted line represents phase 2 (urgent treatment).

Apart from patients with symptomatic carotid stenosis and endarterectomy, to date, only the Fast Assessment of Stroke and Transient Ischemic Attack to Prevent Early Recurrence (FASTER) trial has addressed the difference between specific treatments administered early for patients with TIA and minor stroke (Kennedy et al. 2007). 

The acute onset, the pattern of the cerebellar deficit, and the absence of features of epilepsy suggested that the episode was a transient ischemic attack. Aspirin is not known to cause transient ischemic attacks, and only rarely causes headache, flushing, and diarrhea. Since headache, flushing, and diarrhea, which can be caused by dipyridamole, occurred at the same time as the transient ischemic attacks and did not recur after withdrawal, dipjridamole may have caused the transient ischemic attacks. However, it was not clear whether the attacks occurred despite treatment rather than because of it. 

WEST 664 postmenopausal women with recent stroke or transient ischemic attack Oral 17y6-estradiol, 1 mg/day or placebo No reduction in risk of stroke, death, or coronary events among women in the hormone therapy group during 2.8 years of treatment In the first 6 months of treatment, a 2.3-fold increase in the risk of stroke was observed among women in the hormone therapy group. 

Mortality in patients with peripheral vascular disease is most commonly due to cardiovascular disease, and treatment of coronary disease remains the central focus of therapy. Many patients with advanced peripheral arterial disease are more limited by the consequences of peripheral ischemia than by myocardial ischemia. In the cerebral circulation, arterial disease may be manifest as stroke or transient ischemic attacks. The painful symptoms of peripheral arterial disease in the lower extremities (claudication) typically are provoked by exertion, with increases in skeletal muscle O2 demand exceeding blood flow impaired by proximal stenoses. When flow to the extremities becomes critically limiting, peripheral ulcers and rest pain from tissue ischemia can become debilitating. 

Due to the narrow time window available for the initiation of thrombolytic treatment, speed is of the essence. The rationale in the work up for acute stroke is, therefore, to identify as quickly as possible those patients who may benefit from lA or IV thrombolysis or other available acute stroke therapies. Importantly, CTA excludes from treatment patients with occlusive stroke mimics (e.g., transient ischemic attack [TIA], complex migraine, seizure) who will not benefit from, and may be harmed by, such therapies. 

Sulfinpyrazone is a structural derivative of the anti-inflammatory drug phenylbutazone. Unlike phenylbutazone, however, sulfinpyrazone does not have significant anti-inflammatory activity. It does have potent uricosuric effects and frequently is used in the treatment of gout. At least four metabolites of sulfinpyrazone have been identified, including the sulfide, sulfone, p-hydroxysulfide, and p-hydroxysulfinpyrazone derivatives (Fig. 31.16) (24). Only the parent sulfinpyrazone and its reduced sulfide metabolite, however, are active as COX inhibitors (98). Because these compounds are reversible inhibitors, the antithrombotic activity lasts only as long as blood levels of the drug and metabolite persist (half-life, 4-6 hours for parent sulfinpyrazone, 11-14 hours for the sulfide metabolite). Sulfinpyrazone is not yet approved in the United States for use in acute myocardial infarction or for transient ischemic attack prophylaxis. 

In order to avoid potential biases, the choice of the specific outcome should be considered. The previous section emphasized the advantages of prospective collection and possibly adjudication of outcome events. However, even in the presence of randomization, there may be differences in ascertainment between the treatment arms. For example, if an unrelated side effect of a tieafmenf resulfs in additional health care utilization, there may be more opportunity to detect the outcome of interest. The use of hard outcomes may offer some profections against this phenomenon. For example, if vital status can be obtained for the whole analysis population, then a death outcome would not exhibit this phenomenon. Stroke and myocardial infarction may be more consistently and unbiasedly ascertained than other cardiovascular events such as arrhythmia and transient ischemic attacks. 

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