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Long-Term Risk of Stroke After Transient Ischemic Attack or Minor Stroke A Systematic Review and Meta-Analysis


Writing Committee for the PERSIST Collaborators

2025년03월 26일

JAMA2025;333(17):1508-1519.

DOI:10.1001/jama.2025.2033



Abstract

 

Importance   After a transient ischemic attack (TIA) or minor stroke, the long-term risk of stroke is not well-known.


Objective  To determine the annual incidence rates and cumulative incidences of stroke up to 10 years after TIA or minor stroke.


Data Sources MEDLINE, Embase, and Web of Science were searched from inception through June 26, 2024.


Study Selection Prospective or retrospective cohort studies reporting stroke risk during a minimum follow-up of 1 year in patients with TIA or minor stroke.


Data Extraction and Synthesis   Two reviewers independently performed data extraction and assessed study quality. Unpublished aggregate-level data on number of events and person-years during discrete follow-up intervals were obtained directly from the authors of the included studies to calculate incidence rates in individual studies. Data across studies were pooled using random-effects meta-analysis.


Main Outcome and Measures   The primary outcome was any stroke. Study-level characteristics were investigated as potential sources of variability in stroke rates across studies.


Results   The analysis involved 171 068 patients (median age, 69 years [IQR, 65-71]; median proportion of male patients, 57% [IQR, 52%-60%]) from 38 included studies. The pooled rate of stroke per 100 person-years was 5.94 events (95% CI, 5.18-6.76; 38 studies; I2 = 97%) in the first year, 1.80 events (95% CI, 1.58-2.04; 25 studies; I2 = 90%) annually in the second through fifth years, and 1.72 events (95% CI, 1.31-2.18; 12 studies; I2 = 84%) annually in the sixth through tenth years. The 5- and 10-year cumulative incidence of stroke was 12.5% (95% CI, 11.0%-14.1%) and 19.8% (95% CI, 16.7%-23.1%), respectively. Stroke rates were higher in studies conducted in North America (rate ratio [RR], 1.43 [95% CI, 1.36-1.50]) and Asia (RR, 1.62 [95% CI, 1.52-1.73]), compared with Europe, in cohorts recruited in or after 2007 (RR, 1.42 [95% CI, 1.23-1.64]), and in studies that used active vs passive outcome ascertainment methods (RR, 1.11 [95% CI, 1.07-1.17]). Studies focusing solely on patients with TIA (RR, 0.68 [95% CI, 0.65-0.71) or first-ever index events (RR, 0.45 [95% CI, 0.42-0.49]) had lower stroke rates than studies with an unselected patient population.


Conclusions and Relevance   Patients who have had a TIA or minor stroke are at a persistently high risk of subsequent stroke. Findings from this study underscore the need for improving long-term stroke prevention measures in this patient group.





                      Figure 1.  Ten-Year Cumulative Incidence and Incidence Rate of Any Stroke After Transient Ischemic Attack or Minor Stroke
Figure 1.  Ten-Year Cumulative Incidence and Incidence Rate of Any Stroke After Transient Ischemic Attack or Minor Stroke


    Figure 2.  Incidence Rate of Any Stroke Within the First Year by Study Characteristics
Figure 2.  Incidence Rate of Any Stroke Within the First Year by Study Characteristics

  Key Points

 

Question  What is the long-term risk of stroke after transient ischemic attack (TIA) or minor stroke?


Findings   In this systematic review and meta-analysis of 171 068 patients with TIA or minor stroke from 38 studies, the risk of subsequent stroke was 5.9% within 1 year, 12.8% within 5 years, and 19.8% within 10 years.


Meaning   Patients who have had a TIA or minor stroke are at a persistently high risk of subsequent stroke. There is a need for continued improvement in long-term stroke prevention.


요약

 

·         중요성 : 일과성 허혈 발작(TIA) 또는 경미한 뇌졸중 이후의 장기적인 뇌졸중 위험은 잘 알려져 있지 않다.

 

·         목적 : TIA 또는 경미한 뇌졸중 이후 최대 10년 동안의 연간 발생률과 누적 발생률을 평가하는 것이다.

 

·         자료원 : MEDLINE, Embase, Web of Science에서 데이터베이스 시작 시점부터 2024년 6월 26일까지 자료를 검색하였다.

 

·         연구 선택 기준 : TIA 또는 경미한 뇌졸중 환자에서 최소 1년 이상 추적관찰을 통해 뇌졸중 위험을 보고한 전향적 또는 후향적 코호트 연구를 포함하였다.

 

·         자료 추출 및 분석 : 두 명의 검토자가 독립적으로 자료를 추출하고 연구의 질을 평가하였다. 포함된 연구의 저자들로부터 특정 추적 구간 동안의 사건 수와 사람-연수(person-years)에 대한 집계 수준의 미공개 자료를 직접 확보하여 개별 연구의 발생률을 계산하였다. 연구 간 데이터를 무작위 효과 메타분석(random-effects meta-analysis)으로 통합하였다.

 

 

·         주요 결과 및 측정 :  주요 결과는 모든 종류의 뇌졸중 발생이었다. 연구 수준의 특성을 바탕으로 연구 간 발생률 차이에 영향을 미칠 수 있는 요인을 평가하였다.

 

·          결과 : 총 38개 연구, 171,068명의 환자(중앙값 연령 69세 [IQR, 65~71세]; 남성 비율 중앙값 57% [IQR, 52%~60%])가 포함되었다. 뇌졸중의 100인-연당 발생률은 다음과 같았다.


-첫 해: 5.94건 (95% CI, 5.18–6.76; 38개 연구; I²=97%)

-2~5년: 연간 1.80건 (95% CI, 1.58–2.04; 25개 연구; I²=90%)

-6~10년: 연간 1.72건 (95% CI, 1.31–2.18; 12개 연구; I²=84%)


5년 및 10년 누적 뇌졸중 발생률은 각각 12.5% (95% CI, 11.0%~14.1%)와 19.8% (95% CI, 16.7%~23.1%)이었다. 유럽에 비해 북미(RR 1.43 [95% CI, 1.36–1.50]) 및 아시아(RR 1.62 [95% CI, 1.52–1.73])에서 뇌졸중 발생률이 높았다. 2007년 이후 모집된 코호트(RR 1.42 [95% CI, 1.23–1.64])와 적극적 결과 확인 방법을 사용한 연구(RR 1.11 [95% CI, 1.07–1.17])에서도 더 높았다. 반면, TIA만 포함한 연구(RR 0.68 [95% CI, 0.65–0.71])나 최초 사건만 포함한 연구(RR 0.45 [95% CI, 0.42–0.49])에서는 발생률이 낮았다.


·         결론 및 의의 : TIA 또는 경미한 뇌졸중을 경험한 환자는 지속적으로 높은 재발성 뇌졸중 위험에 놓여 있다. 본 연구 결과는 이 환자군에서 장기적인 뇌졸중 예방 대책 개선의 필요성을 강조한다.

 

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