The Daily Dose- 12/18/08

Dear Dr. Spence,
I recently had a mini-stroke. The doctor in the ER told me I am at huge risk for a full stroke in the next several months. Now I’m panicked – what can I do?
Signed, Hardly Strolling

Dear Hardly,
Mini-strokes, or transient ischemic attacks (TIAs) occur anywhere from 200 to 500 thousand times per year in the United States. The risk of TIA increases dramatically with age, with the majority occurring in patients over the age of 70. The definition of a TIA is a neurologic event that resolves within a 24-hour period. In other words, signs and symptoms of stroke (whether it is numbness, weakness, speech disturbance etc), disappears over the course of only a day. Risk of full stroke appears to be higher at two days (3.1% risk), one week (5.2%) and three months (10-15% increased risk). Patients with TIAs need rapid assessment and may require evaluation of the carotid arteries for blockage, or ultrasounds of the heart to rule out clot formation.
More recent studies suggest a so-called "ABCD" system for predicting future stroke risk. This allows patients to be stratified according to their inherent medical risks and determines whether or not they need elaborate investigation. The ABCDs studied are age (greater than age 60 = 1 point), blood pressure (> 140/90 = 1 point), diabetes (present = 1 point), clinical features (weakness = 2 points, speech impairment = 1 point), and duration of symptoms (>60 minutes = 2 points, 10-59 minutes = 1 point). Any score greater than three warrants further evaluation. A score of three imparts only a 1% risk at 90 days out from the previous TIA, whereas a score of seven increases the 90-day risk to 6%.
It’s hard to say whether or not you need formal evaluation, as more clinical information is required. I will say that obvious risk prevention measures are in order. I recommend lowering LDL (bad cholesterol) to less than 70. Use of a statin like zocor may be indicated regardless of lipid levels given their potential ability to stabilize plaques and prevent strokes and heart attacks. Blood pressure should probably be lowered to less than 130/80. If you are a smoker, you need to quit, as this remains a huge risk for recurrence. Finally, the addition of an anti-clotting agent like aspirin has definitive data behind and I add 81 mg of aspirin to nearly all patients who have suffered a TIA.

Do you have any medical questions or concerns that you would like addressed? You can contact Dr. Spence by email at panhandledailydose@hotmail.com or by mailing your question to Daily Dose, P.O. Box 6107, Marianna, FL 32446.