APR 22, 2016


The story

The best part of a transient ischemic attack (TIA) is when it's over. And now, thanks to specialized care, TIA patients are less likely to have subsequent strokes and heart attacks.

The basics

TIA: the bend-don't-break of brain injuries. Affected patients have transient stroke symptoms due to underlying ischemic injury without tissue infarction. But the lack of lasting damage is about where the good news ends, because historical studies have found patients to have a 12 - 20% chance of stroke or heart attack in the 3 months following TIA.

The research

Say hello to the project, an international collection of almost 5,000 TIA patients and their 1 and 5 year outcomes. All patients were treated at experienced stroke centers. Stroke or vascular event rate was 3.7% at 90 days (6.2% at one year), less than half of what prior studies predicted. The authors identified three criteria – an ABCD2 score of 6 - 7, large-artery atherosclerosis and multiple infarctions on MRI – as independent predictors of stroke risk following TIA. 

The treatments

The AHA has complex guidelines for preventing stroke in patients with TIA. Key strategies include prompt administration of antiplatelet agents, urgent revascularization of carotid stenoses, and secondary prevention with blood pressure control and statin therapy.

The takeaway

TIA patients are less vulnerable than previously thought, but only if they get expert care. Broadening expert stroke practices to inexperienced centers is a logical next step. 

Say it on rounds

When the hospital's tap water is a shade off color

Might be time to fix the pipes. The same goes for coronary artery bypass grafting (CABG) in ischemic cardiomyopathy (ICM). The STITCHES trial looked at 10-year outcomes for ICM patients who underwent CABG in addition to optimal medical therapy compared to medical therapy alone. CABG reduced mortality by roughly 7% and reduced hospitalizations. The study adds extra incentive to look for ischemia (often underdiagnosed) as the cause of new heart failure, especially in patients who can tolerate surgery.

When you get your fourth cold of the winter

The immune system is more impressive when unlocked to fight cancer. Add head and neck squamous cell carcinoma (SCC) to the long list of cancers where programmed cell death 1 (PD-1) inhibitors show efficacy. In relapsed SCC, PD-1 inhibition with nivolumab resulted in a 30% reduced risk of death vs. chemotherapy in a phase 3 trial. PD-1 inhibition also showed benefit in Merkel cell carcinoma. We didn't know either, but it has something to do with skin
AACR Abstracts

When the wrong person whispers sweet nothings

There might be a better option. Apply that logic to heparin induced thrombocytopenia (HIT), an uncommon but feared complication of unfractionated heparin (UFH) use. An initiative to avoid UFH in hospitalized patients and instead use low-molecular weight heparin (LMWH) reduced HIT incidence by 40% at a tertiary hospital in Toronto.

When you need more beeps in your hospital environment

The PERT pager – it's a thing. PERT (Pulmonary Embolism Response Team) is a rapid response initiative for suspected pulmonary embolism, similar to a stroke or STEMI pager. A single center PERT trial found about 400 activations in a month, of which 90% of involved patients were confirmed to have PE. The program is spreading to a hospital near you through a national consortium.

Brush up


2015's SPRINT mega-trial found that an SBP target of less than 120 mmHg lowered the risk of major cardiovascular events and mortality compared to a target of less than 140 mmHg in non-diabetic patients with cardiovascular risk factors. Benefit, including an overall 27% lower relative risk of mortality, was seen regardless of age, sex, race, choice of treatment agent, or medical history. Patients often required treatment with more than one drug to achieve target BP.

Get meta

With beta blockers (BB) in heart failure with reduced ejection fraction (HFrEF). The meds have been scrutinized in women and the elderly, but a pooled analysis of 13,000 patients found a mortality and readmission benefit with the use of BB in HFrEF patients in sinus rhythm, regardless of age or sex.

You're doing it wrong

The handwashing edition. A group in Scotland says you can reduce bacteria on your hands by using a way-too-hard handwashing technique. They lost us at step 10.

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