Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom.
Stroke. 2022 Feb;53(2):488-496. doi: 10.1161/STROKEAHA.121.034279. Epub 2021 Oct 28.
Urgent assessment aimed at reducing stroke risk after transient ischemic attack or minor stroke is cost-effective over the short-term. However, it is unclear if the short-term impact is lost on long-term follow-up, with recurrent events being delayed rather than prevented. By 10-year follow-up of the EXPRESS study (Early Use of Existing Preventive Strategies for Stroke), previously showing urgent assessment reduced 90-day stroke risk by 80%, we determined whether that early benefit was still evident long-term for stroke risk, disability, and costs.
EXPRESS was a prospective population-based before (phase 1: April 2002-September 2004; n=310) versus after (phase 2: October 2004-March 2007; n=281) study of the effect of early assessment and treatment of transient ischemic attack/minor stroke on early recurrent stroke risk, with an external control. This report assesses the effect on 10-year recurrent stroke risk, functional outcomes, quality-of-life, and costs.
A reduction in stroke risk in phase 2 was still evident at 10 years (55/23.3% versus 82/31.6%; hazard ratio=0.68 [95% CI, 0.48-0.95]; =0.024), as was the impact on risk of disabling or fatal stroke (17/7.7% versus 32/13.1%; hazard ratio=0.54 [0.30-0.97]; =0.036). These effects were due to maintenance of the early reduction in stroke risk, with neither additional benefit nor rebound catch-up after 90 days (post-90 days hazard ratio=0.88 [0.65-1.44], =0.88; and hazard ratio=0.83 [0.42-1.65], =0.59, respectively). Disability-free life expectancy was 0.59 (0.03-1.15; =0.043) years higher in patients in phase 2, as was quality-adjusted life expectancy (0.49 [0.03-0.95]; =0.036). Overall, 10-year costs were nonsignificantly higher in patients attending the phase 2 clinic ($1022 [-3865-5907]; =0.66). The additional cost per quality-adjusted life year gained in phase 2 versus phase 1 was $2103, well below current cost-effectiveness thresholds.
Urgent assessment and treatment of patients with transient ischemic attack or minor stroke resulted in a long-term reduction in recurrent strokes and improved outcomes, with little atrophy of the early benefit over time, representing good value for money even with a 10-year time horizon. Our results suggest that other effective acute treatments in transient ischemic attack/minor stroke in the short-term will also have the potential to have long-term benefit.
对短暂性脑缺血发作或小卒中患者进行紧急评估，以降低卒中风险，这种策略在短期内具有成本效益。然而，目前尚不清楚这种短期影响是否会在长期随访中消失，因为复发事件被延迟而不是预防。通过对 EXPRESS 研究（早期使用现有的预防策略治疗卒中）10 年随访，我们此前发现紧急评估可将 90 天内的卒中风险降低 80%，因此我们确定了这种早期获益在长期内对卒中风险、残疾和成本是否仍然存在。
EXPRESS 是一项前瞻性的基于人群的研究，在早期评估和治疗短暂性脑缺血发作/小卒中对早期复发性卒中风险的影响之前（第 1 阶段：2002 年 4 月至 2004 年 9 月；n=310）和之后（第 2 阶段：2004 年 10 月至 2007 年 3 月；n=281）进行，有外部对照。本报告评估了对 10 年复发性卒中风险、功能结局、生活质量和成本的影响。
第 2 阶段的卒中风险降低在 10 年内仍然明显（55/23.3%比 82/31.6%；风险比=0.68[95%CI，0.48-0.95]；=0.024），致残或致死性卒中风险的影响也是如此（17/7.7%比 32/13.1%；风险比=0.54[0.30-0.97]；=0.036）。这些影响归因于早期卒中风险降低的维持，90 天后没有额外的获益或反弹追赶（90 天后风险比=0.88[0.65-1.44]，=0.88；风险比=0.83[0.42-1.65]，=0.59）。第 2 阶段的患者无残疾预期寿命延长了 0.59 年（0.03-1.15；=0.043），质量调整预期寿命也延长了（0.49[0.03-0.95]；=0.036）。总体而言，第 2 阶段就诊患者的 10 年成本无显著增加（$1022[-3865-5907]；=0.66）。第 2 阶段与第 1 阶段相比，每增加一个质量调整生命年的额外成本为 2103 美元，远低于当前的成本效益阈值。
对短暂性脑缺血发作或小卒中患者进行紧急评估和治疗可长期降低复发性卒中风险，并改善结局，随着时间的推移，早期获益几乎没有萎缩，即使考虑到 10 年的时间范围，也具有良好的性价比。我们的结果表明，在短期内对短暂性脑缺血发作/小卒中采用其他有效的急性治疗方法也有可能具有长期获益。
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