Among patients with transient ischemic attack (TIA) without evidence of structural damage, worsened health-related quality of life (HRQOL) after the event is likely caused by worse health before the attack rather than by any associations between TIA and worse health status, according to a study published in JAMA Network Open.
After TIA, however, researchers found that interval stroke, hospital admission, and hypertension were independently associated with clinically relevant worsening in physical health scores.
Irene L. Katzan, MD, Neurological Institute, Cleveland Clinic, Ohio, and fellow researchers enrolled 236 patients (mean age: 67.9 years; 52.5% women) who received a clinical diagnosis of TIA to assess patient-reported health before and after. A full 76% of patients were 60 years or older, 47.9% had hypertension, and 30% diabetes.
The primary outcome was Patient-Reported Outcome Measurement Information System Global Health (PROMIS GH) scale score pre- and post-TIA, with changes of five or more points considered clinically relevant. Secondary outcomes included changes in patient-reported global health by clinical impression of the probability of a TIA events, the pattern of neurological deficits, and short-term risk of stroke (ABCD2 score). TIA was classified as probable (42.6%), possible (28.5%), and nondocumented. Deficits were characterized as focal (55.9%), nonfocal (19.8%), and mixed (23.6%).
At baseline, mean physical health score in these patients was 43.4, which was significantly lower compared to that among the general population (50; P˂0.001), a clinically relevant difference. Mean baseline mental health score in TIA patients was 47.7, which was again, statistically significantly lower than that of the general population mean of 50 (P˂ 0.001). This difference, however, was not clinically relevant.
Changes in mean physical and mental health scores after TIA were not statistically significant, however (physical health: 44.1; mean improvement: 0.65 points; P=0.09; and mental health: 47.4; mean worsening: 0.25 points; P=0.51).
Katzan et al found no significant differences in pre-event patient-reported global health scale summary scores in the following subgroups:
- Clinicians’ impression of the probability of TIA.
- Pattern of deficits.
- Short-term risk of stroke, with a stroke risk score of 4 or greater.
Sixty-five patients had changes in their pain medications, 131 in antithrombotic medications, and 36 in antimicrobial medications. Katzan and colleagues found a statistically significant improvement in physical health scores in pre- versus post-TIA in patients who had at least one medication change of any kind (mean: 42.9 versus 43.8; mean change: 0.88 points; P=0.03). This change, however, was not clinically relevant.
Upon univariate analysis, researchers also found that the independent variables associated with clinically relevant worsening in physical health scores included:
- Increased stroke risk score (OR per each 1-unit score increase: 1.26; 95% CI: 1.02-1.55; P=0.03).
- Hypertension (OR: 3.31; 95% CI: 1.34-8.15; P=0.009).
- Interval hospital admission (OR: 2.37; 95% CI: 1.07-5.24; P=0.03).
Independent variables that were associated with decreased patient-reported PROMIS GH scale mental health scores included:
- Outpatient evaluation of TIA (OR: 2.31; 95% CI: 1.10-4.82; P=0.03).
- Interval stroke (OR: 12.2; 95% CI: 1.25-12.01; P=0.03).
- Interval hospital admission (OR: 2.31; 95% CI: 1.07-5.01; P=0.03).
Upon multivariable logistic regression, researchers found that the following variables were independently associated with clinically relevant worsening physical health scores:
- Stroke risk score (OR per each 1-unit increase in score: 1.34; 95% CI: 1.05-1.71; P=0.02).
- Male sex (OR: 2.18; 95% CI: 1.05-4.54; P=0.04).
Interestingly, being married was associated with a lower odds of worsening physical health scores (OR: 0.49; 95% CI: 0.24-0.98; P=0.04). The presence of any nonfocal symptoms was associated with clinically relevant worsening in patient-reported GH scale mental health scores (OR: 2.39; 95% CI: 1.02-5.63; P=0.046).
“In the sensitivity analysis to assess for selection bias, we compared the mean postevent patient-reported GH scale scores among patients seen in the cerebrovascular clinic who had pre-event patient-reported GH scale scores with the post-vent GH scores among patients who did not have pre-event GH scores (and so were not included in the study cohort). Among patients with pre-event scores, compared with those without pre-event scores, the mean (SD) postevent patient-reported GH scale scores were 44.5 (9.1) versus 45.1 (9.0) for PH, for a difference of 0.6 points, and 47.8 (8.8) versus 48.2 (9.1) for MH, for a difference of 0.4 points; these differences were not clinically relevant,” wrote Katzan et al.
Upon further sensitivity analysis to assess the ability of patient-reported GH scale to detect changes, the physical and mental health scores of 10 patients with transient symptoms that were excluded due to MRI-verified acute infarct decreased more compared with other patients.
“These findings suggest that the impaired HRQOL found among patients diagnosed with TIA without imaging evidence of structural damage reflect, at least in part, an impaired premorbid state of health. We found that TIA events were not associated with worsening of health status overall, although they were associated with worsening on 2 of 10 GH scale items. However, interval stroke and hospital admission were associated with clinically relevant worsening. Further evaluation is necessary to confirm these findings using different patient-reported outcomes and objective performance measures,” concluded Katzan and colleagues.
Limitations of the study include likely selection bias in patients with pre-event patient-reported GH scale score, small number of patients, GH scale’s failure to pick up on subtle changes, and available MRI in only 60% of patients.
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Impaired health-related quality of life (HRQOL) seen in patients diagnosed with TIA reflects an impaired premorbid state of health rather than worsening health after the TIA event.
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Physical health and mental health summary scores were not statistically significantly different after TIA events compared with before.
Liz Meszaros, Deputy Managing Editor, BreakingMED™
Katzan reported no disclosures.
Cat ID: 130
Topic ID: 82,130,730,745,130,38,192,925
