scholarly journals High ABCD2 Scores and In-Hospital Interventions following Transient Ischemic Attack

2016 ◽  
Vol 6 (3) ◽  
pp. 76-83 ◽  
Author(s):  
Shawna Cutting ◽  
Elizabeth Regan ◽  
Vivien H. Lee ◽  
Shyam Prabhakaran
Keyword(s):  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Heart Association ◽  
Reperfusion Therapy ◽  
Large Artery ◽  
Increased Risk ◽  
Risk Patients ◽  
Abcd2 Score ◽  
Ischemic Attack ◽  
Ischemic Events

Background and Purpose: Following transient ischemic attack (TIA), there is increased risk for ischemic stroke. The American Heart Association recommends admission of patients with ABCD2 scores ≥3 for observation, rapid performance of diagnostic tests, and potential acute intervention. We aimed to determine if there is a relationship between ABCD2 scores, in-hospital ischemic events, and in-hospital treatments after TIA admission. Methods: We reviewed consecutive patients admitted between 2006 and 2011 following a TIA, defined as transient focal neurological symptoms attributed to a specific vascular distribution and lasting <24 h. Three interventions were prespecified: anticoagulation for atrial fibrillation, carotid or intracranial revascularization, and intravenous or intra-arterial reperfusion therapies. We compared rates of in-hospital recurrent TIA or ischemic stroke and the receipt of interventions among patients with low (<3) versus high (≥3) ABCD2 scores. Results: Of 249 patients, 11 patients (4.4%) had recurrent TIAs or strokes during their stay (8 TIAs, 3 strokes). All 11 had ABCD2 scores ≥3, and no neurological events occurred in patients with lower scores (5.1 vs. 0%; p = 0.37). Twelve patients (4.8%) underwent revascularization for large artery stenosis, 16 (6.4%) were started on anticoagulants, and no patient received intravenous or intra-arterial reperfusion therapy. The ABCD2 score was not associated with anticoagulation (p = 0.59) or revascularization (p = 0.20). Conclusions: Higher ABCD2 scores may predict early ischemic events after TIA but do not predict the need for intervention. Outpatient evaluation for those with scores <3 would potentially have delayed revascularization or anticoagulant treatment in nearly one-fifth of ‘low-risk' patients.

Left Atrial Size and Ischemic Events after Ischemic Stroke or Transient Ischemic Attack in Patients with Nonvalvular Atrial Fibrillation

2020 ◽  
Vol 49 (6) ◽  
pp. 619-624
Author(s):  
Keisuke Tokunaga ◽  
Masatoshi Koga ◽  
Sohei Yoshimura ◽  
Yasushi Okada ◽  
Hiroshi Yamagami ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Left Atrial ◽  
Nonvalvular Atrial Fibrillation ◽  
Ischemic Event ◽  
Increased Risk ◽  
Ischemic Attack ◽  
Ischemic Events

<b><i>Background:</i></b> The present study aimed to clarify the association between left atrial (LA) size and ischemic events after ischemic stroke or transient ischemic attack (TIA) in patients with nonvalvular atrial fibrillation (NVAF). <b><i>Methods:</i></b> Acute ischemic stroke or TIA patients with NVAF were enrolled. LA size was classified into normal LA size, mild LA enlargement (LAE), moderate LAE, and severe LAE. The ischemic event was defined as ischemic stroke, TIA, carotid endarterectomy, carotid artery stenting, acute coronary syndrome or percutaneous coronary intervention, systemic embolism, aortic aneurysm rupture or dissection, peripheral artery disease requiring hospitalization, or venous thromboembolism. <b><i>Results:</i></b> A total of 1,043 patients (mean age, 78 years; 450 women) including 1,002 ischemic stroke and 41 TIA were analyzed. Of these, 351 patients (34%) had normal LA size, 298 (29%) had mild LAE, 198 (19%) had moderate LAE, and the remaining 196 (19%) had severe LAE. The median follow-up duration was 2.0 years (interquartile range, 0.9–2.1). During follow-up, 117 patients (11%) developed at least one ischemic event. The incidence rate of total ischemic events increased with increasing LA size. Severe LAE was independently associated with increased risk of ischemic events compared with normal LA size (multivariable-adjusted hazard ratio, 1.75; 95% confidence interval, 1.02–3.00). <b><i>Conclusion:</i></b> Severe LAE was associated with increased risk of ischemic events after ischemic stroke or TIA in patients with NVAF.

scholarly journals Coronary Artery Disease in Patients Presenting With Acute Ischemic Stroke or Transient Ischemic Attack and Elevated Troponin Levels

2022 ◽  
Vol 12 ◽  
Author(s):  
Mathieu Kruska ◽  
Anna Kolb ◽  
Christian Fastner ◽  
Iris Mildenberger ◽  
Svetlana Hetjens ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Ischemic Stroke ◽  
Cardiovascular Risk ◽  
Coronary Artery ◽  
Transient Ischemic Attack ◽  
Large Artery ◽  
Elevated Troponin ◽  
Stroke Patients ◽  
Artery Disease ◽  
Ischemic Attack

Background: There is little information concerning the invasive coronary angiography (ICA) findings of patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) with elevated troponin levels and suspected myocardial infarction (MI). This study analyzed patient characteristics associated with ICA outcomes.Methods: A total of 8,322 patients with AIS or TIA, treated between March 2010 and May 2020, were retrospectively screened for elevated serum troponin I at hospital admission. Patients in whom ICA was performed, due to suspected type 1 MI based on symptoms, echocardiography, and ECG, were categorized according to ICA results (non-obstructive coronary artery disease (CAD): ≥1 stenosis ≥50% but no stenosis ≥80%; obstructive CAD: any stenosis ≥80% or hemodynamically relevant stenosis assessed by FFR/iwFR).Results: Elevated troponin levels were detected in 2,205 (22.5%) patients, of whom 123 (5.6%) underwent ICA (mean age 71 ± 12 years; 67% male). CAD was present in 98 (80%) patients, of whom 51 (41%) were diagnosed with obstructive CAD. Thus, ICA findings of obstructive CAD accounted for 2.3% of patients with troponin elevation and 0.6% of all stroke patients. The clinical hallmarks of myocardial ischemia, including angina pectoris (31 vs. 15%, p &lt; 0.05) and regional wall motion abnormalities (49 vs. 32%, p = 0.07), and increased cardiovascular risk indicated obstructive CAD. While there was no association between lesion site or stroke severity and ICA findings, causal large-artery atherosclerosis was significantly more common in patients with obstructive coronary disease (p &lt; 0.05).Conclusion: The rate of obstructive CAD in patients with stroke or TIA and elevated troponin levels with suspected concomitant type I MI is low. The cumulation of several cardiovascular risk factors and clinical signs of MI were predictive. AIS patients with large-artery atherosclerosis and elevated troponin may represent an especially vulnerable subgroup of stroke patients with risk for obstructive CAD.

scholarly journals Comparison of Carotid Atherosclerotic Plaque Characteristics between Symptomatic Patients with Transient Ischemic Attack and Stroke using High-Resolution Magnetic Resonance Imaging

2021 ◽  
Author(s):  
Mingming Lu ◽  
Lichen Zhang ◽  
Fei Yuan ◽  
Peng Peng ◽  
Hongtao Zhang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Magnetic Resonance ◽  
Transient Ischemic Attack ◽  
Carotid Arteries ◽  
Plaque Burden ◽  
Plaque Morphology ◽  
Stroke Patients ◽  
Carotid Plaques ◽  
Ischemic Attack ◽  
Ischemic Events

Abstract Background:This study aimed to compare the characteristics of carotid plaques between patients with transient ischemic attack (TIA) and ischemic stroke using magnetic resonance (MR) imaging.Methods：Patients with a recent ischemic stroke or TIA who exhibited atherosclerotic plaques of carotid arteries in the symptomatic sides determined by MR vessel wall imaging were recruited. The plaque morphology and compositions including intraplaque hemorrhage (IPH), lipid-rich necrotic-core (LRNC) and calcification were compared between TIA and stroke patients. Logistic regression was performed to relate the plaque characteristics to the types of ischemic events.Results:A total of 270 patients with TIA or ischemic stroke were recruited. Stroke patients had significantly higher prevalence of diabetes (42.2% vs. 28.2%, p=0.021), greater mean wall area (35.1 ± 10.1 mm2 vs. 32.0 ± 7.7 mm2, p = 0.004), mean wall thickness (1.3 ± 0.2 mm vs. 1.2 ± 0.2 mm, p=0.001), maximum normalized wall index (NWI)(63.9% ± 6.0% vs. 62.2% ± 5.9%, p=0.023) and %volume of LRNC (9.7%± 8.2% vs. 7.4% ±7.9%, p=0.025) in carotid arteries compared to those with TIA. After adjusted for clinical factors, above characteristics of carotid arteries were significantly associated with the type of ischemic events. After further adjusted for maximum NWI, this association remained statistically significant (OR, 1.41; CI, 1.01-1.96; p=0.041).Conclusions:Ischemic stroke patients had larger plaque burden and greater proportion of LRNC in carotid plaques compared to those with TIA. This study suggests that ischemic stroke patients had more vulnerable plaques compared to those with TIA.

scholarly journals Time Course for Benefit and Risk of Clopidogrel and Aspirin After Acute Transient Ischemic Attack and Minor Ischemic Stroke

Circulation ◽  
2019 ◽  
Vol 140 (8) ◽  
pp. 658-664 ◽  
Author(s):  
S. Claiborne Johnston ◽  
Jordan J. Elm ◽  
J. Donald Easton ◽  
Mary Farrant ◽  
William G. Barsan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
High Risk ◽  
Transient Ischemic Attack ◽  
Time Course ◽  
Hazard Ratio ◽  
Major Hemorrhage ◽  
Minor Ischemic Stroke ◽  
Ischemic Attack ◽  
Ischemic Events ◽  
Benefit And Risk

Background: In patients with acute minor ischemic stroke or high-risk transient ischemic attack enrolled in the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke [POINT] Trial), the combination of clopidogrel and aspirin for 90 days reduced major ischemic events but increased major hemorrhage in comparison to aspirin alone. Methods: In a secondary analysis of POINT (N=4881), we assessed the time course for benefit and risk from the combination of clopidogrel and aspirin. The primary efficacy outcome was a composite of ischemic stroke, myocardial infarction, or ischemic vascular death. The primary safety outcome was major hemorrhage. Risks and benefits were estimated for delayed times of treatment initiation using left-truncated models. Results: Through 90 days, the rate of major ischemic events was initially high then decreased markedly, whereas the rate of major hemorrhage remained low but relatively constant throughout. With the use of a model-based approach, the optimal change point for major ischemic events was 21 days (0–21 days hazard ratio 0.65 for clopidogrel-aspirin versus aspirin; 95% CI, 0.50–0.85; P =0.0015, in comparison to 22–90 days hazard ratio, 1.38; 95% CI, 0.81–2.35; P =0.24). Models showed benefits of clopidogrel-aspirin for treatment delayed as long as 3 days after symptom onset. Conclusions: The benefit of clopidogrel-aspirin occurs predominantly within the first 21 days, and outweighs the low, but ongoing risk of major hemorrhage. When considered with the results of the CHANCE trial (Clopidogrel in High-Risk Patients With Non-disabling Cerebrovascular Events), a similar trial treating with clopidogrel-aspirin for 21 days and showing no increase in major hemorrhage, these results suggest that limiting clopidogrel-aspirin use to 21 days may maximize benefit and reduce risk after high-risk transient ischemic attack or minor ischemic stroke. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00991029.

scholarly journals Searching for Atrial Fibrillation Poststroke

Circulation ◽  
2019 ◽  
Vol 140 (22) ◽  
pp. 1834-1850 ◽  
Author(s):  
Renate B. Schnabel ◽  
Karl Georg Haeusler ◽  
Jeffrey S. Healey ◽  
Ben Freedman ◽  
Giuseppe Boriani ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Vitamin K ◽  
Transient Ischemic Attack ◽  
Embolic Stroke ◽  
Ecg Monitoring ◽  
Electrocardiographic Monitoring ◽  
Unknown Source ◽  
Increased Risk ◽  
Ischemic Attack

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non–vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non–vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

scholarly journals Residual Inflammatory Risk Predicts Poor Prognosis in Acute Ischemic Stroke or Transient Ischemic Attack Patients

Stroke ◽  
2021 ◽  
Author(s):  
Jiejie Li ◽  
Yuesong Pan ◽  
Jie Xu ◽  
Shiyu Li ◽  
Mengxing Wang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Transient Ischemic Attack ◽  
Recurrent Stroke ◽  
Hazard Ratio ◽  
Adjusted Hazard Ratio ◽  
Large Artery ◽  
Poor Functional Outcome ◽  
Ischemic Attack

Background and Purpose: It is still unclear whether the residual cholesterol and inflammatory risk in the acute phase is associated with prognosis of stroke. We aimed to investigate the proportion and relative contribution of residual cholesterol and inflammatory risk, determined by baseline low-density lipoprotein cholesterol (LDL-C) and high-sensitivity C-reactive protein (hsCRP) levels, to the risk of recurrent stroke and poor functional outcome at 1 year. Methods: In this prospective multicenter cohort study, 10 499 consecutive acute ischemic stroke and transient ischemic attack patients with levels of LDL-C and hsCRP were enrolled. Patients were divided into 4 groups: residual cholesterol risk only (LDL-C ≥2.6 mmol/L and hsCRP <3 mg/L), residual inflammatory risk (RIR) only (LDL-C <2.6 mmol/L and hsCRP ≥3 mg/L), both risk (LDL-C ≥2.6 mmol/L and hsCRP ≥3 mg/L), and neither risk (LDL-C <2.6 mmol/L and hsCRP <3 mg/L). The primary outcomes consisted of stroke recurrence and a modified Rankin Scale score of 2 to 6 within 1 year. Results: The relative proportions of patients with RIR only, residual cholesterol risk only, both risk, and neither were 21.3%, 23.7%, 14.4%, and 40.6%, respectively. RIR only was independently associated with recurrent stroke (adjusted hazard ratio, 1.18 [95% CI, 1.00–1.40]; P =0.05). The association was slightly attenuated after further adjusting for usage of antiplatelet agent and statin during 1-year follow-up in addition to the traditional risk factors (hazard ratio, 1.31 [95% CI, 0.99–1.76]; P =0.07). When applying the LDL-C cutoff value of 1.8 mmol/L in the sensitivity analyses, such association in large-artery atherosclerosis subtype was more significant (adjusted hazard ratio, 1.69 [95% CI, 1.06–2.67]; P =0.03). Patients with RIR only also had increased risk of poor functional outcome (adjusted odds ratio, 1.43 [95% CI, 1.24–1.64]; P <0.0001). Conclusions: In the patients with acute ischemic stroke or transient ischemic attack, RIR only could be predictive for recurrent stroke, especially for those with large-artery atherosclerosis, and poor functional outcome.

scholarly journals Carotid Stenosis and Recurrent Ischemic Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Shadi Yaghi ◽  
Adam de Havenon ◽  
Sara Rostanski ◽  
Alexandra Kvernland ◽  
Brian Mac Grory ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
High Risk ◽  
Carotid Stenosis ◽  
Transient Ischemic Attack ◽  
Stroke Risk ◽  
Hazard Ratio ◽  
Minor Ischemic Stroke ◽  
Increased Risk ◽  
Ischemic Stroke Risk ◽  
Ischemic Attack

Background and Purpose: Randomized trials demonstrated the benefit of dual antiplatelet therapy in patients with minor ischemic stroke or high-risk transient ischemic attack. We sought to determine whether the presence of carotid stenosis was associated with increased risk of ischemic stroke and whether the addition of clopidogrel to aspirin was associated with more benefit in patients with versus without carotid stenosis. Methods: This is a post-hoc analysis of the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke) that randomized patients with minor ischemic stroke or high-risk transient ischemic attack within 12 hours from last known normal to receive either clopidogrel plus aspirin or aspirin alone. The primary predictor was the presence of ≥50% stenosis in either cervical internal carotid artery. The primary outcome was ischemic stroke. We built Cox regression models to determine the association between carotid stenosis and ischemic stroke and whether the effect of clopidogrel was modified by ≥50% carotid stenosis. Results: Among 4881 patients enrolled POINT, 3941 patients met the inclusion criteria. In adjusted models, ≥50% carotid stenosis was associated with ischemic stroke risk (hazard ratio, 2.45 [95% CI, 1.68–3.57], P <0.001). The effect of clopidogrel (versus placebo) on ischemic stroke risk was not significantly different in patients with <50% carotid stenosis (adjusted hazard ratio, 0.68 [95% CI, 0.50–0.93], P =0.014) versus those with ≥50% carotid stenosis (adjusted hazard ratio, 0.88 [95% CI, 0.45–1.72], P =0.703), P value for interaction=0.573. Conclusions: The presence of carotid stenosis was associated with increased risk of ischemic stroke during follow-up. The effect of added clopidogrel was not significantly different in patients with versus without carotid stenosis. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03354429.

scholarly journals Balancing Benefits and Risks of Long-Term Antiplatelet Therapy in Noncardioembolic Transient Ischemic Attack or Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Nina A. Hilkens ◽  
Ale Algra ◽  
Hans Christoph Diener ◽  
Philip M. Bath ◽  
László Csiba ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Major Bleeding ◽  
Transient Ischemic Attack ◽  
Bleeding Risk ◽  
Net Benefit ◽  
Antiplatelet Treatment ◽  
Ischemic Attack ◽  
Ischemic Events

Background and Purpose: Lifelong treatment with antiplatelet drugs is recommended following a transient ischemic attack or ischemic stroke. Bleeding complications may offset the benefit of antiplatelet drugs in patients at increased risk of bleeding and low risk of recurrent ischemic events. We aimed to investigate the net benefit of antiplatelet treatment according to an individuals’ bleeding risk. Methods: We pooled individual patient data from 6 randomized clinical trials (CAPRIE [Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events], ESPS-2 [European Stroke Prevention Study-2], MATCH [Management of Atherothrombosis With Clopidogrel in High-Risk Patients], CHARISMA [Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance], ESPRIT [European/Australasian Stroke Prevention in Reversible Ischemia Trial], and PRoFESS [Prevention Regimen for Effectively Avoiding Second Strokes]) investigating antiplatelet therapy in the subacute or chronic phase after noncardioembolic transient ischemic attack or stroke. Patients were stratified into quintiles according to their predicted risk of major bleeding with the S 2 TOP-BLEED score. The annual risk of major bleeding and recurrent ischemic events was assessed per quintile for 4 scenarios: (1) aspirin monotherapy, (2) aspirin-clopidogrel versus aspirin or clopidogrel monotherapy, (3) aspirin-dipyridamole versus clopidogrel, and (4) aspirin versus clopidogrel. Net benefit was calculated for the second, third, and fourth scenario. Results: Thirty seven thousand eighty-seven patients were included in the analyses. Both risk of major bleeding and recurrent ischemic events increased over quintiles of predicted bleeding risk, but risk of ischemic events was consistently higher (eg, from 0.7%/y (bottom quintile) to 3.2%/y (top quintile) for major bleeding on aspirin and from 2.5%/y to 10.2%/y for risk of ischemic events on aspirin). Treatment with aspirin-clopidogrel led to more major bleedings (0.9%–1.7% per year), than reduction in ischemic events (ranging from 0.4% to 0.9/1.0% per year) across all quintiles. There was no clear preference for either aspirin-dipyridamole or clopidogrel according to baseline bleeding risk. Conclusions: Among patients with a transient ischemic attack or ischemic stroke included in clinical trials of antiplatelet therapy, the risk of recurrent ischemic events and of major bleeding increase in parallel. Antiplatelet treatment cannot be individualized solely based on bleeding risk assessment.

Abstract 24: Transesophageal Echocardiography and Risk of Acute Respiratory Failure in Patients With Ischemic Stroke and Transient Ischemic Attack

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Samuel S Bruce ◽  
Babak B Navi ◽  
Hooman Kamel
Keyword(s):  
Mechanical Ventilation ◽  
Ischemic Stroke ◽  
Respiratory Failure ◽  
Acute Respiratory Failure ◽  
Transesophageal Echocardiography ◽  
Endotracheal Intubation ◽  
Transient Ischemic Attack ◽  
Medicare Beneficiaries ◽  
Increased Risk ◽  
Ischemic Attack

Introduction: Transesophageal echocardiography (TEE) is often used as an adjunct to transthoracic echocardiography (TTE) to identify sources of cardiac embolism after ischemic stroke and transient ischemic attack (TIA). Unlike TTE, TEE is invasive and may lead to aspiration. Few data exist on the risk of respiratory complications after TEE in patients with stroke and TIA. Methods: We performed a retrospective cohort study using inpatient and outpatient claims data between 2008 through 2016 from a 5% sample of Medicare beneficiaries. We included patients ≥65 years old and hospitalized with acute ischemic stroke or TIA, defined by validated ICD-9 and ICD-10 diagnosis codes. CPT codes and ICD procedure codes were used to ascertain whether TEE, endotracheal intubation, mechanical ventilation, intravenous thrombolysis, or mechanical thrombectomy were performed during the stroke/TIA hospitalization. The exposure was TEE, modeled as a time-varying covariate, and the outcome was acute respiratory failure, defined as endotracheal intubation and/or mechanical ventilation. Patients were censored at hospital discharge or 21 days from admission. Cox proportional hazards regression was used to adjust for age, race, Charlson comorbidities, diagnosis of stroke versus TIA, thrombolysis, and thrombectomy. Results: Of 103,072 patients included during the study period, 72,981 (70.8%) had a diagnosis of ischemic stroke and 30,091 (29.2%) had a diagnosis of TIA. A total of 5,096 (4.9%) underwent TEE. The cumulative rate of respiratory failure at 21 days was higher after TEE (13.1%; 95% CI, 8.8-19.2%) than in patients without TEE (9.7%; 95% CI, 8.7-10.9%). After adjustment for potential confounders, TEE was associated with an increased risk of intubation (HR, 1.6; 95% CI, 1.3-2.0). This association was present when we assessed TIA patients only (HR, 2.7; 95% CI, 1.1-6.8). Conclusions: In a large cohort of Medicare beneficiaries, we found that TEE was associated with an increased risk of respiratory failure in patients with ischemic stroke or TIA.

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