To the Editor: In their cohort study, Dr Bos and colleagues1 show Kaplan-Meier curves for the risk of ischemic heart disease and vascular death, as well as stroke, after transient neurological attacks (TNAs). These appear to indicate that the absolute event rates of these outcomes in this population equal or surpass the 20% 10-year risk of coronary events associated with coronary risk equivalents used in US guidelines to determine aggressiveness of use of statins and other therapies.2 There is evidence that patients with a history of ischemic stroke have a risk of coronary events equal to that of coronary risk equivalents,3 - 4 although patients with stroke are included as risk equivalents only in European (not US) guidelines.5
The results of the study by Bos et al may provide evidence that patients with TNAs, including but not limited to those with a cerebral ischemic etiology, are also at sufficiently increased risk of coronary events to warrant aggressive lipid control and other vascular risk reduction therapies. Inclusion of stroke in a composite outcome measure of “stroke or coronary risk equivalents” would increase overall event rates and lead to inclusion of a larger number of patients in the high-risk category.
While the mechanism for an increased risk of vascular events among patients with nonfocal TNAs remains uncertain, the greatest risk of ischemic heart disease and vascular death was seen in those with mixed TNAs, implying that nonfocal symptoms may serve as a marker of systemic or cardiac dysfunction. To better evaluate the potential inclusion of TNAs as a coronary risk equivalent, it would be helpful to know what the absolute event rates were for the combined outcomes of myocardial infarction and coronary death after TNA.
Financial Disclosures: Dr Elkind reported receiving research funding from BMS-Sanofi Partnership and diaDexus; receiving honoraria for speaking from Boehringer-Ingelheim and BMS-Sanofi Partnership; and serving as a consultant to Boehringer-Ingelheim, Pfizer, GlaxoSmithKline, and Daiichi Sankyo.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Instructions
Comments are moderated and will appear on the site at the discretion of the Journal of American Medical Association editors. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest* Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Register Now
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.