Baja tasa de infarto cerebral, infarto de miocardio y muerte vascular con el diagnóstico y tratamiento etiológico rápido del ataque isquémico transitorio / Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death

Introducción: El riesgo de infarto cerebral dentro de los primeros 90 días tras un ataque isquémico transitorio (AIT) se estima entre un 8-20%. Existe escaso consenso sobre cuál es la estrategia diagnóstica más eficaz. Nuestro objetivo fue evaluar del beneficio del estudio precoz con ecocardiografía transtorácica (ETT) y ultrasonografía carotídea y transcraneal (DTSA/TC) en los pacientes con AIT. Métodos: Evaluamos de forma prospectiva todos los pacientes con AIT atendidos en urgencias durante 24 meses. Recogimos variables demográficas, factores de riesgo vascular y escala ABCD2. La etiología del AIT fue clasificada según criterios TOAST. En todos los pacientes se realizó el estudio vascular precoz (< 72 h) con ETT y DTSA/TC. Los objetivos primarios fueron la recurrencia vascular cerebral, infarto de miocardio (IAM) o muerte vascular durante el primer año. Resultados: Evaluamos 92 pacientes con una edad media de 68,3 ± 13 años y el 61% fueron hombres. La media de la escala ABCD2 fue de 3 puntos (≥ 5 en un 30%). La distribución etiológica fue la siguiente: aterotrombótico de gran vaso 12%; cardioembólico 30%; pequeño vaso 10%; indeterminado 40% e inhabitual 8%. Los hallazgos de la ETT cambiaron el tratamiento en 6 pacientes (6,5%) con exploración física y ECG normal. Al año de seguimiento 3 pacientes (3,2%) sufrieron un infarto cerebral, uno (1%) un IAM y no detectamos ninguna muerte vascular. Conclusiones: El estudio etiológico precoz en los pacientes con AIT y la detección de pacientes con cardiopatía silente puede haber contribuido a la baja tasa de recurrencia vascular

Introduction: The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. Methods: Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD2 score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (< 72 hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. Results: We evaluated 92 patients enrolled over 24 months. Mean age was 68.3 ± 13 years and 61% were male. The mean ABCD2 score was 3 points (≥ 5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. Conclusions: In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence

Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death.

INTRODUCTION: The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. METHODS: Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD(2) score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. RESULTS: We evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD(2) score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. CONCLUSIONS: In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.

[Cognitive and functional decline in the stage previous to the diagnosis of Alzheimers disease]. / Deterioro cognitivo y funcional en la fase previa al diagnóstico de enfermedad de Alzheimer.

INTRODUCTION: The decline in the phase prior to diagnosis of Alzheimers disease (AD) is not well known, although this knowledge is necessary to evaluate the efficiency of new drugs that can influence in disease course prior to diagnosis. OBJECTIVE: To contribute to better knowledge of the decline prior to diagnosis, we have investigated the cognitive and functional deterioration for 2-3 years before the probable AD diagnosis was established. PATIENTS AND METHODS: We compared results obtained by 17 control subjects and 27 patients at the time of diagnosis of a probable AD with results obtained 2-3 years before (interval of 27.7 4 months). We compared memory functions (logical, recognition, learning and autobiographical memory), naming, visual and visuospatial gnosis, visuoconstructive praxis, verbal fluency and the Mini-Mental State Examination (MMSE), Informant Questionnaire and Blessed's Scale scores. RESULTS: Performance of control subjects did not change. AD patients showed a significant decline in scores, except for verbal fluency. In order of importance, cognitive decline was more marked in scores of learning memory, visuospatial gnosis, autobiographical memory and visuoconstructive praxis. CONCLUSIONS: Decline prior to diagnosis of AD is characterized by an important learning memory impairment. Deterioration of visuospatial gnosis and visuoconstructive praxis is greater than deterioration of MMSE and Informant Questionnaire scores.

Deterioro cognitivo y funcional en la fase previa al diagnóstico de enfermedad de Alzheimer / Cognitive and functional decline in the stage previous to the diagnosis of Alzheimer´s disease

Introducción: El deterioro en la fase previa al diagnóstico de enfermedad de Alzheimer (EA) no es bien conocido, a pesar de que este conocimiento es necesario a fin de evaluar la eficacia de nuevos fármacos que puedan ser capaces de incidir en el curso anterior al diagnóstico de la enfermedad. Objetivos: Con el ánimo de contribuir a un mejor conocimiento del deterioro previo al diagnóstico, hemos investigado el deterioro cognitivo y funcional acaecido en un período de al menos 2-3 años antes de que el diagnóstico de probable EA fuese establecido. Métodos: Comparamos los resultados obtenidos por 17 sujetos control y 27 pacientes en el momento de establecer el diagnóstico de probable EA con aquellos obtenidos de 2 a 3 años antes (intervalo promedio de 27,7ñ4 meses). Comparamos funciones mnésicas (memoria reciente lógica, de reconocimiento, de aprendizaje y autobiográfica), denominación, gnosis visuales y visuoespaciales, praxis visuoconstructivas, fluencias y las puntuaciones del Miniexamen del estado mental (MMSE), el Test del informador y la escala de Blessed. Resultados: Las puntuaciones obtenidas por los sujetos control no variaron. Las puntuaciones en los pacientes con EA empeoraron significativamente a excepción de las fluencias. El grado de deterioro cognitivo fue más acentuado, y por este orden, en las puntuaciones de memoria de aprendizaje, gnosis visuoespaciales, memoria autobiográfica y praxis visuoconstructiva. Conclusiones: El deterioro previo al diagnóstico de EA está caracterizado por una marcada afectación de la memoria de aprendizaje. Funciones como la gnosis visuoespacial y la praxis visuoconstructiva se deterioran en mayor medida que lo que decrece la puntuación global en el MMSE o lo que aumenta la puntuación en el Test del informador (AU)

Atención sostenida en la fase preclínica de la enfermedad de Alzheimer / Sustained attention in the preclinical phase of Alzheimer´s disease

Introducción. El deterioro atencional en la fase preclínica de la demencia de tipo Alzheimer (DTA) no se conoce bien, ni los estudios disponibles son concluyentes. Objetivo. Planteamos la posibilidad de identificar un trastorno de la atención sostenida en la fase preclínica de la DTA y explorar si este trastorno ayudaría a identificar a aquellos pacientes que, remitidos inicialmente por quejas subjetivas de pérdida de memoria (QSPM), involucionarán en pocos años a DTA. Pacientes y métodos. Comparamos la exploración inicial en una prueba de atención sostenida (CPT) de 70 pacientes remitidos por QSPM, de los cuales 27 involucionaron a DTA en el plazo de 2 años y 43 permanecieron estables. Resultados. Los pacientes que involucionaron presentaron, 2 años antes de su diagnóstico, rendimientos significativamente inferiores a aquellos otros que no involucionaron. Cometieron un mayor número de errores de omisión y obtuvieron un menor número de aciertos. Conclusiones. La prueba de vigilancia tipo CPT es capaz de detectar el deterioro de atención sotenida en la fase preclínica de la DTA y podría ser un indicador objetivo del declinar cognitivo en la fase preclínica de la enfermedad de Alzheimer (AU)

Introduction. Deterioration of attention in the preclinical phase of dementia of Alzheimer’s type (DAT) is not very well-known neither available studies are conclusive. Objective. We outline if would be possible to identify a deficit of sustained attention in preclinical phase of DAT and if this attentional dysfunction could help to identify those patients, referred by subjective memory complaints (SMC), who will progress in a few years to DAT. Patients and methods. We compared basal exploration in a task of sustained attention (CPT) of 70 patients referred by SMC and followed longitudinally for 2 years. Twenty-seven patients developed probable DAT and forty-three remained clinically stable. Results. Patients who will be diagnosed 2 years later with DAT performed significantly more poorly than patients who did not develop DAT. Patients who will be diagnosed 2 years later with DAT made a higher number of omission errors and obtained a lower number of correct responses. Conclusion. CPT paradigm is a vigilance task that detects deterioration of sustained attention in the preclinical phase of DAT and could be an objective indicator of the cognitive decline in the preclinical phase of Alzheimer’s disease (AU)

[Sustained attention in the preclinical phase of Alzheimer's disease]. / La atencion sostenida en la fase preclinica de la enfermedad de Alzheimer.

INTRODUCTION: Deterioration of attention in the preclinical phase of dementia of Alzheimer s type (DAT) is not very well known neither available studies are conclusive. OBJECTIVE: We outline if would be possible to identify a deficit of sustained attention in preclinical phase of DAT and if this attentional dysfunction could help to identify those patients, referred by subjective memory complaints (SMC), who will progress in a few years to DAT. PATIENTS AND METHODS: We compared basal exploration in a task of sustained attention (CPT) of 70 patients referred by SMC and followed longitudinally for 2 years. Twenty seven patients developed probable DAT and forty three remained clinically stable. RESULTS: Patients who will be diagnosed 2 years later with DAT performed significantly more poorly than patients who did not develop DAT. Patients who will be diagnosed 2 years later with DAT made a higher number of omission errors and obtained a lower number of correct responses. CONCLUSION: CPT paradigm is a vigilance task that detects deterioration of sustained attention in the preclinical phase of DAT and could be an objective indicator of the cognitive decline in the preclinical phase of Alzheimer s disease.