Aggressive early tx after TIA/minor stroke improves outcomes (EXPRESS)

Clinical Question

Does the early use of antiplatelet therapy, statins, and blood pressure control in patients with transient ischemic attacks or minor strokes improve short-term outcomes?

Bottom Line

In this quasi-experimental study, early aggressive management of patients with transient ischemic attacks (TIAs) or minor strokes who were not admitted to the hospital were less likely to have a subsequent stroke than patients receiving customary care. Since the current approach is to admit virtually all of these patients, I'd love to see a multipronged study comparing inpatient versus outpatient evaluation and management strategies. (LOE = 2b-)


Rothwell PM, Giles MF, Chandratheva A, et al. for the Early use of Existing Preventive Strategies for Stroke (EXPRESS) study. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet 2007;370(9596):1432-1442.  [PMID:17928046]

Study Design

Time series




Inpatient (any location) with outpatient follow-up


These authors used a quasi-experimental design to assess whether early aggressive treatment of patients with TIAs or minor strokes prevented subsequent strokes. This study had 2 periods. During the first period (April 2002 to September 2004), the researchers established a referral clinic to assist in managing patients with TIAs or minor strokes who were not admitted to the hospital. These patients had computed tomography scans, electrocardiograms, carotid ultrasounds, and echocardiograms. They were seen daily in an outpatient clinic (or daily home visits for frail patients) for approximately 1 week. The primary care physicians received treatment recommendations tailored to the patient, but they generally included antiplatelet therapy, statins, and blood pressure control. In the second phase of the study (October 2004 to March 2007), the patients were still referred, but the team began treatment immediately. During both study periods, the same standard assessments were conducted. The primary outcome -- subsequent stroke in the 90 days after first seeking care -- was evaluated independently by researchers unaware of treatment period. During the first period, 34 patients (8.5%) had a subsequent stroke compared with 16 (4.1%) during the second period (number needed to treat = 23; 95% CI,13 - 100). The reductions appear to be unaffected by the age or sex of the patients. Quasi-experimental studies like this have many potential threats to the validity of their conclusions. For example, in the second treatment period other secular trends in managing high-risk patients might account for the outcomes and not the program itself. The only way to be certain is to conduct studies using contemporaneous comparison groups.