Patients with transient ischemic attack (TIA) or minor stroke face a sustained risk of recurrent stroke extending beyond a decade. A systematic review and meta-analysis published in the Circulation was conducted to identify prognostic factors associated with long-term stroke risk and to estimate their population attribution fraction (PAF). 

Databases including MEDLINE, Embase, and Web of Science were searched for cohort studies enrolling patients with TIA or minor stroke, with a minimum follow-up of ≥1 year. Studies assessing predictors of subsequent stroke were included, and pooled adjusted hazard ratios (aHR) were calculated using random-effects models. Certainty of evidence was evaluated using the GRADE framework.

A total of 28 cohort studies comprising 86,810 patients (median age 69 years; 52–60% male) were analyzed. High-certainty evidence identified multiple factors associated with increased long-term stroke risk. These included advancing age (aHR 1.04 per year), male sex (aHR 1.25; PAF 13.0%), atrial fibrillation (AF) (aHR 1.34; PAF 3.8%), diabetes mellitus (DM) (aHR 1.52; PAF 7.7%), hypertension (HTN) (aHR 1.60; PAF 19.3%), and ischemic heart disease (IHD) (aHR 1.67; PAF 10.7%). Prior stroke or TIA (aHR 1.70; PAF 12.0%) and smoking (aHR 1.29; PAF 11.2%) were also significant contributors.

Clinical and imaging characteristics were additionally associated with risk, including ABCD2 score ≥4 (aHR 1.59; PAF 18.0%), acute infarction on neuroimaging (aHR 1.97; PAF 19.0%), and diffusion-weighted imaging positivity (aHR 1.86; PAF 14.0%). Minor stroke (vs TIA) (aHR 1.75; PAF 28.0%), speech deficits, motor deficits, and etiologic subtypes such as cardioembolism, large artery atherosclerosis, and small vessel disease were also linked with elevated risk.

These findings highlight multiple demographic, clinical, and imaging predictors of long-term stroke risk following TIA or minor stroke.