Autopsy prevalence of coronary atherosclerosis in patients with fatal stroke

Influence of matrix metalloproteinase 9 variant rs17576 on ischemic stroke risk and severity in acute coronary syndrome

BACKGROUND

Ischemic injury is a common mechanism in both ischemic stroke (IS) and acute coronary syndrome (ACS). Matrix metalloproteinase 9 (MMP-9), an endopeptidase that degrades extracellular matrix, is important in the pathogenesis of IS. The purpose of this study is to evaluate the association between the SNP rs17576 in MMP-9 gene with (1) the risk and severity of acute ischemic stroke in Saudi Arab individuals with recent acute coronary syndrome, and (2) the risk of acute coronary syndrome in Saudi Arab individuals without ischemic stroke.

METHODS

A case control study of 200 IS patients, 520 ACS patients (without IS), and 500 aged-matched healthy controls were genotyped to detect the MMP-9 polymorphism rs17156.

RESULTS

Our study demonstrated a non-significant difference in the genotype and allele frequencies of the MMP9 rs17576 polymorphism between the patients with IS and patients with ACS without IS (P = 0.31 for the GA genotype, 0.25 for the AA genotype and P = 0.20 for the A allele). AA genotype was found to be statistically significant between IS and control groups; [OR=1.84, 95 % CI (1.08-3.14), p =0.015]. A allele showed a significant difference between the two groups [OR=1.28, 95 % CI (1.00-1.64), p =0.028]. By comparing ACS without IS and controls, AA genotype was significant [OR=1.46, 95 % CI (1.01-2.12), p =0.029]. Stratification by NIHSS score revealed higher mortality and early neurologic deterioration in IS patients with NIHSS score ≥ 16 (p < 0.001, 0.044 respectively).

CONCLUSION

We deduced the lack of association either with allele or genotype frequencies (p>0.05) between the IS cases and the cases of ACS without IS. In contrast there was a significant association of mutant genotype AA between either the IS group or ACS (without IS) group, and the control group. In addition, different rs17576 genotypes were not associated with raised mortality or a tendency to develop early neurologic deterioration.

High Prevalence of New Clinically Significant Findings in Patients With Embolic Stroke of Unknown Source Evaluated by Cardiac Magnetic Resonance Imaging

BACKGROUND

Embolic stroke of unknown source (ESUS) accounts for 1 in 6 ischemic strokes. Current guidelines do not recommend routine cardiac magnetic resonance (CMR) imaging in ESUS, and beyond the identification of cardioembolic sources, there are no data assessing new clinical findings from CMR in ESUS. This study aimed to assess the prevalence of new cardiac and noncardiac findings and to determine their impact on clinical care in patients with ESUS.

METHODS AND RESULTS

In this prospective, multicenter, observational study, CMR imaging was performed within 3 months of ESUS. All scans were reported according to standard clinical practice. A new clinical finding was defined as one not previously identified through prior clinical evaluation. A clinically significant finding was defined as one resulting in further investigation, follow-up, or treatment. A change in patient care was defined as initiation of medical, interventional, surgical, or palliative care. From 102 patients recruited, 96 underwent CMR imaging. One or more new clinical findings were observed in 59 patients (61%). New findings were clinically significant in 48 (81%) of these patients. Of 40 patients with a new clinically significant cardiac finding, 21 (53%) experienced a change in care (medical therapy, n=15; interventional/surgical procedure, n=6). In 12 patients with a new clinically significant extracardiac finding, 6 (50%) experienced a change in care (medical therapy, n=4; palliative care, n=2).

CONCLUSIONS

CMR imaging identifies new clinically significant cardiac and noncardiac findings in half of patients with recent ESUS. Advanced cardiovascular screening should be considered in patients with ESUS.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04555538.

Imaging Carotid Plaque Inflammation Using Positron Emission Tomography: Emerging Role in Clinical Stroke Care, Research Applications, and Future Directions

Atherosclerosis is a chronic systemic inflammatory condition of the vasculature and a leading cause of stroke. Luminal stenosis severity is an important factor in determining vascular risk. Conventional imaging modalities, such as angiography or duplex ultrasonography, are used to quantify stenosis severity and inform clinical care but provide limited information on plaque biology. Inflammatory processes are central to atherosclerotic plaque progression and destabilization. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a validated technique for quantifying plaque inflammation. In this review, we discuss the evolution of FDG-PET as an imaging modality to quantify plaque vulnerability, challenges in standardization of image acquisition and analysis, its potential application to routine clinical care after stroke, and the possible role it will play in future drug discovery.

Additional prognostic value of stress cardiovascular magnetic resonance for cardiovascular risk stratification after a cryptogenic ischemic stroke

Background

One-third of ischemic strokes are “cryptogenic” without clearly identified etiology. Although coronary artery disease (CAD) is the main cause of death after stroke, the interest in CAD screening in patients with cryptogenic stroke is still debated.

Aim

The aim of the study was to assess the incremental prognostic value of stress cardiovascular magnetic resonance (CMR) beyond traditional risk factors for predicting cardiovascular events in patients with a prior cryptogenic ischemic stroke.

Materials and methods

Between 2008 and 2021, consecutive patients with prior cryptogenic strokes referred for stress CMR were included and followed for the occurrence of major adverse cardiovascular events (MACEs), defined by cardiovascular death or non-fatal myocardial infarction (MI). Univariable and multivariable Cox regressions were performed to determine the prognostic value of unrecognized MI and silent ischemia.

Results

Of 542 patients (55.2% male, mean age 71.4 ± 8.8 years) who completed the follow-up (median 5.9 years), 66 (12.2%) experienced MACE. Silent ischemia and unrecognized MI were detected in 18 and 17% of patients, respectively. Using Kaplan–Meier analysis, silent ischemia and unrecognized MI were associated with the occurrence of MACE [hazard ratio, HR: 8.43 (95% CI: 5.11–13.9); HR: 7.87 (95% CI: 4.80–12.9), respectively, p < 0.001]. In multivariable analysis, silent ischemia and unrecognized MI were independent predictors of MACE [HR: 8.08 (95% CI: 4.21–15.5); HR: 6.65 (95% CI: 3.49–12.7), respectively, p < 0.001]. After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors (C-statistic improvement: 0.13; NRI = 0.428; IDI = 0.048).

Conclusion

In patients with prior cryptogenic stroke, stress CMR findings have an incremental prognostic value to predict MACE over traditional risk factors.

Incidence of Acute Myocardial Infarction in Patients Presenting With Cerebrovascular Accident in a Tertiary Care Centre in Eastern India

Acute myocardial infarction in individuals who have had a cerebrovascular accident or transient ischemic attack (CVA-TIA) is a medical emergency, which must be examined and treated as soon as possible. Physicians face a significant problem in managing this scenario because early treatment of one ailment would surely postpone treatment of the other. Early detection and treatment will have an impact on the patient's morbidity and mortality in the future, as well as aid in the patient's rehabilitation. On the basis of ECG alterations and cardiac biomarkers, a prospective observational study was conducted in 103 diagnosed CVA patients to investigate the incidence of myocardial infarction. Infarct and hemorrhagic CVA cases were evenly distributed. According to the age-based distribution, the highest rate of myocardial infarction (8%, 8) was observed in those aged 51-60 years. The male-to-female ratio is 1.86:1. Thirty-two patients had diabetes, among them 75% had only elevated creatine kinase MB (CKMB) with no myocardial infarction (MI), whereas 59 patients had hypertension of which 70% had only elevated CK-MB with no MI. ST-elevation myocardial infarction (STEMI) with high CKMB accounted for 14.78% (15) of the cases, but the majority (71%, 73) of the cases had elevated CKMB with no MI, and the rest presented with normal CKMB. Elevated CKMB with or without STEMI serves as a poor prognosticating factor. Therefore, these patients should be managed on a priority basis for a better outcome.

Metabolic syndrome in patients with first-ever ischemic stroke: prevalence and association with coronary heart disease

The metabolic syndrome (MetS) has been well linked with coronary heart disease (CHD) in the general population, but studies have rarely explored their association among patients with stroke. We examine prevalence of MetS and its association with CHD in patients with first-ever ischemic stroke. This hospital-based study included 1851 patients with first-ever ischemic stroke (mean age 61.2 years, 36.5% women) who were hospitalized into two university hospitals in Shandong, China (January 2016–February 2017). Data were collected through interviews, physical examinations, and laboratory tests. MetS was defined following the National Cholesterol Education Program (NCEP) criteria, the International Diabetes Federation (IDF) criteria, and the Chinese Diabetes Society (CDS) criteria. CHD was defined following clinical criteria. Data were analyzed using binary logistic regression models. The overall prevalence of MetS was 33.4% by NECP criteria, 47.2% by IDF criteria, and 32.5% by CDS criteria, with the prevalence being decreased with age and higher in women than in men (p < 0.05). High blood pressure, high triglycerides, and low HDL-C were significantly associated with CHD (multi-adjusted odds ratio [OR] range 1.27–1.38, p < 0.05). The multi-adjusted OR of CHD associated with MetS defined by the NECP criteria, IDF criteria, and CDS criteria (vs. no MetS) was 1.27 (95% confidence interval 1.03–1.57), 1.44 (1.18–1.76), and 1.27 (1.03–1.57), respectively. In addition, having 1–2 abnormal components (vs. none) of MetS was associated with CHD (multi-adjusted OR range 1.66–1.72, p < 0.05). MetS affects over one-third of patients with first-ever ischemic stroke. MetS is associated with an increased likelihood of CHD in stroke patients.

Prediction of Hidden Coronary Artery Disease Using Machine Learning in Patients With Acute Ischemic Stroke

BACKGROUND AND OBJECTIVES

A machine learning technique for identifying hidden coronary artery disease (CAD) might be useful. We developed and validated machine learning models to predict patients with hidden CAD and assess long-term outcomes in patients with acute ischemic stroke.

METHODS

Multidetector coronary computed tomography was performed for patients without known history of CAD. Primary outcomes were defined as having any degree of CAD and having obstructive CAD (≥50% stenosis). Demographic variables, risk factors, laboratory results, Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification, NIH Stroke Scale score, blood pressure, and carotid artery stenosis were used to develop and validate machine learning models to predict CAD. Area under the receiver operating characteristic curves (AUC) was calculated for performance analysis, and Kaplan-Meier and Cox survival analyses of long-term outcomes were performed. Major adverse cardiovascular events (MACE) were defined as ischemic stroke, myocardial infarction, unstable angina, urgent coronary revascularization, and cardiovascular mortality.

RESULTS

Overall, 1,710 patients were included for the training dataset and 348 patients for the validation dataset. An Extreme Gradient Boosting model was developed to predict any degree of CAD, which showed an AUC of 0.763 (95% CI 0.711-0.814) on validation. A logistic regression model was used to predict obstructive CAD and had an AUC of 0.714 (95% CI 0.692-0.799). During the first 5 years of follow-up, MACE occurred more frequently when predicted of any CAD (P = 0.022) or obstructive CAD (P < 0.001). Cox proportional analysis showed that the hazard ratio of MACE was 1.5 (95% CI 1.1-2.2; P = 0.016) when predicted of any CAD, whereas it was 1.9 (95% CI 1.3-2.6; P < 0.001) for obstructive CAD.

DISCUSSION

We demonstrated that machine learning may help identify hidden CAD in patients with acute ischemic stroke. Long-term outcomes were also associated with prediction results.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that in patients with acute ischemic stroke with CAD risk factors but no known history of CAD, a machine learning model predicts CAD on multidetector coronary computed tomography with an AUC of 0.763 (95% CI 0.711-0.814).

Use of Coronary CT Angiography as a Screening Tool for Coronary Artery Disease in Asymptomatic Healthy Individuals or Patients

심장 돌연사 환자들은 종종 흉통 또는 운동성 호흡곤란 등의 전조증상이 나타나지 않기 때문에 잠재적인 무증상 관상동맥 질환을 조기에 발견하는 것이 매우 중요하다. 관상동맥 전산화단층촬영 혈관조영술은 방사선 노출로 인한 위험성 때문에 무증상 환자에서 스크리닝 검사로 정당화되지 못했었지만 최근에 전산화단층촬영 기술의 비약적인 발전으로 방사선량을 1 mSv 미만으로 최소화함으로써 무증상 환자의 관상동맥 질환 선별 검사의 유용성에 대한 많은 연구가 진행되어 왔다. 그러나, 여전히 무증상 정상인 또는 환자의 관상동맥 질환 선별 검사에 대한 관상동맥 전산화단층촬영 혈관조영술의 유용성에 대해서는 다양한 의견들이 있다. 이 종설에서는 무증상 정상인 또는 환자들에게 관상동맥 질환 선별 검사로 관상동맥 칼슘 점수와 관상동맥 전산화단층촬영 혈관조영술 유용성에 대해서 다양한 문헌고찰을 통해서 알아보았다. 관상동맥 전산화단층촬영 혈관조영술상 무증상 정상인의 2.6%에서 70% 이상의 유의한 관상동맥 협착이 발견되었고, 선별 목적의 관상동맥 전산화단층촬영 혈관조영술이 무증상 건강한 사람의 미래의 심혈관 질환 발생을 예측할 수 있다. 그러나 현재 미국국립보건원에서 진행하고 있는 SCOT-HEART 2 연구가 끝나면 관상동맥 전산화단층촬영 혈관조영술이 무증상 성인의 심혈관 예방에 선별 검사로 적절한지 결정을 내릴 수 있을 것으로 생각된다.

Cervicocerebral atherosclerosis and its hepatic and coronary risk factors in patients with liver cirrhosis

Background/Aims

We aimed to investigate the silent atherosclerotic burden of cervicocephalic vessels in cirrhotic patients compared with the general population, as well as the relevant risk factors including coronary parameters.

Methods

This study included 993 stroke-free patients with liver cirrhosis (LC) who underwent magnetic resonance angiography (MRA) of the head and neck as a pre-liver transplant assessment and 6,099 health checkup participants who underwent MRA examination. The two cohorts were matched for cerebrovascular risk factors, and the prevalence of atherosclerosis in major intracranial and extracranial arteries was compared in 755 matched pairs. Moreover, traditional, hepatic, and coronary variables related to cerebral atherosclerosis were assessed in cirrhotic patients.

Results

Overall, intracranial atherosclerosis was significantly less prevalent in the LC group than in the matched control group (2.3% vs. 5.4%, P=0.002), whereas the prevalence of extracranial atherosclerosis was similar (4.4% vs. 5.8%, P=0.242). These results were maintained in multivariate analyses of the pooled samples, with corresponding adjusted odds ratios [ORs] of LC of 0.56 and 0.77 (95% confidence intervals [CIs], 0.36–0.88 and 0.55–1.09). In the LC group, lower platelet count was inversely correlated with intracranial atherosclerosis (adjusted OR, 0.31; 95% CI, 0.13–0.76). Coronary artery calcium (CAC) score ≥100 was the only predictive factor for both intracranial and extracranial atherosclerosis (adjusted ORs, 4.06 and 5.43, respectively).

Conclusions

LC confers protection against intracranial atherosclerosis, and thrombocytopenia may be involved in this protective effect. High CAC score could serve as a potential surrogate for cervicocerebral vascular screening in asymptomatic cirrhotic patients.

Risk Stratification in Patients with Ischemic Stroke and Residual Cardiovascular Risk with Current Secondary Prevention

Purpose

Suboptimal secondary prevention in patients with stroke causes a remaining cardiovascular risk desirable to reduce. We have validated a prognostic model for secondary preventive settings and estimated future cardiovascular risk and theoretical benefit of reaching guideline recommended risk factor targets.

Patients and Methods

The SMART-REACH (Secondary Manifestations of Arterial Disease-Reduction of Atherothrombosis for Continued Health) model for 10-year and lifetime risk of cardiovascular events was applied to 465 patients in the Norwegian Cognitive Impairment After Stroke (Nor-COAST) study, a multicenter observational study with two-year follow-up by linkage to national registries for cardiovascular disease and mortality. The residual risk when reaching recommended targets for blood pressure, low-density lipoprotein cholesterol, smoking cessation and antithrombotics was estimated.

Results

In total, 11.2% had a new event. Calibration plots showed adequate agreement between estimated and observed 2-year prognosis (C-statistics 0.63, 95% confidence interval 0.55–0.71). Median estimated 10-year risk of recurrent cardiovascular events was 42% (Interquartile range (IQR) 32–54%) and could be reduced to 32% by optimal guideline-based therapy. The corresponding numbers for lifetime risk were 70% (IQR 63–76%) and 61%. We estimated an overall median gain of 1.4 (IQR 0.2–3.4) event-free life years if guideline targets were met.

Conclusion

Secondary prevention was suboptimal and residual risk remains elevated even after optimization according to current guidelines. Considerable interindividual variation in risk exists, with a corresponding variation in benefit from intensification of treatment. The SMART-REACH model can be used to identify patients with the largest benefit from more intensive treatment and follow-up.

Predictors of Concomitant Coronary Artery Disease and Major Cardiovascular Events in Patients with Acute Ischemic Stroke

Background

Coronary artery disease (CAD) and ischemic stroke share the same risk factors.

Objective

The aim of the study was to explore the prevalence and predictors of concomitant CAD in acute ischemic stroke patients.

Methods

One hundred and five patients (64.3 ± 15.0 years, 61 male) presenting with acute ischemic stroke documented by neuroimaging were consecutively included. All patients were carefully evaluated to determine their cardiovascular disease risk scores. The patients who had been previously shown to have ≥50% stenosis in at least one of the major coronary arteries by coronary angiography were grouped as CAD patients.

Results

Of the 105 stroke patients, 27 patients had documented concomitant CAD. The stroke patients with CAD had higher cardiovascular risk scores and troponin I levels and carotid plaques were more prevalent. ROC analysis determined cut-off values as ≥22% for Framingham Heart Study Risk Score, ≥0.05 ng/mL for Troponin I, and ≥0.80 mm for carotid artery intima-media thickness to predict concomitant CAD. During 6 months of follow-up, among the 78 stroke patients without documented CAD, 16 patients had experienced major cardiovascular events including myocardial infarction, recurrent stroke, or cardiovascular death. These patients had higher Framingham Heart Study Risk Score and high-sensitive C reactive protein levels.

Conclusion

Our study suggests stroke patients with higher Framingham Heart Study Risk Score and troponin I levels and carotid plaques be further investigated for the presence of concomitant CAD.

Population-based Study Comparing Predictors of Ischemic Stroke Recurrence After Index Ischemic Stroke in Non-elderly Adults with or without Diabetes

BACKGROUND AND PURPOSE

Factors associated with ischemic stroke (IS) recurrence and the contribution of pharmacological treatment as secondary preventions among nondiabetics especially in the non-elderly population are unclear and not widely investigated. This was a population-based study that aimed to identify recurrent IS predictors and to determine the possible impact of secondary preventive medications on the IS recurrence in non-elderly adults with or without diabetes.

METHODS

Data of 3386 patients <60 years old who had a history of index IS were extracted from the Malaysian National Neurology Registry (NNEUR) from 2009 to 2016. Recurrent IS was defined as any IS event recorded after the index IS in the NNEUR database. Multivariate logistic regression analysis was performed by using SPSS version 22.

RESULTS

Ischemic heart disease (IHD) was the significant predictor of IS recurrence in non-elderly adults both with or without diabetes (adjusted odds ratio (AOR) of 3.210; 95%CI: 1.909-5.398 and 2.989; 95%CI: 1.515-5.894) respectively). Receiving antiplatelet as secondary stroke prevention (AOR: 0.194; 95%CI: 0.046-0.817) and continuation of antidiabetic medication after the index IS event (AOR: 0.510; 95%CI: 0.298-0.872) reduced the odds of IS recurrence only in non-elderly diabetic adults. Among non-elderly adults without diabetes, hyperlipidemia and every increased in 1 mmHg of systolic blood pressure significantly increased the odds of IS recurrence following the indexing event (AOR: 1.796; 95%CI: 1.058-3.051 and 1.009; 95%CI: 1.002-1.016 respectively).

CONCLUSION

IHD was found as the main predictor of IS recurrence regardless of diabetes status in non-elderly adults after the index IS event. Receiving antidiabetic and antiplatelet medications upon discharge after index IS were significant predictors of recurrent IS in non-elderly diabetic adults. A proper randomized clinical trial may be required to determine the impact of secondary preventive medication on IS recurrence, especially in non-elderly adults.

Risk of a coronary event in patients after ischemic stroke or transient ischemic attack

Coronary artery disease (CAD) together with stroke are the leading causes of death worldwide, and together, they pre-sent a health and economic burden. Ischemic stroke survivors and patients who suffered transient ischemic attack (TIA) have a higher prevalence of coronary atherosclerosis, and they have a relatively high risk of myocardial infarcti-on and nonstroke vascular death. Pubmed was searched for studies focused on investigating coronary atherosclerosis in ischemic stroke survivors or patients who suffered TIA and their cardiovascular risk assessment. There were corona-ry plaques in 48%-70% of stroke survivors without a known history of CAD, and significant stenosis of at least one coronary artery can be found in 31% of these patients. CAD is a major cause of morbidity and mortality in stroke survivors. Detection and treatment of silent CAD may improve the long-term outcome and survival of these patients.

Association between Pre-Existing Coronary Artery Disease and 5-Year Mortality in Stroke Patients with High-Grade Carotid Artery Stenosis

BACKGROUND

The coincidence of coronary artery disease (CAD) and carotid artery stenosis (CAS) was observed. However, the association between pre-existing CAD and ischemic stroke (IS) outcome in patients with high-grade CAS remains unclear. We aimed to investigate the association between pre-existing CAD and outcomes of acute IS patients with high-grade CAS.

METHODS

From January 1, 2007, to April 30, 2012, we enrolled 372 acute IS patients with high-grade CAS and prospectively observed them for 5 years. Demographic features, vascular risk factors, comorbidities, and outcomes were compared between patients with and without pre-existing CAD.

RESULTS

Among 372 individuals, 75 (20.2%) patients had pre-existing CAD and 297 (79.8%) patients did not have pre-existing CAD. The prevalence rates of hypertension, congestive heart failure, chronic kidney disease, and gout in patients with pre-existing CAD were significantly higher than in those without pre-existing CAD (p = 0.017, p < 0.001, p = 0.002, and p < 0.001, respectively). The multivariate Cox proportional hazards model revealed that pre-existing CAD was a significant risk factor for a 5-year all-cause mortality in acute IS patients with high-grade CAS (hazard ratio = 2.26; 95% confidence interval = 1.35-3.79; p = 0.002).

CONCLUSION

Pre-existing CAD was associated with an increased risk of 5-year mortality in acute IS patients with high-grade CAS. Intensive treatment for the pre-existing CAD may reduce long-term mortality in acute IS patients with high-grade CAS.

Prognostic Value of Coronary CT Angiography for Predicting Poor Cardiac Outcome in Stroke Patients without Known Cardiac Disease or Chest Pain: The Assessment of Coronary Artery Disease in Stroke Patients Study

Objective

To assess the incremental prognostic value of coronary computed tomography angiography (CCTA) in comparison to a clinical risk model (Framingham risk score, FRS) and coronary artery calcium score (CACS) for future cardiac events in ischemic stroke patients without chest pain.

Materials and Methods

This retrospective study included 1418 patients with acute stroke who had no previous cardiac disease and underwent CCTA, including CACS. Stenosis degree and plaque types (high-risk, non-calcified, mixed, or calcified plaques) were assessed as CCTA variables. High-risk plaque was defined when at least two of the following characteristics were observed: low-density plaque, positive remodeling, spotty calcification, or napkin-ring sign. We compared the incremental prognostic value of CCTA for major adverse cardiovascular events (MACE) over CACS and FRS.

Results

The prevalence of any plaque and obstructive coronary artery disease (CAD) (stenosis ≥ 50%) were 70.7% and 30.2%, respectively. During the median follow-up period of 48 months, 108 patients (7.6%) experienced MACE. Increasing FRS, CACS, and stenosis degree were positively associated with MACE (all p < 0.05). Patients with high-risk plaque type showed the highest incidence of MACE, followed by non-calcified, mixed, and calcified plaque, respectively (log-rank p < 0.001). Among the prediction models for MACE, adding stenosis degree to FRS showed better discrimination and risk reclassification compared to FRS or the FRS + CACS model (all p < 0.05). Furthermore, incorporating plaque type in the prediction model significantly improved reclassification (integrated discrimination improvement, 0.08; p = 0.023) and showed the highest discrimination index (C-statistics, 0.85). However, the addition of CACS on CCTA with FRS did not add to the prediction ability for MACE (p > 0.05).

Conclusion

Assessment of stenosis degree and plaque type using CCTA provided additional prognostic value over CACS and FRS to risk stratify stroke patients without prior history of CAD better.

Coronary Calcium Score and Stratification of Coronary Artery Disease Risk in Patients with Atherosclerotic and Non-Atherosclerotic Ischemic Stroke

BACKGROUND

Ischemic Stroke (IS) and Coronary Artery Disease (CAD) frequently coexist and share atherosclerotic disease risk factors. According to the American Heart Association, IS subtypes may be considered CAD risk equivalents, but the evidence for non-atherosclerotic IS is uncertain. Additionally, the Coronary Calcium Score (CCS) is an accurate marker to address CAD risk; however, CCS distribution between IS subtypes is not well characterized.

OBJECTIVES

To compare the CCS between atherosclerotic and non-atherosclerotic IS groups; and to determine which covariates were associated with high CCS in IS.

METHODS

This cross-sectional design included all patients with IS, 45 to 70 years of age at the time of the stroke, consecutively admitted to a rehabilitation hospital between August 2014 and December 2016, without prevalent CAD. All patients underwent CT scanning for CCS measurement. CCS≥100 was considered a high risk for CAD, with a significance level of p<0.05.

RESULTS

From the 244 studied patients (mean age 58.4±6.8 years; 49% female), 164 (67%) had non-atherosclerotic etiology. The proportions of CCS≥100 were similar between the atherosclerotic and the non-atherosclerotic groups (33% [n=26] x 29% [n=47]; p= 0.54). Among all IS patients, only age ≥60 years was independently associated with CCS≥100 (OR 3.5; 95%CI 1.7-7.1), accounting for hypertension, dyslipidemia, diabetes, sedentarism, and family history of CAD.

CONCLUSION

Atherosclerotic IS did not present a greater risk of CAD when compared to non-atherosclerotic IS according to CCS. Only age ≥60 years, but not etiology, was independently associated with CCS≥100.

Prevalence and predictors of coronary artery disease in patients undergoing carotid artery stenting

INTRODUCTION

A relationship between carotid stenosis and coronary arterial disease (CAD) is widely accepted; however, data on the exact prevalence of coronary disease in patients with severe carotid stenosis are lacking. Information on the prevalence and predictors of CAD among these patients could impact diagnostic and treatment approaches.

AIM

The primary aim of this study was to determine the prevalence of significant CAD among patients referred for carotid artery revascularization. The secondary objectives included characterizing the association between the level of advancement of carotid stenosis and the presence of CAD, and between atherosclerotic risk factors and the presence of CAD in patients with carotid stenosis, and also to determine whether there was a difference in the prevalence of CAD between patients with symptomatic versus asymptomatic carotid stenosis.

PATIENTS AND METHODS

We included 200 patients with severe carotid stenosis, of whom 77 (38.5%) had symptomatic stenosis. All patients underwent coronary angiography no more than 6 months before the scheduled carotid revascularization. Of the 200 total of patients, 192 underwent carotid stenting, six underwent carotid endarterectomy, and two were treated conservatively. CAD was defined as stenosis of at least 50% on recent coronary angiography or a history of previous percutaneous coronary intervention and/or coronary aortic bypass graft; the prevalence was 77.5% among our patients. There was no statistically significant difference in the prevalence of CAD between patients with unilateral versus bilateral carotid stenosis or contralateral carotid occlusion. The difference in the severity of coronary disease, which was given by the SYNTAX score, was not significant between these groups. Factors associated with the presence of CAD were male sex, a history of smoking, and global or regional wall motion disorder on echocardiography. We did not find any significant difference in the prevalence of CAD between patients with symptomatic versus asymptomatic carotid stenosis.

CONCLUSION

We observed a very high prevalence of concomitant CAD in patients with severe carotid stenosis. The results of our study suggest that routine preprocedural screening for CAD in patients with carotid artery stenosis could identify a large proportion of patients with silent CAD; whether treatment for CAD before carotid revascularization can prevent periprocedural myocardial infarction should be addressed in a randomized-controlled trial.

[Troponin elevation in acute ischemic stroke-unspecific or acute myocardial infarction? : Diagnostics and clinical implications]

Routine determination of troponin levels is recommended for all patients with acute ischemic stroke. In 20-55% of these patients the troponin levels are elevated, which may be caused by ischemic as well as non-ischemic myocardial damage and particularly neurocardiogenic myocardial damage. In patients with acute ischemic stroke, the prevalence of previously unknown coronary heart disease is reported to be up to 27% and is prognostically relevant for these patients; however, relevant coronary stenoses are less frequently detected in stroke patients with troponin elevation compared to patients with non-ST elevation myocardial infarction. The risk of secondary intracerebral hemorrhage due to the necessity for dual platelet aggregation inhibition illustrates the challenging indication for invasive coronary diagnostics and revascularization. Therefore, a diagnostic work-up and interdisciplinary risk evaluation appropriate to the urgency are necessary in order to be able to determine a reasonable treatment approach with timing of the intervention, type and duration of blood thinning. In addition to conventional examination methods, multimodal cardiac imaging is increasingly used for this purpose. This review article aims to provide a pragmatic and clinically oriented approach to diagnostic and therapeutic procedures, taking into account the available evidence.

Coronary Calcium Score for the Prediction of Asymptomatic Coronary Artery Disease in Patients With Ischemic Stroke

Purpose: Many patients with ischemic stroke have concomitant coronary artery disease (CAD). However, it remains unclear which stroke patients should undergo evaluation for asymptomatic CAD, and which screening tools are appropriate. We investigated the role of coronary artery calcium (CAC) score as a screening tool for asymptomatic but severe CAD in acute stroke patients. We determined the selection criteria for CAC screening based on risk factors and cerebral atherosclerosis.

Materials and Methods: The present study included consecutive patients with acute stroke who had undergone cerebral angiography and multi-detector computed tomography coronary angiography. Severe CAD was defined as left main artery disease or three-vessel disease. Enrolled patients were randomly assigned to two sets; a set for developing selection criteria and a set for validation. To develop selection criteria, we identified associated factors with severe CAD regarding clinical factors and cerebral atherosclerosis. CAD predictability of selection criteria with the CAC score was calculated.

Results: Overall, 2,658 patients were included. Severe CAD was present in 360 patients (13.5%). CAC score was associated with CAD severity (P < 0.001). In the development set (N = 1,860), severe CAD was associated with age >65 years [odds ratio (95% confidence interval), 2.62 (1.93–3.55)], male sex (1.81 [1.33–2.46]), dyslipidemia (1.77 [1.25–2.61]), peripheral artery disease (2.64 [1.37–5.06]) and stenosis in the cervicocephalic branches, including the internal carotid (2.79 [2.06–3.78]) and vertebrobasilar arteries (2.08 [1.57–2.76]). We determined the combination of clinical and arterial factors as the selection criteria for CAC evaluation. The cut-off criterion was two or more elements of the selection criteria. The area under the curve (AUC) of the selection criteria was 0.701. The AUC significantly improved to 0.836 when the CAC score was added (P < 0.001). In the validation set (N = 798), the AUC of the selection criteria only was 0.661, and that of the CAC score was 0.833. The AUC of the selection criteria + CAC score significantly improved to 0.861(P < 0.001).

Conclusion: The necessity for CAC evaluation could be determined based on the presence of risk factors and significant stenosis of the cervicocephalic arteries. CAC evaluation may be useful for screening for severe CAD in stroke patients.

Using Network Pharmacology to Explore Potential Treatment Mechanism for Coronary Heart Disease Using Chuanxiong and Jiangxiang Essential Oils in Jingzhi Guanxin Prescriptions

Background

To predict the active components and potential targets of traditional Chinese medicine and to determine the mechanism behind the curative effect of traditional Chinese medicine, a multitargeted method was used. Jingzhi Guanxin prescriptions expressed a high efficacy for coronary heart disease (CHD) patients of which essential oils from Chuanxiong and Jiangxiang were confirmed to be the most important effective substance. However, the interaction between the active components and the targets for the treatment of CHD has not been clearly explained in previous studies.

Materials and Methods

Genes associated with the disease and the treatment strategy were searched from the electronic database and analyzed by Cytoscape (version 3.2.1). Protein-protein interaction network diagram of CHD with Jiangxiang and Chuanxiong essential oils was constructed by Cytoscape. Pathway functional enrichment analysis was executed by clusterProfiler package in R platform.

Results

121 ingredients of Chuanxiong and Jiangxiang essential oils were analyzed, and 393 target genes of the compositions and 912 CHD-related genes were retrieved. 15 coexpression genes were selected, including UGT1A1, DPP4, RXRA, ADH1A, RXRG, UGT1A3, PPARA, TRPC3, CYP1A1, ABCC2, AHR, and ADRA2A. The crucial pathways of occurrence and treatment molecular mechanism of CHD were analyzed, including retinoic acid metabolic process, flavonoid metabolic process, response to xenobiotic stimulus, cellular response to xenobiotic stimulus, cellular response to steroid hormone stimulus, retinoid binding, retinoic acid binding, and monocarboxylic acid binding. Finally, we elucidate the underlying role and mechanism behind these genes in the pathogenesis and treatment of CHD.

Conclusions

Generally speaking, the nodes in subnetwork affect the pathological process of CHD, thus indicating the mechanism of Jingzhi Guanxin prescriptions containing Chuanxiong and Jiangxiang essential oils in the treatment of CHD.

Prevalence of Systemic Atherosclerosis Burdens and Overlapping Stroke Etiologies and Their Associations With Long-term Vascular Prognosis in Stroke With Intracranial Atherosclerotic Disease

Importance

Patients who have experienced stroke with intracranial atherosclerotic disease (ICAD) may also have concomitant atherosclerosis in different arterial beds and other possible causes for ischemic stroke. However, little is known about the frequency and prognostic effect of such overlapping diseases.

Objectives

To describe the prevalence of systemic atherosclerotic burdens and overlapping stroke etiologies and their contributions to long-term prognoses among patients who have experienced stroke with ICAD.

Design, Setting, and Participants

The Asymptomatic Myocardial Ischemia in Stroke and Atherosclerotic Disease study is a single-center prospective study in which 405 patients with acute ischemic stroke within 10 days of onset were consecutively enrolled between June 2005 and December 2008 and followed up for 4 years. After excluding 2 patients because of incomplete investigations, 403 were included in this analysis.

Main Outcomes and Measures

Significant ICAD was defined as having 50% or greater stenosis/occlusion by contrast-enhanced/time-of-flight magnetic resonance angiography, computed tomography angiography, and/or transcranial Doppler ultrasonography. Systemic vascular investigations on atherosclerotic disease were performed with ultrasonography in carotid arteries, aorta and femoral arteries, and by angiography in coronary arteries. Coexistent stroke etiologies were assessed using the atherosclerosis, small-vessel disease, cardiac pathology, other cause, and dissection (ASCOD) grading system. We estimated the 4-year risk of major adverse cardiovascular events (MACE), including vascular death, nonfatal cardiac events, nonfatal stroke, and major peripheral arterial events.

Results

Of 403 participants, 298 (74%) were men and the mean (SD) age was 62.6 (13.1) years. Significant ICAD was found in 146 (36.2%). Patients with significant ICAD more often had aortic arch (70 [60.9%] vs 99 [49.0%]; P = .04) and coronary artery (103 [76.9%] vs 153 [63.2%]; P = .007) atherosclerosis than those without. Among patients with ICAD, concurrent stenosis in the extracranial carotid artery (24 [23.4%] vs 3 [9.0%]; P = .08; adjusted hazard ratio[aHR] = 2.12) and the coronary artery (19 [29.9%] vs 8 [12.8%]; P = .01; aHR = 1.90) increased the MACE risk. Furthermore, patients with ICAD who also had any cardiac pathology (ASCOD grade C1-3) were at a higher MACE risk than others (grade C0) (20 [28.2%] vs 7 [11.4%]; P = .01; aHR = 2.24). By contrast, patients with ICAD with any form of small vessel disease (grade S1-3) had a lower MACE risk than those without (grade S0) (20 [17.3%] vs 6 [34.6%]; P = .05; aHR = 0.23).

Conclusions and Relevance

Patients with ICAD often have coexisting systemic atherosclerosis and multiple potential stroke mechanisms that affect their prognosis, suggesting that extensive evaluations of overlapping diseases may allow better risk stratification.

Reconstruction of the lncRNA-miRNA-mRNA network based on competitive endogenous RNA reveal functional lncRNAs in Cerebral Infarction

Functioning as miRNA sponges, long non-coding RNA (lncRNA) exert its pharmacological action via regulating expression of protein-coding genes. However, the lncRNA-mediated ceRNA in cerebral Infarction (CI) remains unclear. In this study, the expression recordsets of mRNA, lncRNA and miRNA of CI samples were obtained from the NCBI GEO datasets separately. The differentially expressed lncRNAs (DELs), miRNAs (DEMis) and mRNAs (DEMs) were identified by limma package in R platform. A total of 267 DELs, 26 DEMis, and 760 DEMs were identified as differentially expressed profiles, with which we constructed the ceRNA network composed of DELs-DEMis-DEMs. Further, clusterProfiler package in R platform is employed for performing Gene Ontology (GO) and KEGG pathway analysis. An aberrant ceRNA network was constructed according to node degrees in CI, including 28 DELs, 19 DEMs and 12 DEMis, from which we extracted the core network, in which 9 nodes were recognized as kernel genes including Tspan3, Eif4a2, rno-miR-208a-3p, rno-miR-194-5p, Pdpn, H3f3b, Stat3, Cd63 and Sdc4. Finally, with the DELs-DEMis-DEMs ceRNA network provided above, we can improve our understanding of the pathogenesis of CI mediated by lncRNA.

Body mass index and fatal stroke in young adults: A national study

Rates of stroke and obesity have increased in recent years. This study aimed to determine the body mass index (BMI) of fatal stroke cases amongst young adults, their clinical characteristics and the association with BMI with risk factors. All cases aged 15-44 years where death was attributed to stroke for whom BMI was available were retrieved from the National Coronial Information System (1/1/2009-31/12/2016). 179 cases were identified: haemorrhagic (165), ischaemic (5), thrombotic (6), mycotic (3), embolic (0). Proportions in each BMI category were: underweight (5.6%), normal weight (37.4%), overweight (27.4%), obese (29.6%). There was a significant linear trend in the proportion of subarachnoid haemorrhages as BMI increased (p < 0.05), and between higher BMI and hypertension (p < 0.001). There were no group differences in cardiomegaly or left ventricular hypertrophy where known causes were other than hypertension, cardiomyopathy, severe coronary artery atherosclerosis, endocarditis or cerebral arteries atherosclerosis. A history of alcoholism (p < 0.01) was less likely with higher BMI. There was no association between BMI and previous stroke, diabetes, vasculitis, gravid/post-partum, tobacco use, psychostimulant use or injecting drug use. Overweight and obese cases were prominent among young fatalities of stroke. Reducing rates of obesity, and associated hypertension, would be expected to reduce the escalating stoke rates among young adults.

Long-term neurological, vascular, and mortality outcomes after stroke

Background

Despite improved survival and short-term (90-day) outcomes of ischemic stroke patients, only sparse data exist describing the sustained benefits of acute stroke care interventions and long-term prognosis of stroke survivors.

Aim

We review the contemporary literature assessing long-term (5 years or more) outcomes after stroke and acute stroke treatment.

Summary of review

Acute stroke unit care and intravenous thrombolysis have sustained benefits over longer follow-up, but few data exist on the long-term outcome after endovascular thrombectomy (EVT). A large proportion of stroke survivors face challenges of residual disability and neuropsychiatric sequelae (especially affective disorders and epilepsy) which affects their quality of life and is associated with poorer prognosis due to increase in stroke recurrences/mortality. Nearly, a quarter of stroke survivors have a recurrent stroke at 5 years, and nearly double that at 10 years. Mortality after recurrent stroke is high, and half of the stroke survivors are deceased at 5 years after stroke and three fourth at 10 years. Long-term all-cause mortality is largely due to conditions other than stroke. Both stroke recurrence and long-term mortality are affected by several modifiable risk factors, and thus amenable to secondary prevention strategies.

Conclusions

There is a need for studies reporting longer term effects of acute interventions, especially EVT. Better preventive strategies are warranted to reduce the vascular and non-vascular mortality long after stroke.

Mortality of patients with previous stroke undergoing drug-eluting stent implantation

OBJECTIVE

Patients with previous stroke are increasing among patients receiving percutaneous coronary intervention (PCI) with drug-eluting stents (DES); however, data about the influence of previous stroke on patient outcomes are limited. We evaluated whether previous stroke is associated with increased risk for mortality in coronary artery disease.

PATIENTS AND METHODS

A total of 18 650 patients with coronary artery disease undergoing PCI with DES were enrolled. Databases from three real-world PCI registries were merged for a patient-level meta-analysis. The primary outcome was death from any cause. The secondary outcomes were death from a cardiac cause, myocardial infarction, stent thrombosis, stroke, or repeat revascularization.

RESULTS

Patients with previous stroke (n=1361), compared with those without previous stroke (n=17 289), were older and had a higher prevalence of risk factors or comorbidities. At a median follow-up of 47.0 months, patients with previous stroke had a higher risk for death from any cause [adjusted hazard ratio (HR)=1.623; 95% confidence interval (CI): 1.342-1.962; P<0.001], death from a cardiac cause (adjusted HR=1.686; 95% CI: 1.339-2.124; P<0.001), and stroke (adjusted HR=2.456; 95% CI: 1.853-3.255; P<0.001). There were no significant differences in the risks for myocardial infarction, stent thrombosis, or repeat revascularization.

CONCLUSION

Patients with previous stroke showed higher risks for all-cause death and stroke after PCI with DES than those without stroke. Previous stroke should be considered a risk factor for all-cause death and stroke in this patient population.

Use of cardiovascular polypills for the secondary prevention of cerebrovascular disease

INTRODUCTION

There is little control of cardiovascular (CV) risk factors in secondary prevention after an ischaemic stroke, in part due to a lack of adherence to treatment. The CV polypill may contribute to proper treatment adherence, which is necessary for CV disease prevention. This study aimed to establish how and in what cases the CV polypill should be administered.

METHODS

A group of 8 neurologists drafted consensus recommendations using structured brainstorming and based on their experience and a literature review.

RESULTS

These recommendations are based on the opinion of the participating experts. The use of the CV polypill is beneficial for patients, healthcare professionals, and the health system. Its use is most appropriate for atherothrombotic stroke, lacunar stroke, stroke associated with cognitive impairment, cryptogenic stroke with CV risk factors, and silent cerebrovascular disease. It is the preferred treatment in cases of suspected poor adherence, polymedicated patients, elderly people, patients with polyvascular disease or severe atherothrombosis, young patients in active work, and patients who express a preference for the CV polypill. Administration options include switching from individual drugs to the CV polypill, starting treatment with the CV polypill in the acute phase in particular cases, use in patients receiving another statin or an angiotensin ii receptor antagonist, or de novo use if there is suspicion of poor adherence. Nevertheless, use of the CV polypill requires follow-up on the achievement of the therapeutic objectives to make dose adjustments.

CONCLUSIONS

This document is the first to establish recommendations for the use of the CV polypill in cerebrovascular disease, beyond its advantages in terms of treatment adherence.

Similarities and Differences in Epidemiology and Risk Factors of Cerebral and Myocardial Ischemic Disease

Ischemic heart disease and cerebral ischemia represent the leading causes of mortality worldwide. Both entities share risk factors, pathophisiology and etiologic aspects by means of a main common mechanism, atherosclerosis. The autors aimed to investigate differences and similarities in epidemiology and risk factors that could be found between both entities. In a retrospective sudy 403 patients were included and divided into two groups: group of 289 patients with history of myocardial infarction (AMI), and group of 114 patients with history of ischemic stroke (IS). All patients were evaluated for nonmodifiable risk faktors, which included age and sex, and modifiable, such as hypertension, dyslipidemia, diabetes, obesity, physical activity and smoking. Diff erences in some epidemiological aspects were also considered: occupation, marital status, alcohol consumption, exposure to stress. Patients with history of IS were significantly older then AMI patients (64.0 ± 9.9 vs 64.0 ± 9.9, p=0,028), with higher diastolic blood pressure (87,1 ± 10,2 vs 83,6 ± 10,4, p=0,003) and higher Sokolow-Lyon index in ECG, an also index of left ventricular hypertrophy (19,2 ± 9,1 vs 14,7 ± 6,5). Th ere were no significant differences between groups in the estimated body mass index and waist circumference. Differences between groups in stress exposure, occupation, alcohol consumption or physical activity were no significant. Patients in AMI group were more frequently male (199 (69%) vs 59 (52%), p=0,001), married (252 (87%) vs 88 (77%), p=0,037), smokers (162 (56%) vs 50 (44%), p=0,018) and with higher incidence od dyslipidemia (217 (75%) vs 73 (64%), p=0,019) compared with IS group. Incidence of arterial hypertension and diabetes was similar in both groups. Both entities share similar pathophysiological mechanisms and, consequently, main traditional risk factors. However, incidence of myocardial infarction increases with male sex, dyslipidemia, smoking and marital status, while incidense of ischemic stroke increases with age, higher diastolic blood pressure and also with ECG signs of left ventricular hypertrophy.

A Review of Neurogenic Stunned Myocardium

Neurologic stunned myocardium (NSM) is a phenomenon where neurologic events give rise to cardiac abnormalities. Neurologic events like stroke and seizures cause sympathetic storm and autonomic dysregulation that result in myocardial injury. The clinical presentation can involve troponin elevation, left ventricular dysfunction, and ECG changes. These findings are similar to Takotsubo cardiomyopathy and acute coronary syndrome. It is difficult to distinguish NSM from acute coronary syndrome based on clinical presentation alone. Because of this difficulty, a patient with NSM who is at high risk for coronary heart disease may undergo cardiac catheterization to rule out coronary artery disease. The objective of this review of literature is to enhance physician's awareness of NSM and its features to help tailor management according to the patient's clinical profile.

Poor long-term outcomes in stroke patients with asymptomatic coronary artery disease in heart CT

BACKGROUND AND AIMS

Although stroke patients have a high risk of ischemic heart disease, little information is available on the risk of coronary events in stroke patients with asymptomatic coronary artery disease (CAD). We investigated the long-term vascular outcomes in stroke patients with asymptomatic CAD diagnosed with multi-detector coronary computed tomography (MDCT).

METHODS

This study was a retrospective analysis using a prospective cohort of ischemic stroke patients. We included consecutive stroke patients without history or symptoms of CAD who underwent MDCT. We investigated the long-term risk of major adverse cardiovascular events (MACE: cardiovascular mortality, ischemic stroke, myocardial infarction, unstable angina, and urgent coronary revascularization) and composite of MACE/all-cause mortality/elective coronary revascularization. We further investigated the value of MDCT for MACE prediction.

RESULTS

Among the 1893 included patients, 1349 (71.3%) patients had some degree of CAD and 654 patients (34.5%) had significant (≥50%) CAD. At follow-up (median, 4.4 years), MACE occurred in 230 patients (12.2%). Event rates of MACE increased with the increasing extent of CAD. After adjustment for age, sex, and risk factors, the hazard ratios for MACE in mild CAD, 1-VD, 2-VD, and 3-VD or left main coronary disease were 1.28 (95% confidence interval [CI]: 0.88-1.87), 1.39 (95% CI: 0.90-2.16), 2.22 (95% CI: 1.39-3.55), and 2.91 (95% CI: 1.82-4.65), respectively (no CAD as a reference). Diagnosis of asymptomatic CAD significantly improved the prediction of MACE.

CONCLUSIONS

Asymptomatic CAD detected on MDCT was associated with increased risks of vascular events or deaths in acute stroke patients.

Detecting Myocardial Ischemia With 99mTechnetium-Tetrofosmin Myocardial Perfusion Imaging in Ischemic Stroke

BACKGROUND

To assess the myocardial status in patients with stroke, employing myocardial perfusion imaging (MPI) with ^99mTechnetium-tetrofosmin (^99mTc-TF)-single-photon emission computed tomography (SPECT).

METHODS

Fifty-two patients with ischemic stroke were subjected to ^99mTc-TF-SPECT MPI within 1 month after stroke occurrence. None of the patients had any history or symptoms of coronary artery disease or other heart disease. Myocardial perfusion imaging was evaluated visually using a 17-segment polar map. Myocardial ischemia (MIS) was defined as present when the summed stress score (SSS) was >4; MIS was defined as mild when SSS was 4 to 8, and moderate/severe with SSS ≥9. Patients with SSS >4 were compared to patients with SSS <4. Parameters such as age, body mass index, waist perimeter, smoking habits, and medical history (diabetes mellitus, dyslipidemia, etc) were evaluated according to MPI results.

RESULTS

Myocardial ischemia was present in 32 (62%) of 52 patients with stroke. Among them, 20 (62%) of 32 patients had mild abnormalities and 12 (38%) of 32 had moderate/severe. The age and waist perimeter showed a tendency to relate to severe MIS when patients with SSS >9 were compared to patients with SSS <4. In MPI-positive patients, an age was to be association with SSS, with the oldest age exhibiting the highest SSS (P = .01). The association of age with SSS remained statistically significant in the multivariate analysis (P = .04).

CONCLUSION

The study suggested that more than half of patients with stroke without a history of cardiac disease have MIS. Although most of them have mild MIS, we suggest a thorough cardiological evaluation in this group of patients for future prevention of severe myocardial outcome.

MiR-126 Affects Brain-Heart Interaction after Cerebral Ischemic Stroke

Cardiovascular diseases are approximately three times higher in patients with neurological deficits than in patients without neurological deficits. MicroRNA-126 (MiR-126) facilitates vascular remodeling and decreases fibrosis and is emerging as an important factor in the pathogenesis of cardiovascular diseases and cerebral stroke. In this study, we tested the hypothesis that decreased miR-126 after ischemic stroke may play an important role in regulating cardiac function. Wild-type (WT), specific conditional-knockout endothelial cell miR-126 (miR-126^EC-/-), and miR-126 knockout control (miR-126^fl/fl) mice were subjected to distal middle cerebral artery occlusion (dMCAo) (n = 10/group). Cardiac hemodynamics and function were measured using transthoracic Doppler echocardiography. Mice were sacrificed at 28 days after dMCAo. WT mice subjected to stroke exhibited significantly decreased cardiac ejection fraction and increased myocyte hypertrophy, fibrosis as well as increased heart inflammation, infiltrating macrophages, and oxidative stress compared to non-stroke animals. Stroke significantly decreased serum and heart miR-126 expression and increased miR-126 target genes, vascular cell adhesion protein-1, and monocyte chemotactic protein-1 gene, and protein expression in the heart compared to non-stroke mice. MiR-126^EC-/- mice exhibited significantly decreased cardiac function and increased cardiomyocyte hypertrophy, fibrosis, and inflammatory factor expression after stroke compared to miR-126^fl/fl stroke mice. Exosomes derived from endothelial cells of miR-126^EC-/- (miR-126^EC-/-EC-Exo) mice exhibited significantly decreased miR-126 expression than exosomes derived from miR-126^fl/fl (miR-126^fl/fl-EC-Exo) mice. Treatment of cardiomyocytes subjected to oxygen glucose deprivation with miR-126^fl/fl-EC-Exo exhibited significantly decreased hypertrophy than with miR-126^EC-/-EC-Exo treatment. Ischemic stroke directly induces cardiac dysfunction. Decreasing miR-126 expression may contribute to cardiac dysfunction after stroke in mice.

Increased Risk of Cardiovascular Events in Stroke Patients Who had Not Undergone Evaluation for Coronary Artery Disease

PURPOSE

Although asymptomatic coronary artery occlusive disease is common in stroke patients, the long-term advantages of undergoing evaluation for coronary arterial disease using multi-detector coronary computed tomography (MDCT) have not been well established in stroke patients. We compared long-term cardio-cerebrovascular outcomes between patients who underwent MDCT and those who did not.

MATERIALS AND METHODS

This was a retrospective study in a prospective cohort of consecutive ischemic stroke patients. Of the 3117 patients who were registered between July 2006 and December 2012, MDCT was performed in 1842 patients [MDCT (+) group] and not in 1275 patients [MDCT (-) group]. Occurrences of death, cardiovascular events, and recurrent stroke were compared between the groups using Cox proportional hazards models and propensity score analyses.

RESULTS

During the mean follow-up of 38.0±24.8 months, 486 (15.6%) patients died, recurrent stroke occurred in 297 (9.5%), and cardiovascular events occurred in 60 patients (1.9%). Mean annual risks of death (9.34% vs. 2.47%), cardiovascular events (1.2% vs. 0.29%), and recurrent stroke (4.7% vs. 2.56%) were higher in the MDCT (-) group than in the MDCT (+) group. The Cox proportional hazards model and the five propensity score-adjusted models consistently demonstrated that the MDCT (-) group was at a high risk of cardiovascular events (hazard ratios 3.200, 95% confidence interval 1.172-8.735 in 1:1 propensity matching analysis) as well as death. The MDCT (-) group seemed to also have a higher risk of recurrent stroke.

CONCLUSION

Acute stroke patients who underwent MDCT experienced fewer deaths, cardiovascular events, and recurrent strokes during follow-up.

Comparison of Baseline Heart Rate Variability in Stable Ischemic Heart Disease Patients with and without Stroke in Long-Term Observation

GOAL

Decreased heart rate variability (HRV) has predictive value in postinfarction as well as in ischemic stroke patients. However, it is unknown if ischemic heart disease (IHD) patients who are at high risk of stroke have different HRV profile. The goal of this study was to compare baseline HRV (traditional and novel indices) in stable IHD patients with and without stroke in long-term observation.

METHODS

A total of 139 consecutive patients with stable IHD scheduled for coronary angiography were enrolled. Five-minute electrocardiogram readings were taken. Traditional and novel HRV measures were calculated. After 70.06 ± 4.297 months of follow-up, baseline HRV indices in patients who had had a stroke were compared with indices in patients without the aforementioned cerebrovascular event.

RESULTS

During follow-up, 6 patients developed stroke. Compared to patients without such a cerebrovascular event, these patients with stroke had lower values for the following HRV indices: de Hann long-term irregularity (30,521 ± 32,767 versus 46,678 ± 25,328; P < .05), Yeh interval index (.0207 ± .0208 versus .0326 ± .0157; P < .05), Organ BAND (3.0563 ± 3.328 versus 4.515 ± 2.276; P < .05), Dalton standard deviation (SD) (17,887 ± 17,636 versus 29,859 ± 16,478; P < .05), Zugaib short-term variability (.004 ± .00416 versus .00622 ± .00418; P < .05), Zugaib long-term variability (.0161 ± .0151 versus .0247 ± .0115; P < .05), standard deviation of all NN intervals (8,954 ± 8,812 versus 16,724 ± 11,594; P < .05), total power (2,616 ± 4,855 versus 4,678 ± 4,653; P < .05), w2 (.71 ± .338 versus 1.719 ± 1.08; P < .05), w3 (1.399 ± .924 versus 2.552 ± 1.609; P < .05), and w4 (1.367 ± 1.705 versus 2.824 ± 2.027; P < .05). No significant differences in other analyzed indices were observed.

CONCLUSIONS

Patients with IHD and stroke in long-term observation have different baseline profiles of HRV indices. Further investigations are needed to assess the usefulness of HRV analysis in stroke risk assessment.

Coronary Risk Stratification in Patients with Ischemic Stroke or Transient Ischemic Stroke Attack

Background

The risk of coronary artery disease (CAD) is traditionally considered high in patients who had an ischemic stroke or a transient ischemic attack (TIA). However, few studies have specifically assessed the absolute risk of coronary events in those patients and predictors of such events are not well known.

Summary of review

The overall risks of myocardial infarction and nonstroke vascular death are each around 2% per year. However, those risks are only about 1% per year in patients without CAD (i.e. the only ones who are likely to benefit from specific additional strategies). The prevalence of asymptomatic CAD ranges from 15% to 60%. Although potentially higher, the risk of CAD in patients with stroke/TIA related to atherosclerosis also seems to vary widely depending on the extent of the disease. Given the relatively low CAD risk, a simple systematic reinforcement of medical treatment in all patients may be not relevant. Up to now, there have been only limited ways to stratify the CAD risk in stroke/TIA patients. High-risk patients may be identified using the traditional cardiac scoring systems, but their validity has never been specifically assessed in stroke populations. The relative influence of traditional risk factors may be altered after a first vascular event. Stroke patients could also be screened for asymptomatic CAD. However, there is no simple and valid screening test for asymptomatic CAD that could be applied to all patients. Finally, there is still uncertainty about the potential benefits of treating asymptomatic CAD. Therefore, should the identification of patients with asymptomatic CAD requiring revascularization become feasible, the relevance of this strategy would remain to be evaluated by a randomized clinical trial.

Conclusion

The absolute risk of CAD in stroke/TIA patients is moderately high. More research is needed to identify high risk patients who could benefit from specific strategies.

Quantifying the risk of heart disease following acute ischaemic stroke: a meta-analysis of over 50,000 participants

OBJECTIVE

Following an acute stroke, there is a high risk of recurrence. However, the leading cause of mortality following a stroke is due to coronary artery disease (CAD) and myocardial infarction (MI) but that risk has not been robustly quantified. We sought to reliably quantify the risk of ischaemic heart disease (IHD) in patients presenting with acute ischaemic stroke (AIS) in the absence of a known cardiac history.

SETTING

A meta-analysis study. PubMed, MEDLINE, EMBASE and Google Scholar were searched for potential studies up to October 2015. Included studies reported an acute cerebral ischaemic event and followed for CAD or MI within 1 year in patients without known IHD. Using arcsine transformed proportions for meta-analysis, studies were combined using a generic inverse variance random-effects model to calculate the pooled standardised mean difference and 95% CIs. These were interpreted as the percentage prevalence of CAD or incidence of MI following AIS.

RESULTS

17 studies with 4869 patients with AIS demonstrated a mean average of asymptomatic CAD in 52%. Anatomical methods of CAD detection revealed a prevalence of asymptomatic ≥ 50% coronary stenosis in 32% (95% CI 19% to 47%; p<0.00001). 8 studies with 47229 patients with ischaemic stroke revealed an overall risk of MI in the year following stroke of 3% (95% CI 1% to 5%; p<0.00001) despite the absence of any cardiac history.

CONCLUSIONS

One-third of patients with ischaemic stroke with no cardiac history have more than 50% coronary stenosis and 3% are at risk of developing MI within a year. Our findings provide a reliable quantitative measure of the risk of IHD following AIS in patients with no cardiac history.

Peripheral to central: Organ interactions in stroke pathophysiology

Stroke is associated with a high risk of disability and mortality, and with the exception of recombinant tissue-type plasminogen activator for acute stroke, most treatments have proven ineffective. Clinical translation of promising experimental therapeutics is limited by inadequate stroke models and a lack of understanding of the mechanisms underlying acute stroke and how they affect outcome. Bidirectional communication between the ischemic brain and peripheral immune system modulates stroke progression and tissue repair, while epidemiological studies have provided evidence of an association between organ dysfunction and stroke risk. This crosstalk can determine the fate of stroke patients and must be taken into consideration when investigating the pathophysiological mechanisms and therapeutic options for stroke. This review summarizes the current evidence for interactions between the brain and other organs in stroke pathophysiology in basic and clinic studies, and discusses the role of these interactions in the progression and outcome of stroke and how they can direct the development of more effective treatment strategies.

Comparison of Long-Term Clinical Outcomes after Drug-Eluting Stent Implantation in Patients with Coronary Artery Disease with and without Prior Cerebral Infarction

OBJECTIVE

To compare the clinical and angiographic outcomes after implantation of drug-eluting stents (DESs) in patients with coronary artery disease (CAD) with or without prior cerebral infarction.

MATERIALS AND METHODS

Ninety-eight consecutive patients (130 lesions) who underwent successful coronary DES implantation were prospectively classified into two groups: those with a clinical history of symptomatic cerebral infarction (cerebral infarction group, 49 patients, 69 lesions) and those without a clinical history of symptomatic cerebral infarction (noncerebral infarction group, 49 patients, 61 lesions). The primary endpoint was defined as death, nonfatal myocardial infarction, and cerebrovascular events.

RESULTS

The Kaplan-Meier method was used to create a primary endpoint curves to determine the time-dependent cumulative primary endpoint-free rate, which were compared using the log-rank test. The incidence of primary endpoints was higher in the cerebral infarction group than in the noncerebral infarction group (p = 0.0075). The Cox proportional hazards regression model for primary endpoint identified prior cerebral infarction (p = 0.0331, hazard ratio = 2.827) and patients with peripheral artery disease (p = 0.0271, hazard ratio = 2.757) as explanatory factors.

CONCLUSION

The results showed that clinical outcomes were poorer in patients with CAD who had prior cerebral infarctions than in those who did not have infarction.

Higher Left Ventricle Mass Indices Predict Favorable Outcome in Stroke Patients with Thrombolysis

BACKGROUND

We sought to assess the association of left ventricle mass (LVM) indices with the functional outcome of acute ischemic stroke (AIS) patients after intravenous tissue plasminogen activator (IV-tPA).

METHODS

Consecutive AIS patients with IV-tPA were recruited. LVM indices including LVM/weight, LVM/surface, and LVM/heightˆ(2.7) on echocardiogram during hospitalization were retrospectively reviewed. Outcome was 90-day modified Rankin scale (mRS) scores. Multivariate logistic regression was performed to analyze the association of LVM indices with outcome.

RESULTS

Between August 2010 and May 2014, 55 AIS patients (age range from 27 to 78 years, 69.1% men) with echocardiogram after thrombolysis were recruited. Lower baseline National Institutes of Health Stroke Scale (NIHSS; P = .009) and higher LVM indices (LVM/weight [P = .012], LVM/surface [P = .039], and LVM/heightˆ(2.7) [P = .045]) were significantly associated with 90-day favorable outcome (mRS, 0-2). In multivariate logistic regression analysis, LVM/weight independently predicted good outcome with an odds ratio of 3.89 (95% confidence interval, 1.05-14.42, P = .042) after adjustment for baseline NIHSS, onset-to-treatment time, hypertension, hemorrhagic transformation, and systolic left ventricle inner diameters.

CONCLUSIONS

Higher LVM indices on echocardiogram are significantly associated with favorable outcome in stroke patients with IV-tPA, among which LVM/weight seems to be the most effective.

Prediction of myocardial infarction in patients with transient ischaemic attack

BACKGROUND

Determinants of risk of myocardial infarction (MI) after transient ischaemic attack (TIA) are not well defined. The aim of our study was to determine the risk and risk factors for MI after TIA.

METHODS

We prospectively recruited patients within 24 h of transient ischaemic cerebrovascular events between October 2006 and January 2013. A total of 628 TIA patients were followed for six months or more. MI and stroke recurrence (SR) were recorded. The duration and typology of clinical symptoms, vascular risk factors and aetiological work-ups were prospectively recorded and established prognostic scores (ABCD2, ABCD2I, ABCD3I, Essen Stroke Risk Score, California Risk Score and Stroke Prognosis Instrument) were calculated.

RESULTS

Twenty-eight (4.5%) MI and 68 (11.0%) recurrent strokes occurred during a median follow-up period of 31.2 months (16.1-44.9). In Cox proportional hazards multivariate analyses, we identify previous coronary heart disease (CHD) (hazard ratio [HR] 5.65, 95% confidence interval [CI] 2.45-13.04, P < 0.001) and sex male (HR 2.72, 95% CI 1.02-7.30, P = 0.046) as independent predictors of MI. Discrimination for the prognostic scores only ranged from 0.60 to 0.71. The incidence of MI did not vary among the different aetiological subtypes. Positive diffusion weighted imaging (DWI) (7.5% vs 2.5%, P = 0.007), and ECG abnormalities (Q wave or ST-T wave changes) (13.6% vs 3.6%, P = 0.001) were associated to MI.

CONCLUSION

According to our results, discrimination was poor for all previous risk prediction models evaluated. Variables such as previous CHD, male sex, DWI and ECG abnormalities should be considered in new prediction models.

Non-invasive imaging for subclinical coronary atherosclerosis in patients with peripheral artery disease

Patients with peripheral artery disease are at high risk of coronary artery disease. An increasing number of studies show that a large proportion of patients with peripheral artery disease have significant coronary atherosclerosis, even in the absence of symptoms. Although the reported prevalence of subclinical coronary artery disease varies widely in patients with peripheral artery disease, it could include more than half of patients. No consensus exists to date on either the rationale for screening patients with peripheral artery disease for coronary atherosclerosis or the optimal algorithm and method for screening. An increasing number of imaging modalities are emerging that allow improved in vivo non-invasive characterization of atherosclerotic plaques. These novel imaging methods may lead to early detection of high-risk vulnerable plaques, enabling clinicians to improve risk stratification of patients with peripheral artery disease, and thus paving the way for individualized therapy.

Likelihood of myocardial infarction during stroke rehabilitation preceded by cardiovascular screening and an exercise tolerance test: the Locomotor Experience Applied Post-Stroke (LEAPS) trial

BACKGROUND

Coronary artery disease is highly prevalent in patients with stroke, but because revascularization does not improve major clinical outcomes in patients with stable coronary artery disease relative to intensive medical therapy, routine evaluation for this disease is not warranted in stroke patients. However, it might be warranted in patients destined to undergo vigorous physical therapy. The Locomotor Experience Applied Post-Stroke study, a randomized controlled trial of 408 participants that tested the relative efficacy of two rehabilitation techniques on functional walking level, provided the opportunity to address this question.

AIM

The study aims to test the efficacy of screening for cardiovascular disease and an exercise tolerance test in assuring safety among patients undergoing vigorous rehabilitation for gait impairment.

METHODS

All participants were screened for serious cardiovascular and pulmonary conditions. At six-weeks poststroke, they also completed a cardiovascular screening inventory and underwent an exercise tolerance test involving bicycle ergometry. Participants received 36, 90-min sessions of a prescribed physical therapy (three per week), initiated at either two-months or six-months poststroke.

RESULTS

Twenty-nine participants were excluded on the basis of the cardiac screening questionnaire, and 15 failed the exercise tolerance test for cardiovascular reasons. No participant experienced a cardiac event during a treatment session. Two participants experienced myocardial infarctions, but continued in the trial. In three additional participants, myocardial infarctions caused or contributed to death.

CONCLUSIONS

The combination of a negative cardiac screen and the absence of exercise tolerance test failure appeared to have a high negative predictive value for cardiac events during treatment, despite the likelihood of a high prevalence of coronary artery disease in our population.

Computerized detection of noncalcified plaques in coronary CT angiography: evaluation of topological soft gradient prescreening method and luminal analysis

PURPOSE

The buildup of noncalcified plaques (NCPs) that are vulnerable to rupture in coronary arteries is a risk for myocardial infarction. Interpretation of coronary CT angiography (cCTA) to search for NCP is a challenging task for radiologists due to the low CT number of NCP, the large number of coronary arteries, and multiple phase CT acquisition. The authors conducted a preliminary study to develop machine learning method for automated detection of NCPs in cCTA.

METHODS

With IRB approval, a data set of 83 ECG-gated contrast enhanced cCTA scans with 120 NCPs was collected retrospectively from patient files. A multiscale coronary artery response and rolling balloon region growing (MSCAR-RBG) method was applied to each cCTA volume to extract the coronary arterial trees. Each extracted vessel was reformatted to a straightened volume composed of cCTA slices perpendicular to the vessel centerline. A topological soft-gradient (TSG) detection method was developed to prescreen for NCP candidates by analyzing the 2D topological features of the radial gradient field surface along the vessel wall. The NCP candidates were then characterized by a luminal analysis that used 3D geometric features to quantify the shape information and gray-level features to evaluate the density of the NCP candidates. With machine learning techniques, useful features were identified and combined into an NCP score to differentiate true NCPs from false positives (FPs). To evaluate the effectiveness of the image analysis methods, the authors performed tenfold cross-validation with the available data set. Receiver operating characteristic (ROC) analysis was used to assess the classification performance of individual features and the NCP score. The overall detection performance was estimated by free response ROC (FROC) analysis.

RESULTS

With our TSG prescreening method, a prescreening sensitivity of 92.5% (111/120) was achieved with a total of 1181 FPs (14.2 FPs/scan). On average, six features were selected during the tenfold cross-validation training. The average area under the ROC curve (AUC) value for training was 0.87 ± 0.01 and the AUC value for validation was 0.85 ± 0.01. Using the NCP score, FROC analysis of the validation set showed that the FP rates were reduced to 3.16, 1.90, and 1.39 FPs/scan at sensitivities of 90%, 80%, and 70%, respectively.

CONCLUSIONS

The topological soft-gradient prescreening method in combination with the luminal analysis for FP reduction was effective for detection of NCPs in cCTA, including NCPs causing positive or negative vessel remodeling. The accuracy of vessel segmentation, tracking, and centerline identification has a strong impact on NCP detection. Studies are underway to further improve these techniques and reduce the FPs of the CADe system.

What are the potential implications of identifying intracranial internal carotid artery atherosclerotic lesions on cone-beam computed tomography? A systematic review and illustrative case studies

PURPOSE

A systematic literature review was performed to examine the clinical implications of intracranial internal carotid artery calcific atherosclerotic lesions (IICACALs) detected at cone-beam computed tomographic (CBCT) examinations.

MATERIALS AND METHODS

The PubMed database was queried in 2 separate searches using the linked search terms non-contrast enhanced cone beam computed tomography and calcified intracranial vascular lesions and non-contrast enhanced computed tomography and calcified intracranial vascular lesions. Reviewed were all English-language articles using CBCT or CT imaging that enrolled neurologically asymptomatic and symptomatic patients. Excluded were studies describing patients with hemorrhagic stroke. Illustrative cases describing incidentally detected IICACALs on CBCT scans are provided.

RESULTS

Three articles described identification of IICACALs on CBCT scans of almost 1,500 dental patients. Two of these fully addressed the subject, with 1 noting that IICACALs were benign and another urging patient referral for further workup. Five non-contrast-enhanced CT studies were evaluated in detail; all confirmed IICACALs as a substantive risk marker of advanced stenotic disease in the cerebral circulation, central brain atrophy, concomitant advanced atherosclerotic disease in the cardiovascular circulation, and an indicator of future ischemic events. Five CBCT examinations showing IICACALs in the cavernous and ophthalmic segments are presented.

CONCLUSION

Few studies have denoted the importance of identifying IICACALs on CBCT scans. However, all non-contrast-enhanced CT studies emphasized the clinical significance of these lesions in relation to cerebral and cardiovascular disease. Therefore, IICACALs seen on CBCT and CT scans present the same risk and should prompt referral for further evaluation.

Predicting Asymptomatic Coronary Artery Diseasein Patients With Ischemic Stroke and Transient Ischemic Attack

Background and Purpose—

Identifying occult coronary artery stenosis may improve secondary prevention of stroke patients. The aim of this study was to derive and validate a simple score to predict severe occult coronary artery stenosis in stroke patients.

Methods—

We derived a score from a French hospital–based cohort of consecutive patients (n=300) who had an ischemic stroke or a transient ischemic attack and no previous history of coronary heart disease (Predicting Asymptomatic Coronary Artery Disease in Patients With Ischemic Stroke and Transient Ischemic Attack [PRECORIS] score) and validated the score in a similar Korean cohort (n=1602). In both cohorts, severe coronary artery stenosis was defined by the presence of at least 1 ≥50% coronary artery stenosis as detected by 64-section CT coronary angiography.

Results—

A 5-point score (Framingham Risk Score–predicted 10-year coronary heart disease risk [≥20%=3; 10–19%=1; <10%=0] and cervicocephalic artery stenosis [≥50%=2; <50%=1; none=0]) was predictive of occult ≥50% coronary artery stenosis risk in the derivation cohort (C-statistic=0.77 [0.70–0.84]) and in the validation cohort (C-statistic=0.66 [0.63–0.68]). The predictive ability of the score was even stronger when only ≥50% left main trunk disease or 3-vessel disease were considered (C-statistic=0.83 [0.74–0.92] and 0.70 [0.66–0.74] in derivation and validation cohorts, respectively). The prevalence of occult ≥50% coronary artery stenosis and ≥50% left main trunk or 3-vessel disease increased gradually with the PRECORIS score, reaching 44.2% and 13.5% in derivation cohort and 49.8% and 12.8% in validation cohort in patients with a PRECORIS score ≥4.

Conclusions—

The PRECORIS score can identify a population of stroke or transient ischemic attack patients with a high prevalence of occult severe coronary artery stenosis.

The Norwegian Stroke in the Young Study (NOR-SYS): rationale and design

BACKGROUND

Ischemic stroke in young adults is a major health problem being associated with a higher vascular morbidity and mortality compared to controls, and a stroke recurrence rate of 25% during the first decade. The assumed cause of infarction and the detected risk factors determine the early- and long-term treatment. However, for many patients the cause of stroke remains unknown. Risk factor profile and etiology differ in young and elderly ischemic stroke patients, and atherosclerosis is the determined underlying condition in 10 to 15%. However, subclinical atherosclerosis is probably more prevalent and may go unrecognized.

METHODS/DESIGN

NOR-SYS is a prospective long-term research program. Standardized methods are used for anamnestic, clinical, laboratory, imaging, and ultrasound data collection in ischemic stroke patients aged ≤60 years, their partners and joint adult offspring. The ultrasound protocol includes the assessment of intracranial, carotid and femoral arteries, abdominal aorta, and the estimation of VAT. To date, the study is a single centre study with approximately 400 patients, 250 partners and 350 adult offspring expected to be recruited at our site.

DISCUSSION

NOR-SYS aims to increase our knowledge about heredity and the development of arterial vascular disease in young patients with ischemic stroke and their families. Moreover, optimization of diagnostics, prophylaxis and early intervention are major targets with the intention to reduce stroke recurrence and other clinical arterial events, physical disability, cognitive impairment and death.

Coronary Artery Disease and Risk of Major Vascular Events After Cerebral Infarction

Background and Purpose—

The impact of asymptomatic coronary artery disease on the risk of major vascular events in patients with cerebral infarction is unknown.

Methods—

Four hundred five patients with acute cerebral infarction underwent carotid, femoral artery, thoracic, and abdominal aorta ultrasound examination. Of 342 patients with no known coronary heart disease, 315 underwent coronary angiography. We evaluated the 2-year risk of major vascular events (myocardial infarction, resuscitation after cardiac arrest, hospitalization for unstable angina or heart failure, stroke, or major peripheral arterial disease events) in patients with known coronary heart disease (n=63), and in the no known coronary heart disease group (n=315) as a function of coronary angiographic status (n=315).

Results—

At 2 years, the estimated risk of major vascular events was 11.0% (95% confidence interval, 8.2–14.7). According to baseline coronary angiography, estimated risk was 3.4% in patients with no coronary artery disease (n=120), 8.0% with asymptomatic coronary artery stenosis <50% (n=113), 16.2% with asymptomatic coronary artery stenosis ≥50% (n=81), and 24.1% with known coronary heart disease ( P <0.0001). Using no coronary artery disease as the reference, the age- and sex-adjusted hazard ratio (95% confidence interval) of vascular events was 2.10 (0.63–6.96) for asymptomatic coronary stenosis <50%, 4.36 (1.35–14.12) for asymptomatic coronary stenosis ≥50%, and 6.86 (2.15–21.31) for known coronary artery disease.

Conclusions—

In patients with nonfatal cerebral infarction, presence and extent of asymptomatic stenoses on coronary angiography are strong predictors of major vascular events within 2 years.