Echocardiographic wall motion abnormalities in patients with stroke may warrant cardiac evaluation

Background

The aetiology of wall motion abnormalities (WMA) in patients with ischaemic stroke is unclear. We hypothesised that WMAs on transthoracic echocardiography (TTE) in the setting of ischaemic stroke mostly reflect pre-existing coronary heart disease rather than simply an isolated neurocardiogenic phenomenon.

Methods

Data were retrospectively abstracted from a prospective ischaemic stroke database over 18 months and included patients with ischaemic stroke who underwent a TTE. Coronary artery disease was defined as history of myocardial infarction (MI), coronary intervention or ECG evidence of prior MI. The presence (vs absence) of WMA was abstracted. Multivariable logistic regression was used to determine the association between coronary artery disease and WMA in models adjusting for potential confounders.

Results

We identified 1044 patients who met inclusion criteria; 139 (13.3%, 95% CI 11.2% to 15.4%) had evidence of WMA of whom only 23 (16.6%, 95% CI 10.4% to 22.8%) had no history of heart disease or ECG evidence of prior MI. Among these 23 patients, 12 had a follow-up TTE after the stroke and WMA persisted in 92.7% (11/12) of patients. In fully adjusted models, factors associated with WMA were older age (OR per year increase 1.03, 95% 1.01 to 1.05, p=0.009), congestive heart failure (OR 4.44, 95% CI 2.39 to 8.33, p<0.001), history of coronary heart disease or ECG evidence prior MI (OR 27.03, 95% CI 14.93 to 50.0, p<0.001) and elevated serum troponin levels (OR 2.00, 95% CI 1.06 to 3.75, p=0.031).

Conclusion

In patients with ischaemic stroke, WMA on TTE may reflect underlying cardiac disease and further cardiac evaluation may be considered.

Abstract WP263: Wall Motion Abnormalities on Transthoracic Echocardiography in the Setting of Ischemic Stroke Reflect Underlying Cardiac Disease and May Warrant an Ischemic Cardiac Evaluation

Background and Purpose: Patients with acute ischemic stroke (AIS) are at a heightened risk of cardiovascular events. We hypothesize that wall motion abnormalities (WMA) on transthoracic echocardiography (TTE) in the setting of AIS reflect underlying heart disease rather than reversible cardiac strain caused by the stroke.

Methods: Data was abstracted from a single center prospective AIS database over 18 months and included all patients with acute ischemic stroke who underwent a TTE. The presence of WMA was abstracted from the TTE report. Univariate analyses and predefined multivariable models were performed to determine factors associated with WMA, including demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, atrial fibrillation, congestive heart failure, coronary heart disease, and smoking), NIHSS score, cardiac markers (positive troponin, ECG evidence of prior myocardial infarction, ejection fraction), and insular location of infarct.

Results: We identified 1044 patients who met the inclusion criteria; 139 (13.3%) had evidence of WMA, of which only 23 patients had no history of heart disease or ECG evidence of prior myocardial infarction. Among these 23 patients, 12 had a follow up TTE after the stroke and WMA persisted in 92.7% (11/12) of patients. On fully adjusted models, factors associated with WMA are older age (OR per SD 1.03, 95% CI 1.001-1.05; p=0.009), congestive heart failure (OR 4.44, 95% CI 2.39-8.33, p<0.001), history of coronary artery disease or ECG evidence prior myocardial infarction (OR 27.03, 95% CI 14.93-50.0, p<0.001), and elevated serum troponin levels (OR 2.00, 95% CI 1.06-3.75, p=0.031).

Conclusion: In AIS patients, WMA on TTE may reflect underlying cardiac disease and warrant further cardiovascular evaluation particularly in those without known history of cardiac disease. Future studies are needed to investigate the cost-effectiveness of this approach.

Abstract WP279: Cardiac Biomarkers Predict Large Vessel Occlusion in Patients With Ischemic Stroke

Background and Purpose: Cardiac biomarkers may help identify stroke mechanisms and may aid in improving stroke prevention strategies. There is limited data on the association between these biomarkers and large vessel occlusion (LVO) in patients with acute ischemic stroke (AIS). We aim to determine the association between cardiac biomarkers [cardiac troponin and left atrial diameter (LAD)] and the presence of large vessel occlusion.

Methods: Data was abstracted from a single center prospective AIS database over 18 months and included all patients with AIS with intracranial vascular imaging (CT angiogram or MR angiography). The presence of large vessel occlusion was defined as proximal LVO of the internal carotid artery terminus, middle cerebral artery (M1 or proximal M2), or basilar artery. Univariate analyses and predefined multivariable models were performed to determine the association between cardiac biomarkers [positive troponin (troponin > 0.1) and LAD on transthoracic echocardiogram] and LVO adjusting for demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, congestive heart failure, coronary heart disease, and smoking), and atrial fibrillation (AF).

Results: We identified 1234 patients admitted with AIS; 886 patients (71.8%) had intracranial MRA or CTA. Of those with imaging available, 398 patients (44.9%) had LVO and 232 patients (26.2%) underwent thrombectomy. There was an association between positive troponin and LVO after adjusting for age and sex and other risk factors [adjusted OR 1.97 (1.29-3.00), P=0.002)] and this association persisted after including AF in the model [adjusted OR 1.90 (1.24-2.93), p=0.003]. There was an association between LAD and LVO after adjusting for age, sex, and risk factors [adjusted OR per mm 1.04 (1.01-1.06), p = 0.002] but this association was not present when AF was added to the model [adjusted OR 1.01 (0.99-1.04), p = 0.323]. Sensitivity analyses using thrombectomy as an outcome yielded similar findings.

Conclusion: Cardiac biomarkers predict acute LVO in patients with ischemic stroke. Prospective studies are ongoing to confirm this association and to test whether anticoagulation reduces the risk of recurrent embolism in this patient population.

Abstract TP108: Association Between Intracranial Atherosclerotic Calcium Burden and Angiographic Luminal Stenosis Measurements

Background: Recent data have shown that atherosclerotic calcification of the intracranial vasculature is an independent risk factor for ischemic stroke. The relationship between the most commonly used marker of high risk intracranial atherosclerosis, the percent degree of luminal stenosis, and calcium burden in the intracranial circulation has not been investigated.

Materials and Methods: We evaluated the relationship between atherosclerotic calcification and luminal stenosis in the intracranial internal carotid arteries (ICAs). Using a prospective stroke registry, we identified patients who had non-contrast computed tomography (NCHCT) and either CT angiography (CTA) or magnetic resonance angiography (MRA) examinations as part of a diagnostic evaluation for ischemic stroke. We used NCHCTs to qualitatively (Modified Woodcock Visual Score) and quantitatively (Agatston-Janowitz calcium score) evaluate ICA calcium burden and angiography to measure arterial stenosis (Figure). We calculated correlation coefficients between the degree of narrowing and calcium burden measures.

Results: In 470 unique carotid arteries (235 patients), 372 (79.1%) had atherosclerotic calcification detectable on CT while only 160 (34%) had measurable arterial stenosis (p < 0.001). We found a weak linear correlation between qualitative (R = 0.48) and quantitative (R = 0.42) measures of calcium burden and the degree of luminal stenosis (p < 0.001 for both). Of 310 ICAs with 0% luminal stenosis, 216 (69.7%) had measureable calcium scores.

Conclusion: There is only a weak correlation between intracranial atherosclerotic calcium scores and luminal narrowing, which may be explained by the greater sensitivity of NCHCT compared to angiography in detecting the presence of measurable atherosclerotic disease. Future studies are warranted to evaluate the relationship between stenosis and calcium burden in predicting stroke risk.

Abstract TMP17: Safety of Thrombolysis for Acute Ischemic Stroke in Patients with Recent Stroke

Background: The safety of intravenous tissue plasminogen activator (IV-tPA) is uncertain in acute ischemic stroke patients (AIS) with recent stroke because these patients were generally excluded from randomized stroke trials evaluating IV-tPA. We aimed to determine whether history of stroke within the previous 3 months is associated with an increased risk of intracerebral hemorrhage (ICH) or death after thrombolysis for AIS.

Methods: Using previously validated ICD-9-CM codes, we retrospectively analyzed all adult patients with AIS who received IV-tPA in nonfederal EDs or acute care hospitals in CA, FL, and NY from 2005-2013. The primary outcome was the development of ICH (ICD-9-CM code 431) during index hospitalization for AIS. The secondary outcome was inpatient death. Logistic regression was used to compare the rate of ICH and death in patients with previous ischemic stroke within 3 months of IV-tPA therapy for AIS to all other patients treated with IV-tPA for AIS.

Results: We identified 34,461 AIS patients treated with IV-tPA, including 454 with prior ischemic stroke in the past 3 months. Patients with recent stroke were on average younger and had more vascular risk factors and Elixhauser comorbidities than patients without recent stroke. The ICH rate after IV-tPA was similar in patients with AIS within the previous 3 months (6.6%, 95% CI 6.3-6.8) compared to patients without recent AIS (6.8%, 95% CI 4.5–9.1), but the rate of death was higher in those with AIS within the previous 3 months (16.5%, 95% CI 13.1-19.9 vs. 11.1%, 95% CI 10.7-11.4, p<0.001). After adjusting for demographics, vascular risk factors, and the Elixhauser comorbidity index, the risk of ICH following IV-rPA in patients with AIS in the previous 3 months was not different from those without recent AIS (OR=1.0, 95% CI 0.7-1.5, p=0.90), although the risk of death remained higher in patients with AIS in the previous 3 months (OR=1.6, 95% CI 1.2-2.1, p<0.001). Our results were unchanged in sensitivity analyses excluding patients with other approved indications for thrombolysis (e.g., MI, PE, and hemodialysis).

Conclusions: In a large, multistate cohort, prior stroke within 3 months of receiving IV-tPA for AIS was not associated with an increased risk of ICH but was associated with a higher risk of death.