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

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.

Survival and Prognostic Factors After Carotid Artery Stenting in Patients with Concomitant Coronary Disease

AIM: The aim of the study was to analyze the prognostic factors in patients after carotid artery stenting (CAS). METHODS: In 329 patients after CAS, the median survival (MS) and overall survival (OS) were calculated for a follow-up period of 2–101 months. All patients underwent coronary angiography before carotid stenting and, if indicated, coronary revascularization. Four groups of factors were analyzed: Carotid disease, coronary artery disease (CAD), underlying cardiac pathology, and concomitant diseases. RESULTS: MS in all patients was 86 months, OS at 1, 3, 5, and 9 years was - 94%, 85%, 73%, and 51%, respectively. Event free survival was 85 months. Log Rank-Mantel-Cox analysis demonstrated significantly reduced MS in 21 tested factors, most of them related to CAD. Two-step multifactorial Cox regression analysis defined only 7 of them as independent prognostic factors for the survival of patients after CAS: Left main stenosis, complete revascularization, late myocardial infarction, stroke, age over 70 years, valvular disease, and carotid score. CONCLUSION: Survival of patients after CAS is limited mainly by CAD and underlying cardiac pathology. Staged revascularization treatment strategy may improve the prognosis and survival of patients with both carotid and coronary disease.

Comparison of risk factors for ischemic stroke and coronary events in a population-based cohort

BACKGROUND

Although coronary events (CE) and ischemic stroke share many risk factors, there are also some important differences. The aim of this paper was to assess the association of risk factors in relation to incident CE and ischemic stroke and to evaluate the heterogeneity in patterns of risk factors between the two outcomes.

METHOD

Traditional risk factors and inflammatory markers associated with coronary events and ischemic stroke were measured in the Malmö Diet and Cancer Cohort (MDCS, n = 26 519), where a total of 2270 incident ischemic stroke and 3087 incident CE occurred during a mean follow up time 19 ± 6 years, and in relation to inflammatory markers in the cardiovascular sub-cohort (MDC-CV, n = 4795). Cox regression analysis was used to obtain hazard ratios. A modified Lunn-McNeil competing risk analysis was conducted to assess the significance of any differences in risk profiles of these outcomes.

RESULTS

Most cardiovascular risk factors were associated both with incident CE and ischemic stroke. However, current smoking, ApoB, low ApoA1, male sex and education level of ≤ 9 years of schooling were preferentially associated with CE compared to ischemic stroke. Conversely, age showed a stronger association with ischemic stroke than with CE.

CONCLUSION

CE and ischemic stroke have broadly similar risk factors profiles. However, there are some important differential associations, as well as substantial differences in the magnitude of the association. These could reflect the distinct biology of atherogenesis in different vascular beds. The difference in the determinants highlights the importance of looking at CE and ischemic stroke, two manifestations of cardiovascular disease, separately.

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.

Machine Learning to Predict Long-Term Cardiac-Relative Prognosis in Patients With Extra-Cardiac Vascular Disease

Aim: Patients with ischemic stroke (IS), transient ischemic attack (TIA), and/or peripheral artery disease (PAD) represent a population with an increased risk of coronary artery disease. Prognostic risk assessment to identify those with the highest risk that may benefit from more intensified treatment remains challenging. To explore the feasibility and capability of machine learning (ML) to predict long-term adverse cardiac-related prognosis in patients with IS, TIA, and/or PAD. Methods: We analyzed 636 consecutive patients with a history of IS, TIA, and/or PAD. All patients underwent a coronary CT angiography (CCTA) scan. Thirty-five clinical data and 34 CCTA metrics underwent automated feature selection for ML model boosting. The clinical outcome included all-cause mortality (ACM) and major adverse cardiac events (MACE) (ACM, unstable angina requiring hospitalization, non-fatal myocardial infarction (MI), and revascularization 90 days after the index CCTA). Results: During the follow-up of 3.9 ± 1.6 years, 21 patients had unstable angina requiring hospitalization, eight had a MI, 23 had revascularization and 13 deaths. ML demonstrated a significant higher area-under-curve compared with the modified Duke index (MDI), segment stenosis score (SSS), segment involvement score (SIS), and Framingham risk score (FRS) for the prediction of ACM (ML:0.92 vs. MDI:0.66, SSS:0.68, SIS:0.67, FRS:0.51, all P < 0.001) and MACE (ML:0.84 vs. MDI:0.82, SSS:0.76, SIS:0.73, FRS:0.53, all P < 0.05). Conclusion: Among the patients with IS, TIA, and/or PAD, ML demonstrated a better capability of predicting ACM and MCAE than clinical scores and CCTA metrics.

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.

Patient readiness for risk-reduction education and lifestyle change following transient ischemic attack

PURPOSE

Patient readiness for secondary prevention and lifestyle change following transient ischemic attack is not well understood. Understanding patient perspectives about the timing and delivery of secondary prevention education is essential to promote meaningful risk factor reduction in this population.

MATERIALS AND METHODS

A single, semi-structured, telephone interview was conducted with ten individuals (7 male, 3 female) within three months following a transient ischemic attack. Interviews explored transient ischemic attack experiences and post-event education. Data were analyzed using inductive thematic analysis.

RESULTS

Individuals had a variety of experiences with secondary prevention education. Four themes emerged from these experiences including "what the hell happened?", "I mustn't have been quite ready", "what should I be doing?" and "we all see it in different ways." Individual knowledge, personal experience of transient ischemic attack, socio-environmental factors, and the format and content of education influenced patient readiness to receive secondary prevention education and adopt lifestyle changes.

CONCLUSION

Readiness for risk-reduction education and lifestyle change following transient ischemic attack is individual and complex. Logistical factors including the location, time, and cost of education, timing of education delivery, and patient perspectives should be considered in the development and delivery of secondary prevention interventions for these people. Implications for rehabilitation Risk reduction and lifestyle change following transient ischemic attack is vital to prevent recurrent stroke. Patients are ready to receive risk reduction and lifestyle advice approximately one week after their transient ischemic attack. Programs designed to provide risk reduction and lifestyle education should be informed by the unique requirements of this population. Uptake of participation in secondary prevention programs may be maximized by offering flexibility in terms of timing post-event and modes of delivery (e.g. Telehealth).

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.

Risk burdens of modifiable risk factors incorporating lipoprotein (a) and low serum albumin concentrations for first incident acute myocardial infarction

Risk burdens of modifiable risk factors incorporating lipoprotein (a) (Lp(a)) and low serum albumin (LSA) concentrations for first incident acute myocardial infarction (AMI) haven’t been studied previously. Cross-sectional study of 1552 cases and 6125 controls was performed for identifying the association of risk factors with first incident AMI and their corresponding population attributable risks (PARs). Modifiable risk factors incorporating LSA and Lp(a) accounted for up to 92% of PAR for first incident AMI. Effects of these risk factors were different in different sexes across different age categories. Overall, smoking and LSA were the 2 strongest risk factors, together accounting for 64% of PAR for first incident AMI. After multivariable adjustment, Lp(a) and LSA accounted for 19% and 41%, respectively, and together for more than a half (54%) of PAR for first incident AMI. Modifiable risk factors incorporating LSA and Lp(a) have accounted for an overwhelmingly large proportion of the risk of first incident AMI, indicating most first incident AMI is preventable. The knowledge of risk burdens for first incident AMI incorporating Lp (a) and LSA may be beneficial for further reducing first incident AMI from a new angle.

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.

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.

Coronary and carotid atherosclerosis: how useful is the imaging?

The recent advancement of imaging modalities has made possible visualization of atherosclerosis disease in all phases of its development. Markers of subclinical atherosclerosis or even the most advanced plaque features are acquired by invasive (IVUS, OCT) and non-invasive imaging modalities (US, MRI, CTA). Determining plaques prone to rupture (vulnerable plaques) might help to identify patients at risk for myocardial infarction or stroke. The most accepted features of plaque vulnerability include: thin cap fibroatheroma, large lipid core, intimal spotty calcification, positive remodeling and intraplaque neovascularizations. Today, research is focusing on finding imaging techniques that are less invasive, less radiation and can detect most of the vulnerable plaque features. While, carotid atherosclerosis can be visualized using noninvasive imaging, such as US, MRI and CT, imaging plaque feature in coronary arteries needs invasive imaging modalities. However, atherosclerosis is a systemic disease with plaque development simultaneously in different arteries and data acquisition in carotid arteries can add useful information for prediction of coronary events.

Aortic Stiffness Measurement Improves the Prediction of Asymptomatic Coronary Artery Disease in Stroke/Transient Ischemic Attack Patients

Background

Aortic stiffness is an independent predictor of coronary events.

Aims

We assessed the predictive value of aortic stiffness for ⩾50% asymptomatic coronary artery disease in a stroke/transient ischemic attack population.

Methods

We enrolled 300 consecutive patients aged 45–75 years with nondisabling, noncardioembolic ischemic stroke or transient ischemic attack, and no prior history of coronary artery disease. Coronary artery disease was assessed with 64-section computed tomography coronary angiography and all patients had a detailed cervicocephalic arterial work-up. Aortic stiffness was determined from carotid-femoral pulse wave velocity with 9·6 m/s as cutoff value. The predictive value of aortic stiffness was assessed by logistic regression and reclassification tables method after adjustment for the Framingham Risk Score and the presence of cervicocephalic stenosis, which were previously shown to be independent predictor of ⩾50% asymptomatic coronary artery disease.

Results

Among the 274 included patients who had computed tomography coronary angiography, 26% (95% CI, 21%–32%) had an increased stiffness (pulse wave velocity > 9·6 m/s) and 18% (14%–23%) had ⩾50% asymptomatic coronary artery disease. Increased aortic stiffness was associated with the presence of ⩾50% asymptomatic coronary artery disease, both in univariate (odds ratio = 3·4 [1·8–6·4]) and multivariate analyses (odds ratio = 2·3 [1·2–4·7]) after adjustment for Framingham Risk Score and presence of cervicocephalic stenosis. After carotid-femoral pulse wave velocity was added to the standard model including Framingham Risk Score and the presence of cervicocephalic stenosis, net reclassification improvement was 12·6% ( P < 0·005), integrated discrimination index was 2·51% ( P = 0·025), and model fit was improved (likelihood ratio = 4·99, P = 0·025).

Conclusions

In stroke/transient ischemic attack patients, aortic pulse wave velocity improves the prediction of ⩾50% asymptomatic coronary artery disease beyond classical risk factors.

Ischemic stroke: measurement of intracranial artery calcifications can improve prediction of asymptomatic coronary artery disease

PURPOSE

To examine the associations between intracranial artery calcifications (IACs) and coronary artery calcifications (CACs) in patients with ischemic stroke and to assess the predictive value of IAC for asymptomatic coronary artery disease (CAD).

MATERIALS AND METHODS

This retrospective study, approved by an institutional review board that waived the need for informed consent, included 314 consecutive patients who had acute ischemic stroke and who underwent both brain and coronary computed tomography (CT) within 1 month of stroke. IAC was quantified semiautomatically by calculating both Agatston scores (area of calcification multiplied by a weighted value assigned to its highest Hounsfield unit) and volumes on thin-section unenhanced images and was correlated with coronary calcium scores and volumes. Quartiles were created for IAC scores and were used for logistic regression analysis. An optimal IAC score cutoff value was determined and used to predict the presence of asymptomatic CAD. Independent factors for asymptomatic CAD were assessed by using multiple logistic regression analysis. Receiver operating characteristic curve analysis was performed to evaluate the added value of IAC scores for prediction of asymptomatic CAD.

RESULTS

IAC and CAC were significantly correlated for both Agatston scores and volumes (R = 0.665 and 0.663, respectively; P < .001). A graded association was found between IAC scores and presence of asymptomatic CAD. Both IAC scores of 120.11 or greater (odds ratio [OR], 2.57; 95% confidence interval [CI]: 1.45, 4.55) and diabetes mellitus (OR, 4.23; 95% CI: 2.42, 7.4) were independent predictors for asymptomatic CAD. Adding the IAC score to analytic models significantly improved the ability to predict asymptomatic CAD.

CONCLUSION

The IAC scores quantified by using unenhanced CT correlate significantly with coronary calcium scores and may serve as an independent predictor of asymptomatic CAD in patients with ischemic stroke.

Protecting the Brain and the Heart

Novel anticoagulants (NOACs) are the recent therapeutic breakthrough in the prophylaxis of stroke in patients with nonvalvular atrial fibrillation (NVAF). Patients with NVAF seem to have a high atherosclerotic burden, but it has not yet been established whether these agents also protect against cardiovascular disease (CVD). Different NOACs could have cardioprotective properties of different importance, but data come only from indirect comparisons. Patients with NVAF are at risk of stroke when there is concomitant atherosclerosis that also necessitates optimal treatment to reduce CVD risk. Combining antiplatelets with anticoagulants is a common clinical scenario and not always justified by current data and guidelines, putting patients at unnecessary bleeding risk. This review provides current knowledge about the cardioprotective properties of NOACs, the clinical importance of the link between CVD and NVAF, and the pitfalls of combining antiplatelet therapy with warfarin or NOACs.

Coronary and carotid atherosclerosis: similarities and differences

Although a relationship is commonly accepted between coronary and carotid arterial disease, suggesting that atherosclerosis is a systemic condition, the extent of this association and correspondence has not been fully elucidated. This review discusses recent research in this field and highlights areas for future study. The prevalence of severe carotid stenosis increases with prevalence of coronary stenosis, with the latter being found in a significant number of stroke patients, while those with carotid stenosis may be at higher risk of myocardial infarction than stroke. There also appear to be common risk factors (age, diabetes, hypertension, smoking and dyslipidemia), although the effects in both vascular systems may not be identical. Furthermore, while the degree of stenosis in the coronary artery has little ability to predict acute coronary syndrome, which is caused by local thrombosis from a ruptured or eroded plaque, severe carotid stenosis causing hypoperfusion is highly predictive of stroke, although this effect may be time-limited. This apparent difference in event mechanism in the two arteries is interesting as is the difference in the rate of development of collaterals. Overall, the evidence shows that a clear relationship exists between disease in the coronary and carotid arteries, since conventional risk factors and the extent of stenosis and/or previous events emanating from one artery have a strong bearing on the prevalence of events in the other artery. Nevertheless, the exact correspondence between the two arteries is unclear, with sometimes contradictory study results. More research is needed to identify the full extent of risk factors for severe stenosis and cardio- or cerebral vascular events, among which, inflammatory biomarkers such as hs-CRP and prior vascular events are likely to play a key role.

Utility of Framingham Coronary Heart Disease Risk Score for predicting cardiac risk after stroke

BACKGROUND AND PURPOSE

Coronary heart disease (CHD) is a major cause of mortality among stroke patients after the acute period. Simple risk stratification of stroke patients without known CHD may permit prompt implementation of CHD-specific management strategies for those who are at high risk for cardiac events. We assessed the utility of the Framingham Coronary Heart Disease Risk Score (FCRS) as a prognosticator in stroke patients without known CHD.

METHODS

Post hoc analysis of a trial dataset of 3509 recent ischemic stroke patients who were aged 35 years or older, recruited from 56 centers, and followed-up for 2 years. Patients were categorized as having known CHD, high FCRS (≥20%), and low/intermediate FCRS (<20%). The predictive values between baseline FCRS and primary (myocardial infarction [MI]), secondary (MI or vascular death), and tertiary (recurrent stroke) outcomes were assessed in multivariate analyses.

RESULTS

Rates of first MI at 2 years were 6.34%, 4.65%, and 1.44% for the known CHD, high FCRS, and low/intermediate FCRS groups. Compared with stroke patients with low/intermediate FCRS, individuals with high FCRS had a higher risk of MI (adjusted hazard ratio, 3.70; 95% confidence interval, 2.14-6.38) and MI or vascular death (adjusted hazard ratio, 2.21; 95% confidence interval, 1.48-3.28). High FCRS did not predict recurrent stroke.

CONCLUSIONS

Among patients with a recent ischemic stroke without known CHD, high FCRS was associated with a higher risk of MI and vascular death, but not stroke. FCRS could be a simple way to identify recent stroke patients who may benefit from additional CHD-specific management.

Epidemiology and risk factors of cerebral ischemia and ischemic heart diseases: similarities and differences

Cerebral ischemia and ischemic heart diseases, common entities nowadays, are the main manifestation of circulatory diseases. Cardiovascular diseases, followed by stroke, represent the leading cause of mortality worldwide. Both entities share risk factors, pathophisiology and etiologic aspects by means of a main common mechanism, atherosclerosis. However, each entity has its own particularities. Ischemic stroke shows a variety of pathogenic mechanisms not present in ischemic heart disease. An ischemic stroke increases the risk of suffering a coronary heart disease, and viceversa. The aim of this chapter is to review data on epidemiology, pathophisiology and risk factors for both entities, considering the differences and similarities that could be found in between them. We discuss traditional risk factors, obtained from epidemiological data, and also some novel ones, such as hyperhomocisteinemia or sleep apnea. We separate risk factors, as clasically, in two groups: nonmodifiables, which includes age, sex, or ethnicity, and modifiables, including hypertension, dyslipidemia or diabetis, in order to discuss the role of each factor in both ischemic events, ischemic stroke and coronary heart disease.

Prevalence of asymptomatic coronary artery disease in ischemic stroke patients: the PRECORIS study

BACKGROUND

Coronary artery disease (CAD) is a significant cause of morbidity and mortality in stroke patients. Some patients with asymptomatic CAD might benefit from specific prevention, but the prevalence of asymptomatic CAD is not well known. We assessed the prevalence of >or=50% asymptomatic CAD in patients with ischemic stroke or transient ischemic attack and whether the prevalence is related to traditional vascular risk factors and cervicocephalic atherosclerosis.

METHODS AND RESULTS

From January 2006 to February 2009, consecutive patients between 45 and 75 years of age with nondisabling, noncardioembolic ischemic stroke or transient ischemic attack and no prior history of CAD were enrolled in the study. All patients had a 64-section computed tomography coronary angiography and a detailed cervicocephalic arterial workup. Risk factors were assessed individually and through the Framingham Risk Score. Among 300 patients included in the study, 274 had computed tomography coronary angiography. The prevalence of >or=50% asymptomatic CAD was 18% (95% confidence interval [CI], 14 to 23; n=50). Asymptomatic CAD was independently associated with traditional risk factors assessed individually and through the Framingham Risk Score (odds ratio [OR], 2.6; 95% CI, 1.0 to 7.6 for a 10-year risk of coronary heart disease of 10% to 19%; and OR, 7.3; 95% CI, 2.8 to 19.1 for a 10 year-risk of coronary heart disease >or=20%), the presence of at least 1 >or=50% cervicocephalic artery stenosis (OR, 4.0; 95% CI, 1.4 to 11.2), excessive alcohol consumption (OR, 3.1; 95% CI 1.3 to 7.3), and ankle brachial index <0.9 (OR, 2.2; 95% CI, 0.9 to 5.2). The prevalence of >or=50% asymptomatic CAD was also related to the extent of cervicocephalic atherosclerosis.

CONCLUSIONS

About one fifth of patients with nondisabling, noncardioembolic ischemic stroke or transient ischemic attack have >or=50% asymptomatic CAD. In addition to vascular risk factors, the presence of >or=50% cervicocephalic artery stenosis is strongly related to >or=50% asymptomatic CAD.

Optimizing screening and management of asymptomatic coronary artery disease in patients with stroke and patients with transient ischemic attack

BACKGROUND AND PURPOSE

The feasibility of implementing an expert consensus guideline recommending use of a stroke patient's profile to manage undiagnosed coronary artery disease remains unclear.

METHODS

Following a guideline-based algorithm, we screened consecutive patients with ischemic stroke and patients with transient ischemic attack for asymptomatic coronary artery disease using the Framingham Heart Study Coronary Risk Score (FCRS) cutoff of high risk (> or = 20%) for experiencing a hard coronary artery disease event over a 10-year period. Patients with high FCRS received dobutamine stress echocardiogram outpatient screening, additional treatment (beta-blocker), or further management (cardiologist referral).

RESULTS

From July 2004 to September 2007, among 693 patients, 501 (72%) met study criteria, of which 80 (16%) had FCRS > or = 20%. Elevated serum glucose, nonhigh-density lipoprotein, triglycerides, homocysteine, glycosylated hemoglobin as well as large vessel atherosclerotic stroke mechanism were more frequent in high versus low FCRS patients (P<0.05). Among high FCRS patients, 35 (44%) had dobutamine stress echocardiogram performed. Leading reasons for dobutamine stress echocardiogram nonperformance were patient noncompliance (42%) and primary care physician refusal (33%).

CONCLUSIONS

Screening for coronary artery disease risk using FCRS is feasible in hospitalized patients with stroke, but outpatient adherence to stress testing is challenging largely due to patient and primary care physician-related factors.