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Marrero N, Jha K, Hughes TM, Razavi AC, Grant JK, Boakye E, Anchouche K, Dzaye O, Budoff MJ, Rotter JI, Guo X, Yao J, Wood AC, Blumenthal RS, Michos ED, Thanassoulis G, Post WS, Blaha MJ, Ibeh C, Whelton SP. Association of aortic valve calcium with dementia and stroke: The Multi-Ethnic Study of Atherosclerosis. Atherosclerosis 2024:117596. [PMID: 38890039 DOI: 10.1016/j.atherosclerosis.2024.117596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 05/01/2024] [Accepted: 05/22/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND AND AIMS Calcific aortic valve disease is associated with increased thrombin formation, platelet activation, decreased fibrinolysis, and subclinical brain infarcts. We examined the long-term association of aortic valve calcification (AVC) with newly diagnosed dementia and incident stroke in the Multi-Ethnic Study of Atherosclerosis (MESA). METHODS AVC was measured using non-contrast cardiac CT at Visit 1. We examined AVC as a continuous (log-transformed) and categorical variable (0, 1-99, 100-299, ≥300). Newly diagnosed dementia was adjudicated using International Classification of Disease codes. Stroke was adjudicated from medical records. We calculated absolute event rates (per 1000 person-years) and multivariable adjusted Cox proportional hazards ratios (HR). RESULTS Overall, 6812 participants had AVC quantified with a mean age of 62.1 years old, 52.9 % were women, and the median 10-year estimated atherosclerotic cardiovascular disease (ASCVD) risk was 13.5 %. Participants with AVC >0 were older and less likely to be women compared to those with AVC=0. Over a median 16-year follow-up, there were 535 cases of dementia and 376 cases of stroke. The absolute risk of newly diagnosed dementia increased in a stepwise pattern with higher AVC scores, and stroke increased in a logarithmic pattern. In multivariable analyses, AVC was significantly associated with newly diagnosed dementia as a log-transformed continuous variable (HR 1.09; 95 % CI 1.04-1.14) and persons with AVC ≥300 had nearly a two-fold higher risk (HR 1.77; 95 % CI 1.14-2.76) compared to those with AVC=0. AVC was associated with an increased risk of stroke after adjustment for age, sex, and race/ethnicity, but not after adjustment for ASCVD risk factors. CONCLUSIONS After multivariable adjustment, AVC >0 was significantly associated with an increased risk of newly diagnosed dementia, but not incident stroke. This suggests that AVC may be an important risk factor for the long-term risk of dementia beyond traditional ASCVD risk factors.
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Affiliation(s)
- Natalie Marrero
- University of Miami/Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kunal Jha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA; University of Louisville, Division of Cardiology, Louisville, KY, USA
| | - Timothy M Hughes
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA; Center for Heart Disease Prevention, Emory School of Medicine, Atlanta, GA, USA
| | - Jelani K Grant
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ellen Boakye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Khalil Anchouche
- Preventive and Genomic Cardiology, Department of Medicine, McGill University, and the McGill University Health Center Research Institute, Montréal, Québec, Canada
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Matthew J Budoff
- Department of Medicine, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Jerome I Rotter
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Xiuqing Guo
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Jie Yao
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Erin D Michos
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - George Thanassoulis
- Preventive and Genomic Cardiology, Department of Medicine, McGill University, and the McGill University Health Center Research Institute, Montréal, Québec, Canada
| | - Wendy S Post
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Chinwe Ibeh
- Columbia University, Department of Neurology, New York, NY, USA
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Huntley GD, Michelena HI, Thaden JJ, Alkurashi AK, Pislaru SV, Pochettino A, Crestanello JA, Maleszewski JJ, Brown RD, Nkomo VT. Cerebral and Retinal Infarction in Bicuspid Aortic Valve. J Am Heart Assoc 2023; 12:e028789. [PMID: 36942747 PMCID: PMC10122894 DOI: 10.1161/jaha.122.028789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Background Description of cerebral and retinal infarction in patients with bicuspid aortic valve (BAV) is limited to case reports. We aimed to characterize cerebral and retinal infarction and examine outcomes in patients with BAV. Methods and Results Consecutive patients from 1975 to 2015 with BAV (n=5401) were retrospectively identified from the institutional database; those with confirmed cerebral or retinal infarction were analyzed. Infarction occurring after aortic valve replacement was not included. Patients were grouped according to infarction pathogenesis: embolism from a degenerative calcific BAV (BAVi); non-BAV, large artery atherosclerotic or lacunar infarction (LAi); and non-BAV, non-large artery embolic infarction (nLAi). There were 83/5401 (1.5%) patients, mean age 54±12 years and 28% female, with confirmed cerebral or retinal infarction (LAi 23/83 [28%]; nLAi 30/83 [36%]; BAVi 26/83 [31%]; other 4/83 [5%]). Infarction was embolic in 72/83 (87%), and 35/72 (49%) were cardioembolic. CHA2DS2-VASc score was 1.4±1.2 in BAVi (P=0.188 versus nLAi) and 2.3±1.2 in LAi (P=0.005). Recurrent infarction occurred in 41% overall (50% BAVi, P=0.164 and 0.803 versus LAi and nLAi). BAVi was more commonly retinal (39% BAVi versus 13% LAi, P=0.044 versus 0% nLAi, P=0.002). Patients with BAVi and LAi were more likely to have moderate-to-severe aortic stenosis and undergo aortic valve replacement compared with patients with nLAi. Conclusions Cardioembolism, often from degenerative calcification of the aortic valve, is a predominant cause of cerebral and retinal infarction in patients with BAV and is frequently recurrent. Cerebral and retinal infarction should be regarded as a complication of BAV.
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Affiliation(s)
| | | | - Jeremy J Thaden
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Sorin V Pislaru
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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Dai C, Liu M, Zhou Y, Lu D, Chen Z, Qian J, Ge J. Aortic valve calcification predicts poor outcomes after primary percutaneous coronary intervention. Eur J Clin Invest 2022; 52:e13828. [PMID: 35748527 DOI: 10.1111/eci.13828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 06/12/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Aortic valve calcification (AVC) is associated with increased cardiovascular risk in the general population. We sought to investigate whether AVC identified by transthoracic echocardiography could be a predictor of long-term adverse events after primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction. METHODS Patients undergoing primary PCI were consecutively enrolled in this cohort study between 1 January 2009 and 31 December 31 2018. The presence of AVC was identified by transthoracic echocardiography one to three days after PCI. The primary endpoint was major adverse cardiovascular and cerebral events (MACCE) during follow-up. Propensity score matching was adopted to adjust for the baseline differences between groups. RESULTS Of 2117 patients enrolled in the study, 566 (26.7%) were found to have AVC. Patients with AVC were older, more likely to be women, and disposed to have comorbidities and complex lesions. During a median follow-up period of 6.1 years, 699 cases of MACCE occurred, including 243 (42.9%) cases in patients with AVC and 456 (29.4%) cases in patients without AVC. After 1:1 propensity score matching, the presence of AVC increased the risk of MACCE (adjusted hazard ratio: 1.442, 95% confidence interval: 1.186 to 1.754, p < 0.001). This difference persisted when sensitivity and subgroup analyses were made. CONCLUSIONS AVC identified by transthoracic echocardiography independently increased the long-term risk of MACCE after primary PCI in patients with acute myocardial infarction. This imaging feature will contribute to better risk stratification in this population.
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Affiliation(s)
- Chunfeng Dai
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China.,Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Muyin Liu
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China.,Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - You Zhou
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China.,Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Danbo Lu
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China.,Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zhangwei Chen
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China.,Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Juying Qian
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China.,Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China.,Shanghai Clinical Research Center for Interventional Medicine, Shanghai, China
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Sawalha K, Kamdar HA, Gullo T, Okere S, Hamed M, Hinduja A, Hussein O. Cardiovascular Predictors of Intracerebral Hematoma Expansion. J Stroke Cerebrovasc Dis 2022; 31:106527. [PMID: 35523053 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 04/17/2022] [Accepted: 04/21/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is limited evidence on the effect and relevance of cardiovascular parameters on the cerebrovascular system when an intracerebral hemorrhage (ICH) occurs. While recent studies evaluating this relationship are conflicting, one evaluating the effect of systolic cardiac function on clinical outcomes in ICH patients, found low cardiac ejection fractions to be associated with poor clinical outcomes. Our primary objective was to study such correlations and identify various cardiovascular disease states that may be associated with hematoma expansion. METHODS This is an IRB-approved single-center retrospective study utilizing our institutional "Get with the Guidelines"-Stroke registry between 2013 and 2017. Patients included were older than 18 years of age, admitted with an acute ICH, and had an echocardiogram during their hospitalization. Univariate and multivariate logistical regression analyses were used to identify cardiovascular predictors of hematoma expansion. RESULTS Two-hundred forty-nine patients were identified from our GWTG-S registry that met initial inclusion criteria. Of these patients, a history of peripheral arterial disease (PAD) (p = 0.015), presence of aortic stenosis (AS) on the echocardiogram (p = 0.025), and a positive spot sign on the CT-angiogram (CTA) of the head (p < 0.001) were found to be independently associated with ICH expansion. Both a history of hypertension and elevated blood pressure on presentation were not significant predictors. Additionally, patients with a history of congestive heart failure had decreased odds of hematoma expansion (p = 0.027). CONCLUSION This exploratory study highlights potential novel cardiac predictors of hematoma expansion, including PAD and AS, which warrant further study. Larger prospective studies are needed to further investigate such associations to ultimately optimize cardio-cerebral health.
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Affiliation(s)
- Khalid Sawalha
- Department of Internal Medicine, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA, United States
| | - Hera A Kamdar
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Terese Gullo
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Sheila Okere
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Mohammad Hamed
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Archana Hinduja
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Omar Hussein
- Department of Neurology, University of New Mexico Health Sciences Center, MSC10-5620, 1 UNM, 87111, Albuquerque, NM 87131, United States.
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5
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Ito A, Iwata S, Tamura S, Kim AT, Nonin S, Ishikawa S, Ito A, Izumiya Y, Abe T, Shibata T, Yoshiyama M. Prevalence and Risk Factors of Silent Brain Infarction in Patients with Aortic Stenosis. Cerebrovasc Dis Extra 2020; 10:116-123. [PMID: 33032286 PMCID: PMC7588680 DOI: 10.1159/000510438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/23/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction Silent brain infarction (SBI) is an independent risk factor for subsequent symptomatic stroke in the general population. Although aortic stenosis (AS) is also known to be associated with an increased risk of future symptomatic stroke, little is known regarding the prevalence and risk factors for SBI in patients with AS. Methods The study population comprised 83 patients with severe AS with no history of stroke or transient ischemic attack and paralysis or sensory impairment (mean age 75 ± 7 years). All patients underwent brain magnetic resonance imaging to screen for SBI and multidetector-row computed tomography to quantify the aortic valve calcification (AVC) volume. Comprehensive transthoracic and transesophageal echocardiography were performed to evaluate left atrial (LA) abnormalities, such as LA enlargement, spontaneous echo contrast, or abnormal LA appendage emptying velocity (<20 cm/s), and complex plaques in the aortic arch. Results SBI was detected in 38 patients (46%). Multiple logistic regression analysis indicated that CHA<sub>2</sub>DS<sub>2</sub>-VASc score and estimated glomerular filtration rate (eGFR) were independently associated with SBI (p < 0.05), whereas LA abnormalities and AVC volume were not. When patients were divided into 4 groups according to CHA<sub>2</sub>DS<sub>2</sub>-VASc score and eGFR, the group with a higher CHA<sub>2</sub>DS<sub>2</sub>-VASc score (≥4) and a lower eGFR (<60 mL/min/1.73 m<sup>2</sup>) had a greater risk of SBI than the other groups (p < 0.05). Conclusion These findings indicate that AS is associated with a high prevalence of SBI, and that the CHA<sub>2</sub>DS<sub>2</sub>-VASc score and eGFR are useful for risk stratification.
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Affiliation(s)
- Ayaka Ito
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan
| | - Shinichi Iwata
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan,
| | - Soichiro Tamura
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan
| | - Andrew T Kim
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan
| | - Shinichi Nonin
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan
| | - Sera Ishikawa
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan
| | - Asahiro Ito
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan
| | - Takato Abe
- Department of Neurology, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan
| | - Minoru Yoshiyama
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine Osaka, Osaka, Japan
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Juvenile stroke caused by calcific bicuspid aortic valve: A case report. Clin Neurol Neurosurg 2020; 195:106079. [PMID: 32663736 DOI: 10.1016/j.clineuro.2020.106079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/02/2020] [Accepted: 07/06/2020] [Indexed: 11/20/2022]
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7
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Di Minno MND, Di Minno A, Ambrosino P, Songia P, Pepi M, Tremoli E, Poggio P. Cardiovascular morbidity and mortality in patients with aortic valve sclerosis: A systematic review and meta-analysis. Int J Cardiol 2018; 260:138-144. [PMID: 29622430 DOI: 10.1016/j.ijcard.2018.01.054] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 12/18/2017] [Accepted: 01/15/2018] [Indexed: 11/17/2022]
Abstract
AIMS The association between aortic valve sclerosis (AVSc) and cardiovascular (CV) events is not consistent among different studies. We have performed a meta-analysis evaluating the association between AVSc and fatal and/or non-fatal CV and cerebrovascular events. METHODS AND RESULTS A systematic search was performed in the electronic databases (PubMed, Web of Science, Scopus, EMBASE). Studies evaluating coronary artery disease (CAD), stroke and CV mortality in AVSc patients and controls were included. Differences among cases and controls were expressed as Odds Ratio (OR) with pertinent 95% Confidence Intervals (CI). Thirty-one studies on 10,537 AVSc patients and 25,005 controls were included in the final analysis. The absolute risk of CAD was 45.8% (95% CI: 32.9-59.3) in AVSc patients and 29.4% (95% CI: 21.8-38.5) in controls with an OR of 2.02 (95% CI: 1.67-2.44) and an attributable risk of 35.8%. Moreover, stroke was reported in 11.8% (95% CI: 4.4-27.7) of AVSc patients and 7.9% (95% CI: 2.5-22.7) of controls (OR: 1.41, 95% CI: 1.16-1.71) with an attributable risk of 33.0%. CV mortality was 6.2% (95% CI: 2.7-13.5) in AVSc patients and 2.0% (95% CI: 0.5-7.9) in controls (OR: 2.70, 95% CI: 1.45-5.01), with an attributable risk of 67.7%. Results were confirmed when pooling together ORs for CAD, stroke and CV mortality obtained by means of multivariate analysis. CONCLUSIONS AVSc is associated with CAD, stroke and CV mortality. Taken together, these data suggest that patients with AVSc may benefit from a stricter CV risk monitoring and that AVSc screening may be included in the frame of CV risk stratification protocols.
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Affiliation(s)
| | - Alessandro Di Minno
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Dipartimento di Scienze Farmacologiche e Biomolecolare, University of Milan, Milan, Italy
| | - Pasquale Ambrosino
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Paola Songia
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | - Paolo Poggio
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.
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8
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Zhang D, Dai X, Wang C, Han K, Wang J, Dong Y, Chen J, Hou L. Aortic valve calcification and risk of stroke: A systematic review and meta-analysis. J Clin Neurosci 2018; 55:32-37. [PMID: 30041902 DOI: 10.1016/j.jocn.2018.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/04/2018] [Accepted: 07/08/2018] [Indexed: 11/22/2022]
Abstract
Aortic valve calcification (AVC) is common among aged population and reported to be associated with the risk of stroke. However, the conclusions are inconsistent among studies. We performed a rigorous meta-analysis to unravel the AVC-stroke relationship. Embase, PubMed and Cochrane library were retrieved for related cohort studies investigating the correlations between AVC and risk of stroke. The language was limited to English. We selected risk ratio (RR) and 95% confidence intervals (CIs) as the effect size. Random-effects model was used in the data synthesis. A total of 7 cohort studies were identified in our meta-analysis with 21,395 participants and 1025 strokes. We detected statistically significant correlation between AVC and stroke (RR, 1.20; 95% CI, 1.02-1.40, P = 0.02) with low heterogeneity (I2 = 6.9%, P = 0.375). Statistically significant results were detected only in the subgroup of "+" degree of adjustment (P = 0.04). Therefore, a definite relationship between AVC and risk of stroke couldn't be decided based on current available data, and more large scale prospective studies were needed to verify the AVC-stroke relationship.
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Affiliation(s)
- Danfeng Zhang
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Xianliang Dai
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai 200433, China
| | - Chaoqun Wang
- Department of Endocrinology, Changhai Hospital, Second Military Medical University, Shanghai 200003, China
| | - Kaiwei Han
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Junyu Wang
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Yan Dong
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Jigang Chen
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.
| | - Lijun Hou
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.
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Ramírez-Moreno J, Trinidad-Ruiz M, Ceberino D, Fernández de Alarcón L. Mechanical thrombectomy during ischaemic stroke due to a calcified cerebral embolism. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2015.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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10
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Lu MLR, Gupta S, Romero-Corral A, Matejková M, De Venecia T, Obasare E, Bhalla V, Pressman GS. Cardiac Calcifications on Echocardiography Are Associated with Mortality and Stroke. J Am Soc Echocardiogr 2016; 29:1171-1178. [DOI: 10.1016/j.echo.2016.08.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Indexed: 10/20/2022]
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11
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Xu SC, Canter L, Zeeshan A, Elefteriades JA. Deep Crater in Heavily Calcified Aortic Valve Leaflet: A "Smoking Gun" for Embolic Stroke. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2016; 3:172-6. [PMID: 27175368 DOI: 10.12945/j.aorta.2015.15.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/26/2015] [Indexed: 11/18/2022]
Abstract
The association of severe calcific aortic stenosis with clinically significant stroke has not been well established. This case vividly describes the relationship with clinical and pathological (gross and microscopic) findings in a 62-year-old man with a severely calcified bicuspid aortic valve. Eleven months prior to aortic valve surgery, the patient had stigmata of cerebral embolic events in the absence of any other embolic source. During the aortic valve replacement surgery for aortic stenosis, he was found to have a large atheroma on the aortic valve cusp with a crater containing friable debris in its center. These findings support the potential for embolic stroke in patients with severe calcific aortic stenosis. We recommend that the aortic valve be considered as an embolic source in patients with an otherwise cryptogenic cerebrovascular accident.
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Affiliation(s)
- Sarah Chaoying Xu
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lisa Canter
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ahmad Zeeshan
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John A Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
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Macle L, Cairns JA, Andrade JG, Mitchell LB, Nattel S, Verma A. The 2014 Atrial Fibrillation Guidelines Companion: A Practical Approach to the Use of the Canadian Cardiovascular Society Guidelines. Can J Cardiol 2016; 31:1207-18. [PMID: 26429352 DOI: 10.1016/j.cjca.2015.06.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/10/2015] [Accepted: 06/10/2015] [Indexed: 12/19/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Program has generated a comprehensive series of documents regarding the management of atrial fibrillation (AF) between 2010 and 2014. The guidelines provide evidence-based consensus management recommendations in a broad range of areas. These guidelines have proven useful in informing clinical practice, but often lack detail in specifications related to practical application, particularly for areas in which the evidence base is limited or conflicting. Based on feedback from the community, the CCS Atrial Fibrillation Guidelines Committee has identified a number of areas that require clarification to address commonly asked practical questions related to guidelines application. In the present article a number of such questions are presented and suggestions about how they can be answered are suggested. Among the issues considered are: (1) What duration of AF is clinically significant? (2) How are the risk factors in the CCS Algorithm for selecting anticoagulation therapy derived and defined? (3) How is valvular heart disease defined and how do different forms of valve disease affect the choice of anticoagulant therapy for AF patients? (4) How should we quantify renal dysfunction and how does it affect therapeutic choices? The response to these questions and the underlying logic are provided, along with an indication of future research needed where no specific approach can presently be recommended based on the literature.
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Affiliation(s)
- Laurent Macle
- Montreal Heart Institute and Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stanley Nattel
- Montreal Heart Institute and Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada.
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13
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Ramírez-Moreno JM, Trinidad-Ruiz M, Ceberino D, Fernández de Alarcón L. Mechanical thrombectomy during ischaemic stroke due to a calcified cerebral embolism. Neurologia 2015; 32:270-273. [PMID: 26304657 DOI: 10.1016/j.nrl.2015.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 05/26/2015] [Accepted: 06/12/2015] [Indexed: 11/29/2022] Open
Affiliation(s)
- J M Ramírez-Moreno
- Unidad de Ictus, Servicio de Neurología, Complejo Hospitalario Universitario de Badajoz, Badajoz, España; Departamento de Ciencias Biomédicas, Universidad de Extremadura, Badajoz, España.
| | - M Trinidad-Ruiz
- Servicio de Radiología, Unidad Neurointervencionista, Complejo Hospitalario Universitario de Badajoz, Badajoz, España
| | - D Ceberino
- Unidad de Ictus, Servicio de Neurología, Complejo Hospitalario Universitario de Badajoz, Badajoz, España
| | - L Fernández de Alarcón
- Servicio de Radiología, Unidad Neurointervencionista, Complejo Hospitalario Universitario de Badajoz, Badajoz, España
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14
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Nicoll R, Henein MY. The predictive value of arterial and valvular calcification for mortality and cardiovascular events. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VESSELS 2014; 3:1-5. [PMID: 29450162 PMCID: PMC5801264 DOI: 10.1016/j.ijchv.2014.02.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 02/01/2014] [Indexed: 11/16/2022]
Abstract
A review of the predictive ability of arterial and valvular calcification has shown an additive effect of calcification in more than 1 location in predicting mortality and coronary heart disease, with mitral annual calcification being a particularly strong predictor. In individual arteries and valves there is a clear association between calcification presence, extent and progression and future cardiovascular events and mortality in asymptomatic, symptomatic and high risk patients, although adjustment for calcification in other arterial beds generally renders associations non-significant. Furthermore, in acute coronary syndrome, culprit plaque is normally not calcified. This would tend to reduce the validity of calcification as a predictor and suggest that the association with cardiovascular events and mortality may not be causal. The association with stroke is less clear; carotid and intracranial artery calcification show little predictive ability, with symptomatic plaques tending to be uncalcified.
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Affiliation(s)
- Rachel Nicoll
- Department of Public Health and Clinical Medicine and Heart Centre, Umea University, Umea, Sweden.,Canterbury Christ Church University, Kent , UK
| | - Michael Y Henein
- Department of Public Health and Clinical Medicine and Heart Centre, Umea University, Umea, Sweden.,Canterbury Christ Church University, Kent , UK
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15
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Lazaros G, Toutouzas K, Drakopoulou M, Boudoulas H, Stefanadis C, Rajamannan N. Aortic sclerosis and mitral annulus calcification: a window to vascular atherosclerosis? Expert Rev Cardiovasc Ther 2014; 11:863-77. [DOI: 10.1586/14779072.2013.811978] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Chandran V, Pai A, Rao S. Calcified embolism: a rare cause of cerebral infarction. BMJ Case Rep 2013; 2013:bcr-2013-009509. [PMID: 23632190 DOI: 10.1136/bcr-2013-009509] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Calcified cerebral emboli (CCE) are a rare cause of stroke and these emboli can be identified on a CT scan of the brain performed for the initial evaluation of stroke. In this report we present a patient who developed a CCE following cardiac catheterisation that lodged in the left middle cerebral artery with resultant right hemiparesis and aphasia. The calcified embolus was seen on CT but could not be identified on MRI. Predisposing factors for CCE include angiography and valve or vessel wall calcification. The natural history and response to standard therapy in patients with CCE as compared with stroke of other aetiologies have not been studied until now. Increased awareness and ability to identify calcified emboli will help us to have an improved understanding of strokes resulting from CCE.
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Affiliation(s)
- Vijay Chandran
- Department of Neurology, Kasturba Medical College, Manipal, Karnataka, India.
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17
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Bang CN, Greve AM, Boman K, Egstrup K, Gohlke-Baerwolf C, Køber L, Nienaber CA, Ray S, Rossebø AB, Wachtell K. Effect of lipid lowering on new-onset atrial fibrillation in patients with asymptomatic aortic stenosis: the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Am Heart J 2012; 163:690-6. [PMID: 22520536 DOI: 10.1016/j.ahj.2012.01.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 01/26/2012] [Indexed: 01/06/2023]
Abstract
BACKGROUND Lipid-lowering drugs, particularly statins, have anti-inflammatory and antioxidant properties that may prevent atrial fibrillation (AF). This effect has not been investigated on new-onset AF in asymptomatic patients with aortic stenosis (AS). METHODS Asymptomatic patients with mild-to-moderate AS (n = 1,421) were randomized (1:1) to double-blind simvastatin 40 mg and ezetimibe 10 mg combination or placebo and followed up for a mean of 4.3 years. The primary end point was the time to new-onset AF adjudicated by 12-lead electrocardiogram at a core laboratory reading center. Secondary outcomes were the correlates of new-onset AF with nonfatal nonhemorrhagic stroke and a combined end point of AS-related events. RESULTS During the course of the study, new-onset AF was detected in 85 (6%) patients (14.2/1,000 person-years of follow-up). At baseline, patients who developed AF were, compared with those remaining in sinus rhythm, older and had a higher left ventricular mass index a smaller aortic valve area index. Treatment with simvastatin and ezetimibe was not associated with less new-onset AF (odds ratio 0.89 [95% CI 0.57-1.97], P = .717). In contrast, age (hazard ratio [HR] 1.07 [95% CI 1.05-1.10], P < .001) and left ventricular mass index (HR 1.01 [95% CI 1.01-1.02], P < .001) were independent predictors of new-onset AF. The occurrence of new-onset AF was independently associated with 2-fold higher risk of AS-related outcomes (HR 1.65 [95% CI 1.02-2.66], P = .04) and 4-fold higher risk of nonfatal nonhemorrhagic stroke (HR 4.04 [95% CI 1.18-13.82], P = .03). CONCLUSIONS Simvastatin and ezetimibe were not associated with less new-onset AF. Older age and greater left ventricular mass index were independent predictors of AF development. New-onset AF was associated with a worsening of prognosis.
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18
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Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e576S-e600S. [PMID: 22315272 PMCID: PMC3278057 DOI: 10.1378/chest.11-2305] [Citation(s) in RCA: 428] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is > 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recommend VKA therapy until thrombus resolution, and we recommend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitution of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C). We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the first 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C). In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspirin (50-100 mg/d) (Grade 1B). In valve repair patients, we suggest aspirin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fibrinolysis for right-sided valves and left-sided valves with thrombus area < 0.8 cm(2) (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm(2), we recommend early surgery (Grade 2C). CONCLUSIONS These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.
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Affiliation(s)
| | - Jack C Sun
- University of Washington School of Medicine, Seattle, WA
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19
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Calcific aortic valve and spontaneous embolic stroke: A review of literature. J Neurol Sci 2009; 287:32-5. [DOI: 10.1016/j.jns.2009.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 06/28/2009] [Accepted: 07/23/2009] [Indexed: 11/15/2022]
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20
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Stroke secondary to calcific bicuspid aortic valve: Case report and literature review. J Cardiol 2009; 54:158-61. [DOI: 10.1016/j.jjcc.2008.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 10/24/2008] [Accepted: 10/31/2008] [Indexed: 11/20/2022]
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21
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Rennenberg RJMW, Kessels AGH, Schurgers LJ, van Engelshoven JMA, de Leeuw PW, Kroon AA. Vascular calcifications as a marker of increased cardiovascular risk: a meta-analysis. Vasc Health Risk Manag 2009; 5:185-97. [PMID: 19436645 PMCID: PMC2672434 DOI: 10.2147/vhrm.s4822] [Citation(s) in RCA: 338] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background: Several imaging techniques may reveal calcification of the arterial wall or cardiac valves. Many studies indicate that the risk for cardiovascular disease is increased when calcification is present. Recent meta-analyses on coronary calcification and cardiovascular risk may be confounded by indication. Therefore, this meta-analysis was performed with extensive subgroup analysis to assess the overall cardiovascular risk of finding calcification in any arterial wall or cardiac valve when using different imaging techniques. Methods and results: A meta-analysis of prospective studies reporting calcifications and cardiovascular end-points was performed. Thirty articles were selected. The overall odds ratios (95% confidence interval [CI]) for calcifications versus no calcifications in 218,080 subjects after a mean follow-up of 10.1 years amounted to 4.62 (CI 2.24 to 9.53) for all cause mortality, 3.94 (CI 2.39 to 6.50) for cardiovascular mortality, 3.74 (CI 2.56 to 5.45) for coronary events, 2.21 (CI 1.81 to 2.69) for stroke, and 3.41 (CI 2.71 to 4.30) for any cardiovascular event. Heterogeneity was largely explained by length of follow up and sort of imaging technique. Subgroup analysis of patients with end stage renal disease revealed a much higher odds ratio for any event of 6.22 (CI 2.73 to 14.14). Conclusion: The presence of calcification in any arterial wall is associated with a 3–4-fold higher risk for mortality and cardiovascular events. Interpretation of the pooled estimates has to be done with caution because of heterogeneity across studies.
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Affiliation(s)
- R J M W Rennenberg
- Department of Internal Medicine, University Hospital Maastricht and Cardiovascular Research Institute Maastricht, The Netherlands.
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22
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English J, Smith W. Cardio-embolic stroke. HANDBOOK OF CLINICAL NEUROLOGY 2009; 93:719-749. [PMID: 18804677 DOI: 10.1016/s0072-9752(08)93036-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Joey English
- Department of Neurology, University of California, San Francisco, CA 94143, USA
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23
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Zayed H, Ali A, Wendler O, Rashid H. Selective Screening for Asymptomatic Carotid Artery Disease Prior to Isolated Heart Valve Surgery. Angiology 2008; 60:633-6. [DOI: 10.1177/0003319708325446] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To assess the yield of screening for asymptomatic carotid artery disease prior to isolated heart valve surgery (IHVS). Methods Retrospective analysis of the preoperative carotid duplex scans performed in neurologically asymptomatic patients who underwent IHVS between 2003 and 2006 was performed. Internal carotid artery (ICA) stenosis of 70% was considered significant. Patients with concomitant coronary artery disease were excluded. Results A total of 177 patients underwent IHVS (one valve in 165 and 2 valves in 12 patients). No or minor ICA disease detected in 172 patients. Four patients (2.25%) had significant unilateral ICA stenosis and 1 patient (0.56%) had unilateral ICA occlusion. Three patients (1.69%) suffered postoperative stroke, while 2 patients (1.1%) suffered transient ischemic attacks. All neurologically affected patients had normal preoperative carotid duplex. The in-hospital mortality was 4.5%. Conclusion Prevalence of significant ICA disease is low in patients undergoing IHVS. This population does not benefit from preoperative carotid screening.
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Affiliation(s)
- Hany Zayed
- King's College Hospital, Denmark Hill, London
| | - Ahmad Ali
- King's College Hospital, Denmark Hill, London
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24
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Salem DN, O'Gara PT, Madias C, Pauker SG. Valvular and Structural Heart Disease. Chest 2008; 133:593S-629S. [DOI: 10.1378/chest.08-0724] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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25
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Bugnicourt JM, Bonnaire B, Lepage L, Garcia PY, Lefranc M, Godefroy O. Infarctus cérébral par embolie calcaire spontanée révélant un rétrécissement aortique calcifié. ACTA ACUST UNITED AC 2008; 33:106-9. [DOI: 10.1016/j.jmv.2008.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Accepted: 02/21/2008] [Indexed: 11/27/2022]
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26
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Okajima K, Abe Y, Suzuki K, Salameh MJ, Di Tullio MR, Jin Z, Sacco RL, Mohr JP, Homma S. Impact of Valvular Thickness on Stroke Recurrence in Medically Treated Patients with Stroke. Cerebrovasc Dis 2007; 24:375-80. [PMID: 17804905 DOI: 10.1159/000107918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 03/07/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It remains controversial whether left-sided valvular thickening (VaT) is a risk factor for ischemic stroke. Little is known about the relationship between VaT and the recurrent adverse event rate in medically treated patients with stroke. METHODS We examined the outcomes of 627 noncardioembolic stroke patients who were double-blindly assigned to either warfarin or aspirin therapy and assessed VaT using transesophageal echocardiography. Endpoints were recurrent ischemic stroke or death from any cause. The Cox proportional hazards model was used to adjust for covariates. RESULTS VaT was present in 57.3% of the patients (359/627), 34.6% (271/627) involving the aortic valve and 46.4% (291/627) involving the mitral valve. There was no difference in the time to primary endpoints between those with and without VaT of the aortic valve (p = 0.49; hazard ratio, HR: 1.17; 95% CI: 0.74-1.85; 2-year event rates: 18.9 vs. 13.2%) or mitral valve (p = 0.66; HR: 0.91; 95% CI: 0.60-1.38; 2-year event rates: 16.9 vs. 14.7%). Among the patients with VaT, there was no significant difference in the time to primary endpoints between those treated with warfarin and those with aspirin (p = 0.13, HR: 0.65, 95% CI: 0.37-1.14, 2-year event rates: 15.2 vs. 22.7% for the aortic valve; p = 0.22, HR: 0.70, 95% CI: 0.40-1.23, 2-year event rates: 14.2 vs. 19.6% for the mitral valve). CONCLUSIONS VaT does not appear to increase recurrent adverse event rates in medically treated patients with ischemic stroke, regardless of warfarin or aspirin therapy.
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Affiliation(s)
- K Okajima
- Department of Medicine, Columbia University, New York, NY 10032, USA.
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27
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McCabe DJH, Rakhit RD. Antithrombotic and interventional treatment options in cardioembolic transient ischaemic attack and ischaemic stroke. J Neurol Neurosurg Psychiatry 2007; 78:14-24. [PMID: 17172564 PMCID: PMC2117792 DOI: 10.1136/jnnp.2006.092031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Peer-reviewed data pertaining to anti-thrombotic and interventional therapy for transient ischaemic attack (TIA) or ischaemic stroke patients with non-valvular atrial fibrillation, atrial flutter, interatrial septal abnormalities, or left ventricular thrombus were reviewed. Long-term oral anticoagulant therapy with warfarin is the treatment of choice for secondary stroke prevention following TIA or minor ischaemic stroke in association with persistent or paroxysmal non-valvular atrial fibrillation or atrial flutter. If warfarin is contraindicated, long-term aspirin is a safe, but much less effective alternative treatment option in this subgroup of patients with cerebrovascular disease. Management of young patients with TIA or stroke in association with an interatrial septal defect is controversial. Various treatment options are outlined, but readers are encouraged to include these patients in one of the ongoing randomised clinical trials in this area. It is reasonable to consider empirical anticoagulation in patients with TIA or ischaemic stroke in association with left ventricular thrombus formation following myocardial infarction or in association with idiopathic dilated cardiomyopathy. If warfarin is prescribed, one should aim for a target international normalised ratio of 2.5 (range 2-3) to achieve the best balance between adequate secondary prevention of cardioembolic events and the risk of major haemorrhagic complications.
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Affiliation(s)
- D J H McCabe
- Department of Neurology, The Adelaide and Meath Hospital Tallaght, Trinity College Dublin, Dublin 24, Republic of Ireland.
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28
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Salem DN, Stein PD, Al-Ahmad A, Bussey HI, Horstkotte D, Miller N, Pauker SG. Antithrombotic Therapy in Valvular Heart Disease—Native and Prosthetic. Chest 2004; 126:457S-482S. [PMID: 15383481 DOI: 10.1378/chest.126.3_suppl.457s] [Citation(s) in RCA: 225] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This chapter about antithrombotic therapy in native and prosthetic valvular heart disease is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients with rheumatic mitral valve disease and atrial fibrillation (AF), or a history of previous systemic embolism, we recommend long-term oral anticoagulant (OAC) therapy (target international normalized ratio [INR], 2.5; range, 2.0 to 3.0) [Grade 1C+]. For patients with rheumatic mitral valve disease with AF or a history of systemic embolism who suffer systemic embolism while receiving OACs at a therapeutic INR, we recommend adding aspirin, 75 to 100 mg/d (Grade 1C). For those patients unable to take aspirin, we recommend adding dipyridamole, 400 mg/d, or clopidogrel (Grade 1C). In people with mitral valve prolapse (MVP) without history of systemic embolism, unexplained transient ischemic attacks (TIAs), or AF, we recommended against any antithrombotic therapy (Grade 1C). In patients with MVP and documented but unexplained TIAs, we recommend long-term aspirin therapy, 50 to 162 mg/d (Grade 1A). For all patients with mechanical prosthetic heart valves, we recommend vitamin K antagonists (Grade 1C+). For patients with a St. Jude Medical (St. Paul, MN) bileaflet valve in the aortic position, we recommend a target INR of 2.5 (range, 2.0 to 3.0) [Grade 1A]. For patients with tilting disk valves and bileaflet mechanical valves in the mitral position, we recommend a target INR of 3.0 (range, 2.5 to 3.5) [Grade 1C+]. For patients with caged ball or caged disk valves, we suggest a target INR of 3.0 (range, 2.5 to 3.5) in combination with aspirin, 75 to 100 mg/d (Grade 2A). For patients with bioprosthetic valves, we recommend vitamin K antagonists with a target INR of 2.5 (range, 2.0 to 3.0) for the first 3 months after valve insertion in the mitral position (Grade 1C+) and in the aortic position (Grade 2C). For patients with bioprosthetic valves who are in sinus rhythm and do not have AF, we recommend long-term (> 3 months) therapy with aspirin, 75 to 100 mg/d (Grade 1C+).
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Affiliation(s)
- Deeb N Salem
- Tufts New England Medical Center, 750 Washington St, Boston, MA 02111, USA.
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29
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Debruxelles S, Sibon I, Rouanet F, Orgogozo JM. Infarctus cérébral par embolie calcaire : complication spontanée révélatrice d’un rétrécissement aortique calcifié. Rev Neurol (Paris) 2004; 160:582-4. [PMID: 15269680 DOI: 10.1016/s0035-3787(04)70992-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Calcified aortic stenosis (CAS) is an unusual cause of cerebral infarct. The presence of cerebral intra-vascular or intra-parenchymatous calcifications, symptomatic or not, is suggestive of the diagnosis of CAS. We report two patients who experienced stroke induced by spontaneous calcic emboli from a calcified aortic valve and underline the importance of brain CT scan.
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Affiliation(s)
- S Debruxelles
- Fédération de Neurosciences Cliniques, CHU, Bordeaux
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30
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Terramani TT, Hood DB, Rowe VL, Peyre C, Nuno IN, Katz SG, Kohl RD, Starnes VA, Weaver FA. The utility of preoperative routine carotid artery duplex scanning in patients undergoing aortic valve replacement. Ann Vasc Surg 2002; 16:163-7. [PMID: 11972246 DOI: 10.1007/s10016-001-0156-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with aortic valve disease (AVD) typically have a cardiac murmur that radiates to the neck and may be indistinguishable from a cervical bruit secondary to carotid artery occlusive disease. The purpose of this report was to determine the prevalence of significant asymptomatic carotid artery occlusive disease in patients undergoing aortic valve replacement (AVR). All patients scheduled for AVR were prospectively studied. Preoperative carotid artery color-flow duplex was performed in all patients. A total of 204 patients were included in the study and significant carotid disease (>50% stenosis of the internal carotid artery) was found in 17 (8%). In patients with isolated aortic valve disease, 4/129 (3%) had significant stenosis. Of the patients with concurrent aortic valve and coronary artery disease, 13/75 (17%) had significant stenosis. The incidence of significant carotid stenosis in patients with aortic valve disease was over five fold higher in patients with concurrent coronary artery disease (3% vs. 17%, p <0.001). The yield of routine carotid duplex scanning for patients undergoing isolated AVR is low. However, in the subset of patients with concurrent coronary disease, the yield is higher. This finding supports the use of routine carotid duplex scanning in patients with coexistent aortic valve and coronary artery disease.
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Affiliation(s)
- Thomas T Terramani
- Department of Surgery, Division of Vascular Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, USA
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31
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Adler Y, Motro M, Tenenbaum A, Tanne D, Fisman EZ, Wiser I, Hovav B, Stolero D, Shemesh J. Aortic valve calcium on spiral computed tomography is associated with calcification of the thoracic aorta in hypertensive patients. Am J Cardiol 2002; 89:632-5. [PMID: 11867060 DOI: 10.1016/s0002-9149(01)02315-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Yehuda Adler
- Cardiac Rehabilitation Institute, the Chaim Sheba Medical Center, Tel-Hashomer, Israel.
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32
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Salem DN, Daudelin HD, Levine HJ, Pauker SG, Eckman MH, Riff J. Antithrombotic therapy in valvular heart disease. Chest 2001; 119:207S-219S. [PMID: 11157650 DOI: 10.1378/chest.119.1_suppl.207s] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- D N Salem
- New England Medical Center, Boston, MA 02111-1526, USA
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Adler Y, Levinger U, Koren A, Tanne D, Fink N, Vaturi M, Iakobishvili Z, Battler A, Zelikovski A, Sagie A. Relation of nonobstructive aortic valve calcium to carotid arterial atherosclerosis. Am J Cardiol 2000; 86:1102-5. [PMID: 11074207 DOI: 10.1016/s0002-9149(00)01167-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Recently it was shown that subjects with aortic valve calcium (AVC) are at increased risk for future cardiovascular disease including stroke. We hypothesized that the increased risk of stroke may be due to an association with carotid artery atherosclerotic disease. Between 1995 and 1999 our laboratory made a diagnosis of AVC without significant stenosis in 3,949 patients. Of those, 279 patients without other cardiac structural exclusion criteria (148 men and 131 women; mean age 73 +/- 9 years, range 45 to 90) underwent carotid artery duplex ultrasound for various indications, and formed the study group. Age- and sex-matched patients without AVC (n = 277), who underwent carotid artery duplex ultrasound during the same period and for the same indications, served as the control group. Compared with the control group, the AVC group had a significantly higher prevalence of carotid stenosis (> 40% to 60%, 89% vs 78% [p < 0.001]; >60% to 80%, 43% vs 23% [p <0.001];and > 80% to 100%, 32%vs 14% [p < 0.001]). The AVC group had a similar, significantly higher prevalence of > or = 2-vessel disease and bilateral carotid stenosis (stenosis levels of > 20% to 40%, >40% to 60%, > 60% to 80%, and > 80% to 100%). In multivariate analysis, AVC, but not traditional risk factors, was the only independent predictor of severe carotid atherosclerotic disease (stenosis > 80% to 100%; p = 0.0001). Thus, there is a significant association between the presence of AVC and carotid atherosclerotic disease.
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Affiliation(s)
- Y Adler
- Department of Cardiology, Rabin Medical Center, Petah Tiqva, Israel
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Adler Y, Vaturi M, Wiser I, Shapira Y, Herz I, Weisenberg D, Sela N, Battler A, Sagie A. Nonobstructive aortic valve calcium as a window to atherosclerosis of the aorta. Am J Cardiol 2000; 86:68-71. [PMID: 10867095 DOI: 10.1016/s0002-9149(00)00830-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Aortic valve calcium without stenosis and mitral annulus calcium (MAC) are known to correlate with atherosclerotic risk factors. Recently, it has been reported that MAC is associated with atherosclerosis of the cardiovascular system, suggesting MAC as an atherosclerotic process by itself. Hence, the aim of the present study was to determine whether a similar association between aortic valve calcium and aortic atheroma exists. Ninety-six patients (54 men and 42 women, mean age 72 +/- 12 years) with aortic valve calcium who underwent transesophageal echocardiography (TEE) formed the study group. They were compared with 92 sex- and age-matched patients without aortic valve calcium who underwent TEE for the same indications during the same period. The presence and echocardiographic features of aortic atheromas were evaluated by TEE. No differences were found between the groups in risk factors for atherosclerosis or in indications for referral for TEE. Significantly higher rates were found in the aortic valve calcium group for prevalence of aortic atheroma (86% vs 30%, p = 0.001). This significant trend was also consistent with the dimension and complexity of the atheromas. On multivariate analysis aortic valve calcium, and MAC were the only independent predictors of aortic atheroma (p = 0.0001, 0.006 respectively). We conclude that there is a significant association between the presence of aortic valve calcium and the presence and severity of aortic atheroma. Thus, aortic valve calcium may serve as a window to atherosclerosis of the aorta.
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Affiliation(s)
- Y Adler
- Cardiology Department, The Scheingarten Echocardiography Unit, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
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Abstract
At least 20% of all ischemic strokes are cardioembolic. Cardiac conditions that cause cerebral embolism are classified as major or minor depending on whether the causal link has or has not been fully established between the underlying cardiac condition and the stroke. Atrial fibrillation, acute myocardial infarction, valvular heart disease, infective endocarditis, nonbacterial thrombotic endocarditis, and atrial myxoma are the main cardiac causes of cerebral embolism. Patent foramen ovale, atrial septal aneurysm, mitral valve prolapse, mitral annular calcification, calcific aortic stenosis, and mitral valve strands are cardiac conditions with a potential causal link to cerebral embolism, but until now, either they have been found to be poor predictors of recurrent stroke or their risk of recurrent stroke is unknown. The management of patients with a stroke of cardiac source is twofold: 1) treatment of the acute phase of stroke and 2) prophylactic treatment of recurrent thromboembolism. When possible, primary prevention of cerebral embolism should be recommended, particularly in cardiac conditions with known high risk of stroke (eg, atrial fibrillation, mitral stenosis, or presence of mechanical prosthetic heart valves).
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Affiliation(s)
- K Vahedi
- Service de Neurologie, Hôpital Lariboisière, 2 Rue A. Paré, 75010 Paris, France
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Abstract
The use of antithrombotic agents to prevent thromboembolic events in patients with valvular heart disease is common. Recent studies using improved diagnostic techniques have allowed better elucidation of valvular abnormalities and re-evaluated the incidence and risk of thromboembolism. We review the recent literature examining the risk of thromboembolic events in various valvular abnormalities, and the use of different antithrombotic agents in the prevention of thromboembolic events. We also review the current recommended practice in both native valve abnormalities and prosthetic heart valves.
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Affiliation(s)
- A M Al-Ahmad
- Division of Cardiology, New England Medical Center, Box 79, Boston, MA 02111, USA.
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Salem DN, Levine HJ, Pauker SG, Eckman MH, Daudelin DH. Antithrombotic therapy in valvular heart disease. Chest 1998; 114:590S-601S. [PMID: 9822065 DOI: 10.1378/chest.114.5_supplement.590s] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- D N Salem
- New England Medical Center, Boston, MA 02111-1526, USA
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