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Noubiap JJ, Thomas G, Kamtchum-Tatuene J, Middeldorp ME, Sanders P. High-risk carotid plaques and incident ischemic stroke in patients with atrial fibrillation in the Cardiovascular Health Study. Eur J Neurol 2023; 30:2042-2050. [PMID: 37038345 PMCID: PMC10247465 DOI: 10.1111/ene.15817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/01/2023] [Accepted: 04/05/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND AND PURPOSE Whether carotid artery disease could improve stroke risk stratification tools in patients with atrial fibrillation (AF) remains uncertain. This study was undertaken to investigate the risk of ischemic stroke associated with occlusive and nonocclusive carotid atherosclerotic disease in patients with AF in the prospective population-based Cardiovascular Health Study. METHODS We included participants aged ≥65 years with AF. We used multivariable Cox regression analysis to explore the risk of ischemic stroke associated with the percentage of carotid stenosis, plaque irregularity, echogenicity, and vulnerability (markedly irregular, ulcerated, or hypoechoic plaques). RESULTS A total of 1398 participants were included (55.2% female, 61.7% aged 65-74 years). The maximum carotid stenosis was <50%, 50%-99%, and 100% in 94.5%, 5%, and 0.5% of participants, respectively. High-risk plaques based on echogenicity and plaque irregularity were found in 25.6% and 8.9% of participants, respectively. After a median follow-up of 10.9 years (interquartile range = 7.5-15.6), 298 ischemic strokes were recorded. There was no difference in the incidence of ischemic stroke according to the degree of carotid artery stenosis (p = 0.44), plaque echogenicity (low vs. high risk, p = 0.68), plaque irregularity (low vs. high risk, p = 0.55), and plaque vulnerability (p = 0.86). The CHA₂DS₂-VASc score was associated with an increased risk of ischemic stroke (adjusted hazard ratio = 1.28, 95% confidence interval = 1.18-1.40, p < 0.001). Both maximum grade of stenosis and plaque vulnerability were not associated with incident ischemic stroke (all p > 0.05). CONCLUSIONS Neither the degree of carotid stenosis nor the presence of vulnerable plaques was associated with incident ischemic stroke in this cohort of individuals with AF. This suggests that carotid disease was probably not a significant contributor to ischemic stroke in this population.
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Affiliation(s)
| | - Gijo Thomas
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Joseph Kamtchum-Tatuene
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Melissa E. Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Smidt Heart Institute, Cedar-Sinai Medical Centre, Los Angeles, California, USA
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia; Department of Cardiology
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Quesado J, Dias L, Pereira-Macedo J, Duarte-Gamas L, Khairy A, Pinheiro M, Reis P, Andrade JP, Rocha-Neves J, Marreiros A. R2CHA2DS2-VA predicts the cardiovascular risk after carotid endarterectomy. Ann Vasc Surg 2023:S0890-5096(23)00116-4. [PMID: 36868457 DOI: 10.1016/j.avsg.2023.02.016] [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: 10/19/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE R2CHA2DS2-VA score has been used to predict short and long-term outcomes in many cardiovascular diseases. This study aims to validate the R2CHA2DS2-VA score as a long-term major adverse cardiovascular events (MACE) predictor after CEA. Secondary outcomes were also assessed regarding the incidence of all-cause mortality, acute myocardial infarction (AMI), major adverse limb events (MALE), and acute heart failure (AHF). METHODS From January 2012 to December 2021, patients (n= 205) from a Portuguese tertiary care and referral center that underwent CEA with regional anesthesia (RA) for carotid stenosis were selected from a previously collected prospective database, and a post-hoc analysis was performed. Demographics and comorbidities were registered. Clinical adverse events were assessed 30-days after the procedure and in the subsequent long-term surveillance period. Statistical analysis was performed by the Kaplan-Meier method and Cox proportional hazards regression. RESULTS Of the patients enrolled, 78.5% were males with a mean age of 70.44 ± 8.9 years. Higher scores of R2CHA2DS2-VA were associated with long-term MACE (adjusted Hazard Ratio (aHR) 1.390; 95% Confidence Interval (CI) 1.173-1.647) and mortality (aHR 1.295; 95% CI 1.08-1.545) CONCLUSIONS: This study demonstrated the potential of the R2CHA2DS2-VA score to predict long-term outcomes such as AMI, AHF, MACE, and all-cause mortality in a population of patients submitted to carotid endarterectomy.
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Affiliation(s)
- João Quesado
- ICVS, Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
| | - Lara Dias
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of surgery - Centro Hospitalar do Médio Ave; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Ahmed Khairy
- Faculty of Medicine-Assiut University-Assiut-Egypt
| | - Marina Pinheiro
- ICVS, Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal; REQUIMTE, University of Porto, Porto, Portugal; Public Health Unit - ACES Cávado III , Braga, Portugal
| | - Pedro Reis
- Burn Unit-Department of Plastic Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José P Andrade
- CINTESIS@RISE, Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Portugal; Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Portugal
| | - João Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Portugal.
| | - Ana Marreiros
- Faculdade de Medicina e Ciências Biomédicas da Universidade do Algarve, Portugal, ABC, Algarve Biomedical Center, Faro, Portugal
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van der Endt VHW, Milders J, Penning de Vries BBL, Trines SA, Groenwold RHH, Dekkers OM, Trevisan M, Carrero JJ, van Diepen M, Dekker FW, de Jong Y. Comprehensive comparison of stroke risk score performance: a systematic review and meta-analysis among 6 267 728 patients with atrial fibrillation. Europace 2022; 24:1739-1753. [PMID: 35894866 PMCID: PMC9681133 DOI: 10.1093/europace/euac096] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/24/2022] [Indexed: 12/15/2022] Open
Abstract
AIMS Multiple risk scores to predict ischaemic stroke (IS) in patients with atrial fibrillation (AF) have been developed. This study aims to systematically review these scores, their validations and updates, assess their methodological quality, and calculate pooled estimates of the predictive performance. METHODS AND RESULTS We searched PubMed and Web of Science for studies developing, validating, or updating risk scores for IS in AF patients. Methodological quality was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). To assess discrimination, pooled c-statistics were calculated using random-effects meta-analysis. We identified 19 scores, which were validated and updated once or more in 70 and 40 studies, respectively, including 329 validations and 76 updates-nearly all on the CHA2DS2-VASc and CHADS2. Pooled c-statistics were calculated among 6 267 728 patients and 359 373 events of IS. For the CHA2DS2-VASc and CHADS2, pooled c-statistics were 0.644 [95% confidence interval (CI) 0.635-0.653] and 0.658 (0.644-0.672), respectively. Better discriminatory abilities were found in the newer risk scores, with the modified-CHADS2 demonstrating the best discrimination [c-statistic 0.715 (0.674-0.754)]. Updates were found for the CHA2DS2-VASc and CHADS2 only, showing improved discrimination. Calibration was reasonable but available for only 17 studies. The PROBAST indicated a risk of methodological bias in all studies. CONCLUSION Nineteen risk scores and 76 updates are available to predict IS in patients with AF. The guideline-endorsed CHA2DS2-VASc shows inferior discriminative abilities compared with newer scores. Additional external validations and data on calibration are required before considering the newer scores in clinical practice. CLINICAL TRIAL REGISTRATION ID CRD4202161247 (PROSPERO).
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Affiliation(s)
| | - Jet Milders
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Bas B L Penning de Vries
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Serge A Trines
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Ype de Jong
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands,Department of Internal Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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Abolbashari M. Atherosclerosis and Atrial Fibrillation: Double Trouble. Curr Cardiol Rep 2022; 24:67-73. [PMID: 34993746 DOI: 10.1007/s11886-021-01625-w] [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] [Accepted: 09/27/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW This review aims to evaluate the major cardiovascular adverse events (MACE) and antithrombotic approaches in concomitant atrial fibrillation (AF) and atherosclerosis. RECENT FINDINGS MACE in concomitant AF and atherosclerosis has been evaluated in recent studies. A recent retrospective study of 2670 patients with AF revealed that atherosclerosis burden with AF can be a marker of adverse vascular outcomes with extracranial atherosclerosis as a potent predictor of MACE. Trials to evaluate the antithrombotic approaches in concomitant atherosclerotic disease and AF has been mainly in patients with coronary artery disease (CAD). AFIRE trial demonstrated that in patients with AF and stable CAD rivaroxaban alone is not inferior to rivaroxaban plus aspirin with better safety profile. Atherosclerosis is common in AF and poses additional risk to patients. Antithrombotic management of atherosclerosis in AF is not well investigated and needs further trial to identify the subgroups that benefit from more intensive antithrombotic measures.
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Affiliation(s)
- Mehran Abolbashari
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Avenue, El Paso, TX, 79905, USA.
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Shang L, Zhang L, Guo Y, Sun H, Zhang X, Bo Y, Zhou X, Tang B. A Review of Biomarkers for Ischemic Stroke Evaluation in Patients With Non-valvular Atrial Fibrillation. Front Cardiovasc Med 2021; 8:682538. [PMID: 34277733 PMCID: PMC8281032 DOI: 10.3389/fcvm.2021.682538] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/03/2021] [Indexed: 01/06/2023] Open
Abstract
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide and results in a significantly increased ischemic stroke (IS) risk. IS risk stratification tools are widely being applied to guide anticoagulation treatment decisions and duration in patients with non-valvular AF (NVAF). The CHA2DS2-VASc score is largely validated and currently recommended by renowned guidelines. However, this score is heavily dependent on age, sex, and comorbidities, and exhibits only moderate predictive power. Finding effective and validated clinical biomarkers to assist in personalized IS risk evaluation has become one of the promising directions in the prevention and treatment of NVAF. A number of studies in recent years have explored differentially expressed biomarkers in NVAF patients with and without IS, and the potential role of various biomarkers for prediction or early diagnosis of IS in patients with NVAF. In this review, we describe the clinical application and utility of AF characteristics, cardiac imaging and electrocardiogram markers, arterial stiffness and atherosclerosis-related markers, circulating biomarkers, and novel genetic markers in IS diagnosis and management of patients with NVAF. We conclude that at present, there is no consensus understanding of a desirable biomarker for IS risk stratification in NVAF, and enrolling these biomarkers into extant models also remains challenging. Further prospective cohorts and trials are needed to integrate various clinical risk factors and biomarkers to optimize IS prediction in patients with NVAF. However, we believe that the growing insight into molecular mechanisms and in-depth understanding of existing and emerging biomarkers may further improve the IS risk identification and guide anticoagulation therapy in patients with NVAF.
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Affiliation(s)
- Luxiang Shang
- Department of Cardiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Cardiac Electrophysiology and Arrhythmia, Jinan, China
| | - Ling Zhang
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.,Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yankai Guo
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.,Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Huaxin Sun
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.,Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaoxue Zhang
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.,Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yakun Bo
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.,Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xianhui Zhou
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.,Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Baopeng Tang
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.,Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Sukovatykh BS, Bolomatov NV, Sidorov DV, Sukovatykh MB. [Acute cerebral circulation impairment associated with percutaneous coronary intervention]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:175-182. [PMID: 35050264 DOI: 10.33529/angio2021420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The article deals with generalized literature data on the current importance of the problem concerning acute cerebral ischemia occurring during percutaneous coronary interventions. Pathophysiological mechanisms of the development of acute cerebral circulation impairment are described, with their classification. Also considered are various risk factors which may cause this formidable complication, followed by describing modern methods of its surgical treatment. It is noted that the main risk factors for neurological complications appearing after revascularization of coronary arteries include age, accompanying diseases (instability of arterial pressure, diabetes mellitus, atrial fibrillation, atherorosclerotic lesions of the aorta and brachiocephalic arteries, previous stroke), as well as systolic dysfunction, leukocytosis, and a low level of cognitive function prior to operation. The development of acute cerebral circulation impairment during and after percutaneous coronary intervention is an indication for using methods of endovascular treatment. It is most appropriate to use a combination of direct percutaneous thrombectomy and a stent retriever. It is underlined in the article that removal of the thrombus form the cerebral artery is not an independent surgical procedure but rather a methodology envisaging an operation to be performed from the simplest technique to the most complicated one. As the first procedure, it is necessary to perform thrombaspiration and then, if ineffective, a second stage consisting in thrombextraction with the help of a stent retriever. Besides, in order to increase efficacy of thrombaspiration there have been worked out several techniques combining the use of direct thrombextraction and a stent retriever. Described in detail are 4 most commonly used techniques.
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Affiliation(s)
- B S Sukovatykh
- Department of General Surgery, Kursk State Medical University of the RF Ministry of Public Health, Kursk, Russia
| | - N V Bolomatov
- Department of Roentgenosurgical Methods of Diagnosis and Treatment, Pirogov National Medical and Surgical Centre, Moscow, Russia
| | - D V Sidorov
- Department of Roentgenosurgical Methods of Diagnosis and Treatment, Orel Regional Clinical Hospital, Orel, Russia
| | - M B Sukovatykh
- Department of General Surgery, Kursk State Medical University of the RF Ministry of Public Health, Kursk, Russia
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Carotid Intima-Media Thickness, Genetic Risk, and Ischemic Stroke: A Family-Based Study in Rural China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010119. [PMID: 33375320 PMCID: PMC7795493 DOI: 10.3390/ijerph18010119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Carotid intima-media thickness (cIMT) has been associated with an elevated risk of ischemic stroke (IS) in several studies, but the results are inconsistent. We investigated whether the association between cIMT and IS varied across different IS subtypes, and further assessed gene-cIMT interactions' association with IS risk. METHODS A total of 1048 IS cases (795 large-artery atherosclerosis (LAA) cases, 103 small-vessel occlusion (SVO) cases, and 150 other subtypes) and 2696 IS-free controls across 2179 families were included in the analysis. Self-reported IS cases were confirmed through medical records' review and head imaging by computed tomography and/or magnetic resonance imaging. The mean values of the common cIMT obtained in bilateral distal and proximal carotid artery segments were used. The genotype information of rs2910164 polymorphism in microRNA-146a (miR-146a) was also collected. RESULTS We found that cIMT was significantly associated with a higher risk of IS and LAA subtype but not SVO subtype in the multivariate-adjusted models. The odds ratio (OR) and 95% confidence interval (CI) in the highest quartile versus the lowest quartile of cIMT was 2.48 (1.92-3.20) for IS and 2.75 (2.08-3.64) for LAA (both p trend <0.001). The results also showed that there was a significant interaction between cIMT and rs2910164 genotype with the risk of IS (p interaction = 0.03) and LAA (p interaction = 0.02). The associations of cIMT with IS and LAA were strengthened among participants carried rs2910164_GG genotype compared with those with rs2910164_CC genotype. CONCLUSIONS Our results indicate that higher cIMT levels were significantly associated with IS and LAA subtype but not SVO subtype, and the relations were modified by rs2910164 polymorphism in miR-146a.
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