Correspondence
Atherosclerotic Disease of the Aortic Arch as a Risk Factor for Recurrent Ischemic Stroke
N Engl J Med 1996; 335:1464-1465November 7, 1996
- Article
To the Editor:
The excellent article by the French Study of Aortic Plaques in Stroke Group (May 9 issue)1 shows that the presence of large atheromas in the proximal aorta, already known to be an independent risk factor for first ischemic stroke in the elderly, is also an independent risk factor for the recurrence of stroke or peripheral embolic events. Moreover, the risk of embolization increases with the thickness of the atheroma. The authors do not provide data on the risk associated with complex atheromas — that is, those with ulcerated or mobile components.
In our experience, atheromas with ulcerations detectable by transesophageal echocardiography (those with a width and depth of >2 mm) or with superimposed mobile components are associated with cryptogenic ischemic stroke in the elderly. Among 66 patients at least 60 years of age who had acute ischemic stroke and 78 stroke-free control subjects of similar age,2 we found a significantly higher prevalence of proximal aortic atheromas in the subgroup of patients with cryptogenic stroke than in the controls (22 percent vs. 8 percent; odds ratio, 3.4; 95 percent confidence interval, 1.1 to 11.2). Jones et al.3 also found an increased risk of stroke associated with complex atheromas (odds ratio, 7.1; 95 percent confidence interval, 2.7 to 18.4), but they defined complex atheromas to include only those >5 mm thick, so that large atheromas without ulcerated or mobile components were also included. Data from the French study on the risk associated with complex atheromas would help greatly in clarifying this issue.
3 ReferencesMarco R. Di Tullio, M.D.
Ralph L. Sacco, M.D.
Shunichi Homma, M.D.
Columbia University, New York, NY 100321
The French Study of Aortic Plaques in Stroke Group
Full Text | Web of Science | Medline2
Di Tullio MR ,Sacco RL ,Gersony D , et al. Aortic atheromas and acute ischemic stroke: a transesophageal echocardiographic study in an ethnically mixed population. Neurology 1996;46:1560-1566
Web of Science | Medline3
Jones EF ,Kalman JM ,Calafiore P ,Tonkin AM ,Donnan GA . Proximal aortic atheroma: an independent risk factor for cerebral ischemia. Stroke 1995;26:218-224
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Di Tullio and colleagues raise important questions about the potential additive prognostic value of complex plaque morphology. In our study, preventive treatment was left to the discretion of the investigators. However, it appeared that plaque thickness was not a criterion in choosing an anticoagulant or an antiplatelet agent to prevent recurrent vascular events.1 This choice was based mainly on the presence of other risk factors, such as atrial fibrillation or carotid stenosis, and in a few patients on the morphologic features of plaques in the aortic arch — that is, the presence of mobile debris in the aortic arch and hypoechoic plaque suggestive of a thrombus. Patients with such plaques received anticoagulant therapy for one to three months and an antiplatelet agent thereafter.1
We found only one recurrent vascular event among patients with mobile debris in the aortic arch proximal to the ostium of the left subclavian artery (incidence, 11.4 per 100 person-years). With regard to the presence of irregular plaques, the relative risk of recurrent vascular events was 2.44 (P<0.001). The highest relative risk of such events was found among patients with plaques >4 mm thick with no calcification (relative risk, 9.62; P<0.001) — that is, hypoechoic plaque suggestive of a thrombus.2 These preliminary results suggest that the morphology of aortic plaques may be an additional factor, besides the thickness of the plaques, that could help identify patients at greater risk for vascular events. In future therapeutic trials in patients with plaques >4 mm thick in the aortic arch, the patients should probably be stratified on the basis of the morphologic features of the plaques.
2 ReferencesAriel Cohen, M.D., Ph.D.
Pierre Amarenco, M.D.
Saint-Antoine Hospital, Paris 75571 CEDEX 12, Francefor the French Study of Aortic Plaques in Stroke Group
1
The French Study of Aortic Plaques in Stroke Group
Full Text | Web of Science | Medline2
Cohen A, Tzourio C, Amarenco P, Chauvel C, Bertrand B, Bousser M-G. Prognostic implications of atherosclerotic plaques in the aortic arch morphology analysis: results of a cohort follow-up study. Circulation (in press). abstract.
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