Asymptomatic CAD predicts major vascular events after ischemic stroke

Amarenco P, Lavallée PC, Labreuche J, et al.
Stroke. 2013 Jun;44(6):1505-1511

Background

The risk of myocardial infarction after ischemic stroke is well-documented [1-5]. It is known from autopsies after fatal stroke, and of coronary angiography studies after nonfatal stroke or transient ischemic attack that asymptomatic coronary artery disease (CAD) is common [6-8].
However, the risk of future vascular events as a result of CAD in patients with cerebral infarction has not been assessed prospectively.
Imaging of extracranial arteries and coronary angiography has been reported of 405 patients with acute ischemic stroke on MRI [AMISTAD study: 7]. The presence and extent of asymptomatic and symptomatic CAD is now related to the cardiovascular risk of 377 of these patients, after a median follow-up time of 36 months.

Main results

• 41 patients experienced >1 major vascular event, yielding an overall 2-year risk of 11.0% (95%CI: 8.2-14.7). Depending on the intensity of CAD, the incidences of vascular events differed significantly. When using patients without CAD as a reference, patients with asymptomatic <50% coronary stenosis had an age- and sex-adjusted hazard ratio (HR) of 2.10 (95%CI: 0.63-6.96), patients with asymptomatic >50% coronary stenosis had HR:4.36 (95%CI: 1.35-14.12) and patients with known CHD had HR:6.86 (95%CI: 2.15-21.91). Further adjustment for other common risk factors yielded similar results.
• When including only patients with no known CHD at baseline, the presence of asymptomatic coronary plaque was associated with an increased risk of major vascular events after 2 years follow-up (age- and sex adjusted HR: 3.73, 95%CI: 1.22-11.44). The 2-year risk increased with increasing number of arteries affected by plaque, as well as the extent of coronary stenosis.
• Fully adjusted multivariate analysis yielded a hazard ratio for combined vascular events of 4.03 (95%CI: 1.21-13.39) for asymptomatic coronary plaques and 3.77 (95%CI: 1.44-9.87) for asymptomatic coronary stenosis.

Conclusion

Asymptomatic CAD (diagnosed by coronary angiography) after a recent nonfatal cerebral infarction is predictive of major vascular events. Risk increases with severity of asymptomatic CAD and the number of arteries involved, irrespective of the degree of stenosis. Detection of asymptomatic CAD and subsequent preventive measures might be beneficial, but this should be evaluated in randomised controlled trials.

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