Aortic Atheroma and Stroke
Aortic Atheroma and Stroke
ABSTRACT & COMMENTARY
Synopsis: Patients with systemic emboli and mobile aortic atheroma have a high incidence of recurrent vascular events that can be prevented by warfarin therapy.
Source: Dressler FA, et al. J Am Coll Cardiol 1998; 31:134-138.
After the advent of transesophageal echocardiography (TEE), the link between aortic atheroma and stroke was confirmed in living subjects. However, the therapeutic implications of aortic atheroma are largely unknown. Thus, Dressler and associates evaluated the relationship between aortic plaque morphology and systemic emboli and the effect of anticoagulation therapy in 31 patients presenting with a systemic embolic event who were found to have mobile aortic atheroma on TEE. Of the 31 subjects, 25 had a stroke and six had peripheral emboli; none had significant carotid stenoses. The referring physician decided on anticoagulant therapy; 20 patients (65%) received long-term warfarin therapy, seven received aspirin, and four received nothing. The patients on warfarin had the lowest incidence of recurrent vascular events (5% vs 45%, P = 0.006). No patient on warfarin had another stroke or myocardial infarction. Half the patients also had other potential sources of embolus identified (i.e., atrial fibrillation, patent foramen ovale, spontaneous atrial contrast, and atrial appendage thrombus). Dressler et al conclude that patients with systemic emboli and mobile aortic atheroma have a high incidence of recurrent vascular events that can be prevented by warfarin therapy.COMMENT BY MICHAEL H. CRAWFORD, MD
The message of this study is if mobile aortic atheroma are detected on TEE in patients with recent systemic embolus, long-term oral anticoagulation is indicated. It would be hard to disagree with this conclusion, but there are several problems with this study that are worth discussing. TEEs were performed in 1390 patients to arrive at 31 with mobile plaques. Thus, this is an unusual finding in systemic emboli patients.Also, we do not know why these 1390 patients had TEE. Do all systemic emboli patients at St. Louis University get TEE or are they selected because of suspicion of cardiac abnormalities? In this regard, it is interesting to note that about half the 31 mobile atheroma patients had other conditions that could predispose to stroke, such as atrial fibrillation and left atrial appendage thrombus, which are also indications for anticoagulation therapy. Thus, the frequency of patients with mobile atheroma alone among those selected for TEE is 1% or less. This incidence does not seem like a valid reason to perform TEE in all systemic emboli patients. Unfortunately, this retrospective observational study does not provide us with any criteria for who are the high-risk patients for having mobile aortic atheroma.
Of further interest is the relation between less worrisome aortic atheroma (non-mobile) and systemic vascular events and whether they are preventable by anticoagulation therapy. Is a protruding but non-mobile atheroma dangerous? Also, what do you do with the patient who has TEE for another reason and mobile aortic atheroma found incidentally? In addition, Dressler et al did not specify whether the mobile atheroma had to be in the ascending aorta in the stroke patients or whether the risk was increased even if the mobile atheroma were only found in the descending aorta. Like so many retrospective, observational studies, this one raises more questions than it answers.
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