Relation Between Mitral Annular Calcium and Complex Aortic Atheroma in Patients With Cerebral Ischemia Referred for Transesophageal Echocardiography

Abstract

Mitral annular calcium (MAC) has been shown to be an independent predictor of stroke, but the basis for this association remains incompletely defined. We investigated the extent to which aortogenic embolism may mediate the MAC-stroke relationship. In a cross-sectional study of patients referred for transesophageal echocardiography at our institution for evaluation of cerebral ischemia, we assessed the relationship between MAC and proximal and distal complex aortic atheroma (CAA). Among 419 patients composing the study cohort, MAC was associated with atherosclerosis risk factors, prior cardiovascular disease, atrial fibrillation, ipsilateral large-artery stenosis, left-heart abnormalities and aortic valve calcium. MAC was associated with CAA of the proximal and distal thoracic aorta in unadjusted analyses, and these associations became stronger with increasing MAC severity. After adjustment for clinical and echocardiographic covariates, MAC exhibited a significant association with proximal and distal CAA in the entire cohort. In patients without an alternative potential mechanism for cerebral ischemia, however, the relationship with proximal CAA became more pronounced (adjusted odds ratio=2.74, 95% confidence interval=1.22-6.16), but that for distal CAA changed little and became non-significant (adjusted odds ratio=1.97, 95% confidence interval=0. 87-4.45). In this cohort with cerebral ischemia, MAC was significantly associated with proximal and distal CAA independent of clinical and echocardiographic covariates, but among individuals without identifiable alternative mechanisms, the magnitude of the relation increased only for proximal CAA. These findings support the role of proximal CAA as a direct mediator of the increased stroke risk associated with MAC.Mitral annular calcium (MAC) 1 is an independent predictor of stroke, 2-4 but the mechanisms underlying the MAC-stroke relationship are not well delineated. 4 Protruding, ulcerated or mobile atheromatous plaques of the thoracic aorta also exhibit a strong association with stroke; 5-7 the presence of complex plaque of the ascending aorta and aortic arch quadruples the risk

Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack

“…512 Mitral annular calcification is associated with cardiovascular risk factors and atherosclerosis in other vascular distributions. 504,513,514 Therefore, the association between mitral annular calcification and increased risk for stroke observed in some studies may be the result of shared risk factors rather than direct causation. 511 No research has adequately examined the association between mitral annular calcification and risk for recurrent ischemic stroke.…”

Association of Annular Calcification and Aortic Valve Sclerosis With Brain Findings on Magnetic Resonance Imaging in Community Dwelling Older Adults

“…These cardiac lesions may not be just markers of stroke risk based on their association atherosclerotic vascular disease(35,36) but may also play a causative role. Embolization from left-sided cardiac annular or valvular calcifications can vary from friable calcium deposits to non-calcific (thrombus) embolization.…”

Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack

“…273 A cross-sectional study of patients referred for TEE for evaluation of cerebral ischemia found that MAC was significantly associated with proximal and distal complex aortic atheroma. 285 There are no relevant data comparing the safety and efficacy of anticoagulant therapy versus antiplatelet therapy in patients with TIA or stroke.…”