Vascular Events During Follow-up in Patients With Aortic Arch Atherosclerosis

179

Retrospective, unblinded, nonrandomized comparisons between these 2 strategies have been inconclusive 13 and no randomized evaluation of these strategies has been conducted.14 We hypothesized that the combination of aspirin plus clopidogrel was 25% superior to dose-adjusted warfarin on prevention of new vascular Background and Purpose-Severe atherosclerosis in the aortic arch is associated with a high risk of recurrent vascular events, but the optimal antithrombotic strategy is unclear. Methods-This prospective randomized controlled, open-labeled trial, with blinded end point evaluation (PROBE design) tested superiority of aspirin 75 to 150 mg/d plus clopidogrel 75 mg/d (A+C) over warfarin therapy (international normalized ratio 2-3) in patients with ischemic stroke, transient ischemic attack, or peripheral embolism with plaque in the thoracic aorta >4 mm and no other identified embolic source. The primary end point included cerebral infarction, myocardial infarction, peripheral embolism, vascular death, or intracranial hemorrhage. Follow-up visits occurred at 1 month and then every 4 months post randomization. Results-The trial was stopped after 349 patients were randomized during a period of 8 years and 3 months. After a median follow-up of 3.4 years, the primary end point occurred in 7.6% (13/172) and 11.3% (20/177) of patients on A+C and on warfarin, respectively (log-rank, P=0.2). The adjusted hazard ratio was 0.76 (95% confidence interval, 0.36-1.61; P=0.5). Major hemorrhages including intracranial hemorrhages occurred in 4 and 6 patients in the A+C and warfarin groups, respectively. Vascular deaths occurred in 0 patients in A+C arm compared with 6 (3.4%) patients in the warfarin arm (log-rank, P=0.013). Time in therapeutic range (67% of the time for international normalized ratio 2-3) analysis by tertiles showed no significant differences across groups. Conclusions-Because of lack of power, this trial was inconclusive and results should be taken as hypothesis generating. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00235248.

Section: See Related Article P 1239mentioning

confidence: 99%

Clopidogrel Plus Aspirin Versus Warfarin in Patients With Stroke and Aortic Arch Plaques

Amarenco

Davis

Jones

et al. 2014

179

“…6 In a prospective echocardiographic study, an incidence of vascular events of 13.7% in patients with complex aortic plaques was found. 7 AAA is thus an important cause of cerebral embolisms, accounting for nearly 30% of hitherto unexplained or "cryptogenic" strokes.…”

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confidence: 99%

Predictive Value of Inflammatory and Hemostatic Parameters, Atherosclerotic Risk Factors, and Chest X-Ray for Aortic Arch Atheromatosis

Ehlermann

Mirau

Jahn

et al. 2004

Self Cite

Background and Purpose-Aortic arch atheromatosis (AAA) is a common cause of cerebral embolism. Transesophageal echocardiography (TEE) shows not only the extension of atherosclerotic plaques but also the mobility of superimposed thrombi. In most cases AAA is only detected after the embolic event. This study was therefore designed to identify predictive factors for AAA. Methods-One hundred seven consecutive patients referred for routine TEE were included in the study. Patients on warfarin therapy, with a history of recent surgery, or with any signs of infectious, immunological, or malignant diseases were excluded. Results-Diabetes mellitus carried the highest risk for AAA (odds ratio, 3.0), followed by hyperlipidemia (2.5) and arterial hypertension (2.3). Age Ͼ70 years was accompanied with a 1.8-fold increased risk. Patients with aortic calcifications on standard chest x-ray had a 4.6-fold higher prevalence. Severe AAA was associated with higher levels of C-reactive protein (

“…[1][2][3][4][5][6][7][8][9][10] Stroke risk has been shown to increase progressively with increasing plaque thickness, 5 but cutoff points of steeper increase in risk have also been identified. A cutoff point of 4 mm has been widely used for risk stratification 5,9 on the basis of the results of the largest studies on this topic, but a value of 5 mm has also been used in other studies.…”

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confidence: 99%

Gender Differences in the Risk of Ischemic Stroke Associated With Aortic Atheromas

Tullio

Sacco

Savoia

et al. 2000

Background and Purpose-Atherosclerotic plaque of the proximal portion of the aorta is associated with an increased risk of ischemic stroke in the elderly. Different cutoffs of plaque thickness have been used in the literature for risk stratification and have been applied to both men and women. However, the assumption that the relationship between plaque thickness and stroke risk is the same in the 2 genders has not been proven. The aim of this study was to evaluate whether the prevalence of different degrees of aortic plaque thickness differed in men and women with ischemic stroke. Methods-We performed transesophageal echocardiography in 152 patients aged Ͼ59 years with acute ischemic stroke (76 men and 76 women) and in 152 control subjects of similar age (70 men and 82 women). Odds ratios (ORs) for ischemic stroke with 95% CIs for different plaque thickness definitions were calculated for the overall group and separately for men and women by logistic regression analysis after adjusting for age, arterial hypertension, and hypercholesterolemia. Results-Aortic plaques Ն4 mm were significantly more frequent in men than in women (31.5% versus 20.3%, respectively; Pϭ0.025) and were associated with ischemic stroke in both men (adjusted OR 6.0, CI 2.1 to 16.8) and women (adjusted OR 3.2, CI 1.2 to 8.8). However, plaques 3 to 3.9 mm in thickness had a significant association with stroke in women (adjusted OR 4.8, CI 1.7 to 15.0) but not in men (adjusted OR 0.8, CI 0.2 to 3.0). Plaques Ͻ3 mm were not associated with a significantly increased stroke risk for either sex. Conclusions-Smaller aortic plaques are significantly associated with ischemic stroke in women but not in men. If the increased prevalence of smaller plaques in women is confirmed to be associated with increased risk for embolic stroke, different cutoff points may have to be adopted in men and women for risk stratification and for decisions regarding medical intervention.