This Article Full Text Full Text (PDF) CME: Take the course for this article: Circulation: May 5, 2009, Volume 119, Number 17 Data Supplement All Versions of this Article: 119/17/2376    most recent CIRCULATIONAHA.108.811935v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Di Tullio, M. R. Search for Related Content PubMed PubMed Citation Articles by Di Tullio, M. R. Pubmed/NCBI databases Compound via MeSH Substance via MeSH Hazardous Substances DB ACETYLSALICYLIC ACID WARFARIN Medline Plus Health Information Stroke Related Collections Secondary prevention Echocardiography Embolic stroke Anticoagulants Antiplatelets Related Article

(Circulation. 2009;119:2376-2382.)
© 2009 American Heart Association, Inc.

Stroke

Aortic Arch Plaques and Risk of Recurrent Stroke and Death

Marco R. Di Tullio, MD; Cesare Russo, MD; Zhezhen Jin, PhD; Ralph L. Sacco, MD, MS; J.P. Mohr, MD; Shunichi Homma, MD, for the Patent Foramen Ovale in Cryptogenic Stroke Study Investigators

From the Departments of Medicine (M.R.D.T., C.R., S.H.), Biostatistics (Z.J.), and Neurology (J.P.M.), Columbia University, New York, NY, and Departments of Neurology, Epidemiology, and Human Genetics, University of Miami, Miami, Fla (R.L.S.).

Correspondence to Marco R. Di Tullio, MD, Division of Cardiology, Columbia University, College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032. E-mail md42{at}columbia.edu

Received August 1, 2008; accepted March 4, 2009.

Background— Aortic arch plaques are a risk factor for ischemic stroke. Although the stroke mechanism is conceivably thromboembolic, no randomized studies have evaluated the efficacy of antithrombotic therapies in preventing recurrent events.

Methods and Results— The relationship between arch plaques and recurrent events was studied in 516 patients with ischemic stroke who were double-blindly randomized to treatment with warfarin or aspirin as part of the Patent Foramen Ovale in Cryptogenic Stroke Study (PICSS), based on the Warfarin-Aspirin Recurrent Stroke Study (WARSS). Plaque thickness and morphology were evaluated by transesophageal echocardiography. End points were recurrent ischemic stroke or death over a 2-year follow-up. Large plaques (4 mm) were present in 19.6% of patients; large complex plaques (those with ulcerations or mobile components) were seen in 8.5%. During follow-up, large plaques were associated with a significantly increased risk of events (adjusted hazard ratio [HR], 2.12; 95% confidence interval [CI], 1.04 to 4.32), especially those with complex morphology (HR, 2.55; 95 CI, 1.10 to 5.89). The risk was highest among cryptogenic stroke patients, both for large plaques (HR, 6.42; 95% CI, 1.62 to 25.46) and large complex plaques (HR, 9.50; 95% CI, 1.92 to 47.10). Event rates were similar in the warfarin and aspirin groups in the overall study population (16.4% versus 15.8%; P=0.43).

Conclusions— In patients with stroke, especially cryptogenic stroke, large aortic plaques remain associated with an increased risk of recurrent stroke and death at 2 years despite treatment with warfarin or aspirin. Complex plaque morphology confers a slight additional increase in risk.

---

 

CLINICAL PERSPECTIVE

Related Article:

Clinical Summaries
Circulation 2009 119: 2295-2296. [Extract] [Full Text]