Letter by Bhindi and Ormerod Regarding Article, “Aortic Arch Plaques and Risk of Recurrent Stroke and Death”
To the Editor:
We read with interest the findings of the study by Di Tullio and colleagues,1 who observe no difference in recurrent stroke rates in patients treated with either aspirin of warfarin after a cryptogenic stroke. The authors also observe an increase risk of recurrent events in patients with both large and complex aortic plaques.
We wish to point out a few concerns we have with this study. First, the effect of statin therapy, which could modify aortic plaque stability, is not measured in this study, and the authors understate the potential significance of this effect. It is conceivable that if there were differences in statin therapy between the 2 study groups, the actual effects of either aspirin or warfarin could be underestimated or exaggerated. Furthermore, the utilization of clopidogrel is not reported and could also enhance the beneficial effects of aspirin if used in combination. Whether either therapy affects the severity of the recurrent stroke is also not discussed. Finally, there are significant differences in baseline cardiovascular risk factors between the various plaque-size cohorts, which in combination with the low event rate confound the interpretation of this variable as a predictor of recurrent strokes.