Optimizing Screening and Management of Asymptomatic Coronary Artery Disease in Patients With Stroke and Patients With Transient Ischemic Attack

Ovbiagele, Bruce; Liebeskind, David S; Kim, Doojin; Ali, Latisha K; Pineda, Sandra; Saver, Jeffrey L.

doi:10.1161/strokeaha.109.560151

Cited by 6 publications

(5 citation statements)

References 10 publications

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“…Screening for CAD risk using FRS in ischemic stroke patients has been useful [9,30]. Further, coronary CT has been studied as a noninvasive screening tool for the detection of asymptomatic CAD in high-risk groups, including patients with diabetes or ischemic stroke [9,31].…”

Section: Discussionmentioning

confidence: 99%

Comprehensive Evaluation of Coronary Artery Disease and Aortic Atherosclerosis in Acute Ischemic Stroke Patients: Usefulness Based on Framingham Risk Score and Stroke Subtype

et al. 2011

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Background: Evaluation of coronary artery disease (CAD) and aortic atherosclerosis has been performed in patients with acute ischemic stroke. We investigated the usefulness of a dual-source CT (DSCT) protocol enabling the comprehensive evaluation of CAD and aortic atherosclerosis. The clinical characteristics of those patients who would benefit more from this protocol were investigated based on vascular risk factors, Framingham Risk Score (FRS), and stroke subtype. Methods: Of 469 patients with acute ischemic stroke, the 274 who had no history of CAD and had undergone DSCT were analyzed. Predictors of CAD (≧50% stenosis) or complicated aortic plaque (CAP) were evaluated based on vascular risk factors, FRS and stroke subtype. Results: Of the 274 patients analyzed, asymptomatic CAD (≧50% stenosis) was found in 61 (22.3%) and CAP in 58 (21.2%). Furthermore, the severity of CAD or aortic atherosclerosis was correlated with FRS (CAD, r = 0.291, p < 0.001 and aortic atherosclerosis, r = 0.297, p < 0.001). Additionally, severe CAD and aortic atherosclerosis were independent predictors of each other: CAP for the presence of CAD (≧50% stenosis) [odds ratio (OR), 5.71; 95% confidence interval (CI), 1.94–16.87]; CAD (≧50% stenosis) for the presence of CAP (OR, 4.20; 95% CI, 1.82–9.72). Specific stroke subtypes as well as large-artery atherosclerosis (OR, 5.25; 95% CI, 2.24–12.31) and cardioembolism (OR, 5.22; 95% CI, 1.75–15.60) were associated with the presence of CAP. Conclusions: A comprehensive evaluation protocol for CAD and aortic atherosclerosis may be useful in acute ischemic stroke patients, especially in those with higher FRS or specific stroke subtypes.

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Section: Discussionmentioning

confidence: 99%

Comprehensive Evaluation of Coronary Artery Disease and Aortic Atherosclerosis in Acute Ischemic Stroke Patients: Usefulness Based on Framingham Risk Score and Stroke Subtype

et al. 2011

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“…CCTA provides comprehensive information regarding the location, severity, and characteristics of atherosclerotic plaque, and has been validated against conventional coronary angiography and intravascular ultrasound [13][14][15]. However, the role of enhanced risk stratification using non-invasive imaging studies in stroke patients remains a controversial issue [16,17].…”

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confidence: 99%

Incidence of subclinical coronary atherosclerosis in patients with suspected embolic stroke using cardiac computed tomography

Yoon

Chang

Cho

et al. 2010

Int J Cardiovasc Imaging

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The purpose of this study was to investigate the incidence of subclinical coronary artery disease (CAD) in patients with suspected acute embolic stroke or transient ischemic attack (TIA) using 64-row multi-slice computed tomography (MSCT) and to examine its association with conventional risk stratification. We consecutively enrolled 175 patients (66 ± 13 years, 50% men) suspected to have had embolic stroke/TIA clinically or radiologically, and underwent 64-row MSCT to evaluate for a possible cardiac source of embolism. Both coronary artery calcium scoring (CACS) and coronary CT angiography (CCTA) were concurrently performed based on standard scanning protocols. Patients with a history of angina or documented CAD, and those with significant carotid stenosis were excluded. Atherosclerotic plaques were indentified in 105 (60%) individuals; 37 (21%) had occult CAD of ≥50% diameter stenosis on CCTA. Subjects with and without ≥50% occult CAD on CCTA had similar prevalence of cardiovascular risk factors. Thirty out of 175 (17%) individuals with ≥50% occult CAD would have missed further cardiac testing based on the American Heart association and the American Stroke Association guideline. However, these numbers would be reduced to 2% (4/175) using CACS. In logistic regression analysis, only CACS independently predicted the presence ≥50% occult CAD evidenced by CCTA. Subclinical CAD, including ≥50% stenotic disease, is highly prevalent in patients who had suffered a suspected embolic stroke. The current guideline for further cardiac testing may have limited value to identify patients with ≥50% CAD in this patient population, which can be improved by adopting CACS.

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“…A study examining the implementation of this recommendation for poststroke CHD screening found that a minority of eligible patients received testing. 6 When testing was performed, 14% of patients had a positive stress test, with these patients going on to be prescribed β-blockers. 6 While we found that clinicians utilized cardiac stress testing for several approved indications (e.g., chest pain/angina), 21 , 22 our results also demonstrate relative underuse of stress testing among asymptomatic patients with cerebrovascular disease and high-risk FCRS.…”

Section: Discussionmentioning

confidence: 99%

“… 3 Although cardiac evaluation among patients with acute or subacute stroke largely focuses on discerning whether an event was caused by a cardioembolic source, 4 the American Heart Association/American Stroke Association (AHA/ASA) also recommends consideration of cardiac screening for asymptomatic CHD based on a high-risk Framingham Cardiac Risk Score (FCRS ≥20%). 3 , 5 - 7 …”

mentioning

confidence: 99%

“…Investigating the presence of occult CHD among patients with cerebrovascular disease may be clinically prudent, given that CHD is a leading cause of morbidity and mortality in this population. 3 , 5 - 9 Determining whether patients with cerebrovascular disease also have coronary atherosclerotic disease may have important treatment implications, 1 , 10 , 11 but a previous study attempting to implement this guideline found that outpatient providers did not pursue testing, given the lack of evidence regarding whether such screening improved poststroke outcomes. 6 …”

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confidence: 99%

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Receipt of cardiac screening does not influence 1-year post–cerebrovascular event mortality

Sico¹,

Baye²,

Myers³

et al. 2018

Neur Clin Pract

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BackgroundAmerican Heart Association/American Stroke Association expert consensus guidelines recommend consideration of cardiac stress testing to screen for occult coronary heart disease (CHD) among patients with ischemic stroke/TIA who have a high-risk Framingham Cardiac Risk Score (FCRS). Whether this guideline is being implemented in routine clinical practice, and the association of its implementation with mortality, is less clear.MethodsStudy participants were Veterans with stroke/TIA (n = 11,306) during fiscal year 2011 who presented to a VA Emergency Department or who were admitted. Patients were excluded (n = 6,915) based on prior CHD/angina/chest pain history, receipt of cardiac stress testing within 18 months prior to cerebrovascular event, death within 90 days of discharge, discharge to hospice, transfer to a non-VA acute care facility, or missing/unknown race. FCRS ≥20% was classified as high risk for CHD. ICD-9 and Common Procedural Terminology codes were used to identify receipt of any cardiac stress testing.ResultsAmong 4,391 eligible patients, 62.8% (n = 2,759) had FCRS ≥20%. Cardiac stress testing was performed infrequently and in similar proportion among high-risk (4.5% [123/2,759]) vs low/intermediate-risk (4.4% [72/1,632]) patients (adjusted odds ratio [aOR] 0.77, 95% confidence interval [CI] 0.54–1.10). Receipt of stress testing was not associated with reduced 1-year mortality (aOR 0.59, CI 0.26–1.30).ConclusionsIn this observational cohort study of patients with cerebrovascular disease, cardiac screening was relatively uncommon and was not associated with 1-year mortality. Additional work is needed to understand the utility of CHD screening among high-risk patients with cerebrovascular disease.

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Optimizing Screening and Management of Asymptomatic Coronary Artery Disease in Patients With Stroke and Patients With Transient Ischemic Attack

Cited by 6 publications

References 10 publications

Comprehensive Evaluation of Coronary Artery Disease and Aortic Atherosclerosis in Acute Ischemic Stroke Patients: Usefulness Based on Framingham Risk Score and Stroke Subtype

Comprehensive Evaluation of Coronary Artery Disease and Aortic Atherosclerosis in Acute Ischemic Stroke Patients: Usefulness Based on Framingham Risk Score and Stroke Subtype

Incidence of subclinical coronary atherosclerosis in patients with suspected embolic stroke using cardiac computed tomography

Receipt of cardiac screening does not influence 1-year post–cerebrovascular event mortality

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