Atherosclerosis of the aorta. Artur Evangelista

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1 Atherosclerosis of the aorta Artur Evangelista

2 Atherosclerosis of the aorta Diagnosis Classification Prevalence Risk factors Marker of generalized atherosclerosis Risk of embolism Therapy

3 Diagnosis

4 Atherosclerosis of the thoracic aorta TEE

5 JACC 2002;39: Suprasternal harmonic imaging may predict the presence or absence of arch atherosclerosis

6 Classification Grade I Grade II No or minimal intimal thickening Intimal thickening mm without atheroma Grade III Atheroma < 4 mm Grade IV Intimal thickening or atheroma > 4 mm Grade V Any mobile or ulcerated atheroma Tunick,Koronzon J Am Coll Cardiol 2000 Montgomery, J Am Coll Cardiol 1996

7 Severity of Aortic Atherosclerosis

8 Intraoperative TEE vs Pathologic Findings Grade I Grade IV Atheroma > 4 m Grade I Grade II Grade V Vaduganathan P, JACC 1997; 30:357-63

9 Prevalence Bias of most studies SPARC (Stroke prevention assessment of risk in a community) 585 subjects (age > 45y), age and gender stratified. Random sample Olmsted County. TEE assessment ( Atherosclerosis 44% and complex 8%)

10 Risk Factors Cardiovascular risk factors: Age Sex Heredity Hypertension Diabetes Hyperlipidemia Smoking Sedentary life Elevated levels inflamatory markers: Serum C-reactive protein Homocysteine

11 Risk marker of generalized Atherosclerosis Prevalence of Aortic Atheroma yes no Carotid artery disease 38% 16% Abdominal aneurysm 52% 25% Aortic valvular sclerosis 86% 30% Mitral annular calcification 74% 22% Coronary artery disease 93% 22%

12 Aortic atherosclerosis and Risk of Stroke

13 ARTE No Stroke Stroke 345 patients standard TEE indications 59% of aortic atherosclerosis, 6% grade V Complicated atherosclerosis most frequent in patients with previous stroke 58% of patients with grade V had previous stroke and only 18% with grades I-IV OR: 6.5 (2.5 a 16.8) p<

14 Grade V and Stroke 7.5% 2% 10% 0.7% 3% 7% 0% 1% STROKE 6% 0.4% NO STROKE

15 585 subjects (age > 45y), age and gender stratified. Random sample Olmsted County (SPARC) Follow-up: 5y Simple aortic plaques were not independently associated with cardiac or cerebrovascular events. Complex plaques (n:44) were marginally associated with cardiac events, adjusted by age and gender. J Am Coll Cardiol 2004;44:

16 Aortic Plaques and Risk Ischemic Stroke (APRIS) 209 p stroke-free subjects > 50y Aortic arch plaques (62%), large (24%), complex (7%) Follow-up (6 years): 11 stroke, 12 AMI, 6 death

17 255 patients (55y) with stroke and 209 controls. Arch plaques > 4mm were associated with stroke OR: 2.4; ulcer/thrombus OR: 3.3 Prothrombine fragment F 1.2 was associated with larger plaques JACC 2008;52:855-61

18 PFO in Crypyogenetic Stroke Study (PICSS) 516 p with previous stroke < 30 days Arch plaques: 65%, large > 4mm: 20%, complex: 9% Large plaques: HR: 6.4 ; 95% CI, Large complex plaques: HR: 9.5 ;

19 Aortic Atheroma and Cholesterol Embolism Cholesterol crystal embolization Spontaneous Arterial manipulation: Catheterization Intra-aortic balloon Cardiac surgery Central embolism: neurological events Peripheral embolism: Blue toe syndrome, livido reticularis, visceral or renal ischemia

20 Aortic atherosclerosis Treatment

21 Protruding atheroma 139 /1116 patients (85% with embolic event) Patients with aortic plaques > 4mm treated with antiplatelests presented a risk ratio of 5.9 respect to those treated with anticoagulation Am J Cardiol 2002;90;1320-5

22 PICSS based on Warfarin-Aspsirin Recurrent Study (WARSS) 516 p with previous stroke < 30 days Randomized treatment : aspirin 325 mg vs warfarin (INR ) Recurrent stroke or death (16.4% vs 15.8%; p=0.43)

23 Mobile thrombus inserted in atherosclerotic plaques

24 83/287 patients with aortic plaques Treatment; statins 73%, antiplatelet 72%, warfarin 28% 48% remained stable 14% increased (3.9±1.4 to 5.6±1.4 mm, p< % decreased 5.2±1.5 to 3.8±1.5 mm, p<0.001 Multinomial logistic analysis suggest statins reduce the risk of progression (OR: 5.9, 95% CI , p< 0.02) Eur J Echocardiogr :96-102

25 519 patients with severe aortic plaques (24% mobile) (statins 38%, warfarin 40%, antiplatelet 49%) Follow-up 34 m. 111 embolic events Odd ratio for embolic events: statins 0.3 warfarina 0.7 antiplatelet 1.4 Statins effect Lipid lowering Pleitropic effects Attenuates plaque inflamation Antithrombotic properties vulnerable plaque into a stable plaque Am J Cardiol 2002;90:

26

27 Conclusions The question whether aortic atheroma is a risk factor for stroke or an innocent bystander remains unanswered. The association between aortic atherosclerosis and stroke has been reported in many studies with high-risk population but has failed in the low-risk cohort community studies. Aortic atherosclerosis is a marker for diffuse atherosclerosis and may predispose to systemic embolism by association with carotid disease,cad, AF, etc. Protruding proximal atheromas > 4mm, mainly with mobil or ulcer components, appear to have an increased incidence of vascular events. In patients with atheroma, treatment with statins is a resonable option to reduce the risk of stroke. Oral anticoagulation therapy may be considered in stroke patients with proximal complex lesions.

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