Atherosclerosis of the aorta. Artur Evangelista

Atherosclerosis of the aorta Artur Evangelista

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

Diagnosis

Atherosclerosis of the thoracic aorta TEE

JACC 2002;39:1127-32 Suprasternal harmonic imaging may predict the presence or absence of arch atherosclerosis

Classification Grade I Grade II No or minimal intimal thickening Intimal thickening 1-3.9 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

Severity of Aortic Atherosclerosis

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

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%)

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

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%

Aortic atherosclerosis and Risk of Stroke

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< 0.0001.

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

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;44:1018-24

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

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

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, 1.6-25 Large complex plaques: HR: 9.5 ; 1.9-47.1

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

Aortic atherosclerosis Treatment

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

PICSS based on Warfarin-Aspsirin Recurrent Study (WARSS) 516 p with previous stroke < 30 days Randomized treatment : aspirin 325 mg vs warfarin (INR 1.4-2.8) Recurrent stroke or death (16.4% vs 15.8%; p=0.43)

Mobile thrombus inserted in atherosclerotic plaques

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<0.001 38% 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 1.3-28, p< 0.02) Eur J Echocardiogr 200910:96-102

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;90:1320-1325

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.