Aortic Arch Plaques and Risk of Recurrent Stroke and Death

Abstract

Conclusion: Large aortic plaques are associated with an increased risk of recurrent stroke and death at 2 years, even when patients are treated with aspirin or warfarin therapy. Summary: Large aortic plaques (4 mm), as determined by transesophageal echocardiography (TEE), confer an increase risk of stroke (J Am Coll Cardiol 1994;23:1085-90). Ulceration and superimposed thrombi appear to increase risk as well (Am Heart J 2000;139:329-36). It is assumed, without much evidence, that anticoagulation or antiplatelet agents, or both, prevent stroke in patients with large aortic plaques. In this study the authors sought to define event rates in patients with stroke who had large aortic plaques. Patients were randomly assigned in a double-blind fashion to warfarin or aspirin treatment. The primary end point was recurrent ischemic stroke or death resulting from any cause. Recurrent ischemic stroke was a new lesion on magnetic resonance imaging or computed tomography scanning. If new lesions were absent, a clinical syndrome consistent with stroke lasting >24 hours was considered an end point. There were 516 patients with ischemic stroke who were double-blindly randomized. Large plaques (>4 mm) were present in 19.6% of patients, and large complex plaques, defined as those with mobile components or ulcerations, were seen in 8.5%. During the 2-year follow-up period, large plaques were associated with an increase risk of events (adjusted hazard ratio [HR], 2.12; 95% confidence interval [CI], 1.04-4.32). The HR was also increased in those with complex plaque morphology (HR, 2.55; 95% CI, 1.10-5.89). In patients with cryptogenic stroke, the HR was higher for both large plaques (HR, 6.42; 95% CI, 1.62-25.46) and large complex plaques (HR, 9.50; 95% CI, 1.92-47.10). There were no differences in event rates in the warfarin and aspirin groups compared with the overall study population (16.4% vs 15.8%; P = 0.43). Comment: In this study large aortic plaques were associated with a doubling of the risk of recurrent stroke and death despite medical therapy. There was no difference between aspirin and warfarin therapy, and both therapies were relatively ineffective. The HRs observed in this report appeared only slightly lower than those previously reported from studies where treatment was not randomized or even not prescribed (J Am Coll Cardiol 1994;23:1085-90). The study suggests that neither warfarin nor aspirin significantly affect the risk of stroke associated with large aortic plaques.