Predicting Asymptomatic Coronary Artery Stenosis by Aortic Arch Plaque in Acute Ischemic Cerebrovascular Disease: Beyond the Cervicocephalic Atherosclerosis?
Acute ischemic cerebrovascular disease (AICVD) is a significant health concern globally, often associated with severe cardiovascular and cerebrovascular complications. Among these, asymptomatic coronary artery stenosis (ACAS) of 50% or more is particularly prevalent in AICVD patients, portending a poor prognosis. Early identification of ACAS can optimize clinical management and improve outcomes for these high-risk patients. This study investigates whether aortic arch plaque (AAP), an early manifestation of atherosclerosis in the brain blood-supplying arteries, can serve as a predictor for ACAS in AICVD patients.
Background and Significance
ACAS is found in approximately 18% to 33% of patients with AICVD. Despite the initiation of vascular risk factor reduction and antithrombotic therapy after AICVD, the incidence of myocardial infarction within a year remains as high as 3% in patients with no prior coronary artery disease history. ACAS in AICVD patients is associated with recurrent stroke and reduced survival, highlighting the importance of early detection and targeted treatment to alter the prognosis favorably.
Traditionally, patients with high vascular risk profiles and carotid atherosclerotic stenosis were considered more likely to have ACAS. However, recent studies have suggested that intracranial atherosclerotic stenosis may also be associated with ACAS. Despite these findings, there is a lack of consensus on the predictive value of carotid or intracranial atherosclerotic stenosis for ACAS. This study aims to explore the predictive value of AAP, an integral segment of the brain blood-supplying arteries, for ACAS in AICVD patients.
Methods
This cross-sectional study evaluated atherosclerosis of the coronary and brain blood-supplying arteries simultaneously using one-step computed tomography angiography (CTA) in AICVD patients without a history of coronary artery disease. Patients were divided into two groups based on the presence or absence of ACAS of 50% or more. AAP characteristics were assessed in terms of thickness, extent, and complexity.
Results
Among the 118 analyzed AICVD patients, 29 (24.6%) had ACAS of 50% or more, while AAPs were observed in 86 (72.9%) patients. Increased AAP thickness per millimeter (adjusted odds ratio [OR]: 1.56, 95% confidence interval [CI]: 1.18–2.05), severe-extent AAP (adjusted OR: 13.66, 95% CI: 2.33–80.15), and the presence of complex AAP (adjusted OR: 7.27, 95% CI: 2.30–23.03) were independently associated with ACAS in AICVD patients, regardless of clinical demographics and cervicocephalic atherosclerotic stenosis.
The combination of AAP thickness, extent, and complexity predicted ACAS with an area under the receiver-operating characteristic curve of 0.78 (95% CI: 0.70–0.85, P<0.001). These AAP characteristics provided additional predictive power beyond cervical and intracranial atherosclerotic stenosis for ACAS in AICVD patients.
Discussion
The findings of this study underscore the significance of AAP as a marker for ACAS in AICVD patients. Thicker, severe-extent, and complex AAPs were significantly associated with the presence of ACAS, potentially offering superior predictive value compared to cervical and intracranial atherosclerotic stenosis. These results suggest that AAP should not be overlooked in the evaluation of AICVD patients for the presence of ACAS.
The study’s results align with previous research indicating that complex AAP is an independent indicator of coronary stenosis in patients with acute ischemic stroke. However, this study extends these findings by comprehensively profiling AAP characteristics and examining their predictive value from multiple aspects.
The anatomical and physiological differences in various arterial beds may explain why AAP serves as a better marker for ACAS than cervical and intracranial atherosclerotic stenosis. Aortic and coronary arteries are typically affected earlier in the atherosclerotic process, making AAP a more sensitive indicator of ACAS.
Clinical Implications
Early detection of ACAS in AICVD patients is crucial for implementing targeted and integrated monitoring and intervention plans. Routine screening of ACAS in all AICVD patients may not be warranted, but a comprehensive evaluation of AAP characteristics can aid in identifying high-risk patients who should undergo further coronary artery examination.
The feasibility of assessing AAP characteristics using traditional CTA of brain blood-supplying arteries makes this approach highly applicable in current clinical settings. This “one-shot” prediction of ACAS in the acute setting of AICVD without requiring additional screening imaging may be more clinically and economically efficient.
Limitations
The study has several limitations, including a relatively small sample size and the inclusion of only Chinese patients. Ethnic differences in atherosclerotic severity and distribution may affect the generalizability of the findings. Additionally, CTA has limited resolution in imaging small isodense AAPs, which might be overlooked. However, CTA’s non-invasive nature and ability to evaluate AAPs along with routine examination of cervical and intracranial arteries reduce selection bias and enhance the study’s clinical applicability.
Conclusion
Patients with both AICVD and ACAS are more likely to have thicker, severe-extent, and complex AAPs than those with AICVD only. These AAP characteristics are independent markers of ACAS in AICVD and may provide stronger predictive power than cervical and intracranial atherosclerotic stenosis. Evaluating AAP is essential for the early identification of ACAS in AICVD patients without a history of coronary artery disease, enabling timely initiation of integrated clinical management considering both coronary and brain blood-supplying arteries.
Future studies should aim to validate these findings in larger, more diverse populations and explore the underlying mechanisms linking AAP to ACAS. Prospective studies are also needed to evaluate the utility of AAP in risk stratification and clinical management of AICVD patients.
doi.org/10.1097/CM9.0000000000000174
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