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Atherosclerotic Burden and Vascular Risk in Stroke Patients With AF
Quick Takes
- In stroke patients with AF, a higher burden of atherosclerotic vascular disease is associated with an increased risk of incident cardiovascular disease and death.
- In this population, internal carotid atherosclerotic disease had a stronger association with adverse events than intracranial, coronary, or peripheral atherosclerotic disease.
Study Questions:
What is the impact of atherosclerotic disease burden on the risk of vascular events in stroke patients with atrial fibrillation (AF)?
Methods:
The authors used data from the Korean Atrial Fibrillation Evaluation Registry in Ischemic Stroke Patients, a prospective registry that enrolled ischemic stroke patients with AF at 11 South Korean academic medical centers. Atherosclerotic vascular disease (ASVD) was categorized into four subtypes: intracranial, extracranial, coronary, and peripheral vascular disease. The primary outcome was the first occurrence of a major adverse cardiovascular event (MACE), which included stroke, coronary heart disease, or vascular death. All-cause mortality and stroke (ischemic or hemorrhagic) were secondary outcomes. Patients were separated into four groups, based on the number of ASVDs (0, 1, 2, and 3-4). Adjustments were made for comorbidities, including CHA2DS2-VASc score.
Results:
There were 2,670 patients included in the study; 51% were men, the mean age was 73.5 years, and the mean CHA22DS2-VASc score was 5. There were 1,832 (68.6%) patients with ASVD, most (95%) with ASVD in one or two vascular beds. Intracranial ASVD was present in 55.2% of patients; extracranial ASVD was present in 25.2%; coronary ASVD was present in 12.7%; and 1.3% had peripheral ASVD. Patients with more ASVD had more medical comorbidities.
Patients were followed for an average of 1.7 years. Over that time, 25.2% of patients had a MACE, 6.4% of patients had a stroke, and 18.8% of patients died. When compared with patients who had no ASVD, increasing amount of ASVD was associated with an increased risk of MACE and all-cause death, but not associated with an increased risk of stroke. Intracranial and extracranial atherosclerotic diseases were associated with MACE and all-cause death, but coronary and peripheral vascular diseases were not.
Anticoagulation, with direct oral anticoagulants or vitamin K antagonists, compared with no antithrombotic therapy, was associated with a decreased risk of MACE and death. Dual antiplatelet therapy was associated with a decreased risk of death and MACE when compared with single antiplatelet therapy. There was no benefit seen with anticoagulation plus an antiplatelet agent compared with anticoagulation alone.
Conclusions:
In stroke patients with AF, a higher burden of ASVD is associated with an increased risk of cardiovascular events and death.
Perspective:
Patients with AF frequently have concomitant ASVD. This study helped to define how that ASVD contributes to adverse cardiovascular events and death. Extracranial atherosclerotic disease was the strongest predictor of MACE and all-cause death. This work may help with prognostication after patients with AF have a stroke. Limitations include the fact that ASVD was categorized by its presence versus absence, without regard to severity. Additionally, coronary and peripheral ASVDs were only identified if they were symptomatic. Given the increased burden of intracranial atherosclerotic disease in Asian patients, it is unclear if these findings generalize to a Western population.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Prevention, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atherosclerosis, Atrial Fibrillation, Brain Ischemia, Coronary Disease, Fibrinolytic Agents, Geriatrics, Hemorrhage, Intracranial Arteriosclerosis, Peripheral Vascular Diseases, Platelet Aggregation Inhibitors, Secondary Prevention, Stroke, Thrombosis, Vascular Diseases, Vitamin K
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