Coronary Calcium Score. Is There a Difference among Ischemic Stroke Subtypes?

Stroke; Coronary Artery Disease; Calcium Score; Myocardial Ischemia; Atherosclerosis

Ischemic heart disease is an important cause of death in stroke patients during a long-term follow-up.¹ , ² Ischemic stroke survivors have a high prevalence of asymptomatic coronary artery disease (CAD).³ Indeed, half of those with no cardiac history have some degree of coronary atherosclerotic plaques and one-third have more than 50% of coronary stenosis.⁴ For the assessment of CAD risk, a non-invasive stratification score based on the extent and density of computed tomography coronary artery calcium (CAC) was proposed by Agatston et al.⁵ The measurement of CAC to improve clinical risk prediction for cardiovascular events in selected asymptomatic adults is the recommendation of worldwide guidelines.⁶ - ¹⁰ Although there is a strong association between atherosclerosis and subclinical CAD, it is remains uncertain for non-atherosclerotic stroke patients.¹ , ¹¹

In this issue of ABC Cardiol, Negrão et al.¹² conducted a cross-sectional study to compare the coronary calcium score (CCS) between atherosclerotic and non-atherosclerotic ischemic stroke patients who were admitted at Rehabilitation Hospital. Of 244 evaluated patients, 80 (33%) were included in the atherosclerotic etiology group. The non-atherosclerotic group was represented by the remaining etiologies, such as cardioembolism (30%), small artery occlusion (15%), other causes (6%), and undetermined cause (16%). Although there was no difference in CAD risk between those groups, age ≥60 years was an independent predictor for high CAD risk (OR 3.52; 95%CI 1.72-7.18).¹²

This study provided relevant insights that should be addressed. First, stroke and CAD have a close association, sharing common risk factors.¹ , ³ Even among young stroke patients, the prevalence of these risks is substantial. A recent published study reported that the three most common risk factors for stroke at a young age were arterial hypertension, lipid disorders and lifestyle-related factors. More than half of the patients had at least two independent risk factors for stroke.¹³

Likewise, the stroke population in the present study showed a relatively young age (58.4 ± 6.8 years), but had a high frequency of risk factors. Second, acute coronary syndrome results mainly from large-vessel atherosclerosis, whereas ischemic stroke patients are a heterogeneous group, including five categories of etiology classification (large-artery atherosclerosis; cardioembolism; small artery occlusion; other determined cause; and undetermined cause).¹⁴ In addition, it is well recognized that there is a variation in CAD risk according to the stroke mechanism. Patients with artery dissection, other nonatherosclerotic arteriopathies, and paradoxical embolism seem to be at low CAD risk. While those with cardioembolic stroke, mainly attributed to atrial fibrillation, may have a higher likelihood of coronary events. As opposed to a large amount of data on extracranial artery atherosclerosis and CAD, insufficient information is available about intracranial atherosclerosis.¹¹ , ¹⁴ Third, statin therapy may be a confounder in CCS quantification. Since statins can reduce the fibrolipid plaques and promote micro-calcification, it might also lead to an increase in CCS.¹⁵ Finally, as the authors pointed out, there was a possible selection bias, excluding either patients with quite severe limitation or low recovery demand. Therefore, these results should be interpreted taking into account these limitations and the cohort characteristic, before jumping to broad generalization.

Overall, it was not a surprise that the CCS itself was unable to distinguish stroke etiology. Most interestingly, atherosclerotic and non-atherosclerotic stroke patients showed similar proportions for CAD risk. Large studies with longer follow-up periods should be undertaken to determine the CCS value for individual CAD risk stratification in ischemic stroke patients regardless of the etiology. Risk prediction tools are critical for intervention strategies, aiming to prevent major coronary events in stroke patients.

Referências

• ¹
  Bhatia R, Sharma G, Patel C, Garg A, Roy A, Bali P, et al. Coronary Artery Disease in Patients with Ischemic Stroke and TIA. J Stroke Cerebrovasc Dis. 2019 Dec;28(12):104400.
• ²
  Singh RJ, Chen S, Ganesh A, Hill MD. Long-term neurological, vascular, and mortality outcomes after stroke. Int J Stroke. 2018 Oct;13(8):787-96.
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  Adams RJ, Chimowitz MI, Alpert JS, Awad IA, Cerqueria MD, Fayad P, et al. American Heart Association/American Stroke Association. Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: a scientific statement for healthcare professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association. Stroke. 2003 Sep;34(9):2310-22.
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  Gunnoo T, Hasan N, Khan MS, Slark J, Bentley P, Sharma P. Quantifying the risk of heart disease following acute ischaemic stroke: a meta-analysis of over 50,000 participants. BMJ Open. 2016 Jan 20;6(1):e009535.
• ⁵
  Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990 Mar 15;15(4):827-32.
• ⁶
  Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff M, Fayad ZA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2010;56:e50–103.
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  Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al. European guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J. 2012;33(13):1635–701.
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  Goff DC Jr, Lloyd-Jones DM, Bennett G, D’Agostino RB, Gibbons R, Greenland P, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S49-73.
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  Sara L, Szarf G, Tachibana A, shiozaki AA. Villa AV, Oliveira AC,et al. Sociedade Brasileira de Cardiologia. II Diretriz de Ressonância Magnética e Tomografia Computadorizada Cardiovascular da Sociedade Brasileira de Cardiologia e do Colégio Brasileiro de Radiologia. Arq Bras Cardiol. 2014;103(6 Suppl 3):1–86.
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  Hecht H, Blaha MJ, Berman DS, Nazr K, Budoff M, Leipsic J, et al. Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr. 2017 Mar-Apr;11(2):157-68.
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  Conforto AB, Leite Cda C, Nomura CH, Bor-Seng-Shu E, Santos RD. Is there a consistent association between coronary heart disease and ischemic stroke caused by intracranial atherosclerosis? Arq Neuropsiquiatr. 2013 May;71(5):320-6.
• ¹²
  Negrão EM, Freitas MCDN, Marinho PBC, Hora TF, Montanaro VVA, Martins BJAF, et al. Escore de Cálcio Coronário e Estratificação do Risco de Doença Arterial Coronariana em Pacientes com Acidente Vascular Encefálico Isquêmico Aterosclerótico e não-Aterosclerótico. Arq Bras Cardiol. 2020; 115(6):1144-1151.
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  Lasek-Bal A, Kopyta I, Warsz-Wianecka A, Puz P, Łabuz-Roszak B, Zaręba K. Risk factor profile in patients with stroke at a young age. Neurol Res. 2018 Jul;40(7):593-9.
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  Lackland DT, Elkind MS, D’Agostino R Sr, Dhamoon MS, Goff Jr DC, Higashida RT, et al. American Heart Association Stroke Council; Council on Epidemiology and Prevention; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Quality of Care and Outcomes Research. Inclusion of stroke in cardiovascular risk prediction instruments: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012 Jul;43(7):1998-2027.
• ¹⁵
  McEvoy JW, Blaha MJ, Defilippis AP, Budoff MJ, Nasor K, Blumenthal RS, et al. Coronary artery calcium progression: an important clinical measurement? A review of published reports. J Am Coll Cardiol. 2010 Nov 9;56(20):1613-22.

• Short Editorial related to the article: Coronary Calcium Score and Stratification of Coronary Artery Disease Risk in Patients with Atherosclerotic and Non-Atherosclerotic Ischemic Stroke

Publication Dates

• Publication in this collection
  18 Jan 2021
• Date of issue
  Dec 2020