Coronary risk stratification in patients with ischemic stroke or transient ischemic stroke attack

The risk of coronary artery disease (CAD) is traditionally considered high in patients who had an ischemic stroke or a transient ischemic attack (TIA). However, few studies have specifically assessed the absolute risk of coronary events in those patients and predictors of such events are not well known.

The overall risks of myocardial infarction and nonstroke vascular death are each around 2% per year. However, those risks are only about 1% per year in patients without CAD (i.e. the only ones who are likely to benefit from specific additional strategies). The prevalence of asymptomatic CAD ranges from 15% to 60%. Although potentially higher, the risk of CAD in patients with stroke/TIA related to atherosclerosis also seems to vary widely depending on the extent of the disease. Given the relatively low CAD risk, a simple systematic reinforcement of medical treatment in all patients may be not relevant. Up to now, there have been only limited ways to stratify the CAD risk in stroke/TIA patients. High-risk patients may be identified using the traditional cardiac scoring systems, but their validity has never been specifically assessed in stroke populations. The relative influence of traditional risk factors may be altered after a first vascular event. Stroke patients could also be screened for asymptomatic CAD. However, there is no simple and valid screening test for asymptomatic CAD that could be applied to all patients. Finally, there is still uncertainty about the potential benefits of treating asymptomatic CAD. Therefore, should the identification of patients with asymptomatic CAD requiring revascularization become feasible, the relevance of this strategy would remain to be evaluated by a randomized clinical trial.

The absolute risk of CAD in stroke/TIA patients is moderately high. More research is needed to identify high risk patients who could benefit from specific strategies.