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Stroke in patients with aortic stenosis: the Simvastatin and Ezetimibe in Aortic Stenosis study
Anders M Greve1, Morten Dalsgaard2, Casper N Bang2
1From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department of Cardiology, Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany (C.G.-B.); Department of Cardiology, Weill Cornell Medical College, New York, NY (R.B.D., K.W.); and Department of Cardiology, Glostrup University Hospital, Copenhagen, Denmark (K.W.). greve_anders@outlook.com.
Insights
Stroke risk in aortic stenosis is significant, especially after aortic valve replacement (AVR) combined with coronary artery bypass grafting (CABG). Atrial fibrillation and CHA2DS2-VASc scores are key predictors, and stroke increases mortality risk.
Area of Science:
- Cardiology
- Neurology
- Clinical Medicine
Background:
- Aortic stenosis (AS) poses a risk for stroke, but data on risk stratification are limited.
- The Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study provides a cohort for investigating stroke in AS.
- Exclusion criteria included diabetes mellitus, known atherosclerotic disease, and oral anticoagulation use.
Purpose of the Study:
- To identify predictors of stroke in patients with aortic stenosis.
- To evaluate the prognostic implications of stroke in this population.
- To assess the impact of aortic valve replacement (AVR), with or without coronary artery bypass grafting (CABG), on stroke risk and outcomes.
Main Methods:
- Analysis of patients from the SEAS study with mild-to-moderate aortic stenosis.
- Ischemic stroke was the primary endpoint; post-stroke survival was a secondary outcome.
- Cox models were used, treating AVR as a time-varying covariate and adjusting for CHA2DS2-VASc score components.
Main Results:
- Stroke rates were 5.6 per 1000 patient-years before AVR and 21.8 per 1000 patient-years after AVR.
- Independent predictors of stroke included atrial fibrillation, CHA2DS2-VASc score, diastolic blood pressure, and AVR with concomitant CABG.
- Incident stroke was a strong predictor of mortality (HR, 8.1; P<0.001).
Conclusions:
- Atrial fibrillation, CHA2DS2-VASc score, and AVR with concomitant CABG are major stroke predictors in AS patients not on oral anticoagulation.
- Stroke following aortic stenosis management is associated with significantly increased mortality.
- Risk stratification and targeted interventions are crucial for improving outcomes in AS patients.
Background And Purpose:
There are limited data on risk stratification of stroke in aortic stenosis. This study examined predictors of stroke in aortic stenosis, the prognostic implications of stroke, and how aortic valve replacement (AVR) with or without concomitant coronary artery bypass grafting influenced the predicted outcomes.
Methods:
Patients with mild-to-moderate aortic stenosis enrolled in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Diabetes mellitus, known atherosclerotic disease, and oral anticoagulation were exclusion criteria. Ischemic stroke was the primary end point, and poststroke survival a secondary outcome. Cox models treating AVR as a time-varying covariate were adjusted for atrial fibrillation and congestive heart failure, hypertension, age≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years and female sex (CHA2DS2-VASc) scores.
Results:
One thousand five hundred nine patients were followed for 4.3±0.8 years (6529 patient-years). Rates of stroke were 5.6 versus 21.8 per 1000 patient-years pre- and post-AVR; 429 (28%) underwent AVR and 139 (9%) died. Atrial fibrillation (hazard ratio [HR], 2.7; 95% confidence interval [CI], 1.1-6.6), CHA2DS2-VASc score (HR 1.4 per unit; 95% CI, 1.1-1.8), diastolic blood pressure (HR, 1.4 per 10 mm Hg; 95% CI, 1.1-1.8), and AVR with concomitant coronary artery bypass grafting (HR, 3.2; 95% CI, 1.4-7.2, all P≤0.026) were independently associated with stroke. Incident stroke predicted death (HR, 8.1; 95% CI, 4.7-14.0; P<0.001).
Conclusions:
In patients with aortic stenosis not prescribed oral anticoagulation, atrial fibrillation, AVR with concomitant coronary artery bypass grafting, and CHA2DS2-VASc score were the major predictors of stroke. Incident stroke was strongly associated with mortality.
Clinical Trial Registration Url:
http://www.clinicaltrials.gov. Unique identifier: NCT00092677.
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