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Asymptomatic coronary artery disease in ischaemic stroke survivors: A systematic review and meta-analysis
Rahul G Muthalaly1, Timothy B Abrahams1, Nitesh Nerlekar1
1Victorian Heart Institute, Monash University, Clayton, VIC, Australia.
Insights
Asymptomatic coronary artery disease (CAD) is prevalent in ischaemic stroke survivors. The presence and severity of this CAD significantly increase the risk of future major adverse cardiovascular events (MACE).
Area of Science:
- Cardiovascular Medicine
- Neurology
- Epidemiology
Background:
- Ischaemic stroke and coronary artery disease share common risk factors, leading to a high incidence of cardiac events in stroke survivors.
- A significant burden of undiagnosed coronary artery disease (CAD) exists among individuals who have experienced ischaemic stroke.
Approach:
- A systematic review and meta-analysis were conducted following PRISMA guidelines.
- Included studies focused on acute ischaemic stroke or transient ischaemic attack patients with anatomical coronary artery assessments.
- Risk of bias was assessed using the Newcastle-Ottawa Scale, with random-effects modeling employed for analyses.
Key Points:
- The pooled prevalence of any coronary atherosclerosis among ischaemic stroke survivors without known CAD was 66.8%.
- Obstructive stenosis (>50%) was found in 29.3% of survivors, and high-risk coronary anatomy in 7.0%.
- The presence of obstructive CAD was associated with an 8-fold increased risk of future major adverse cardiovascular events (MACE).
Conclusions:
- Asymptomatic coronary artery disease is highly prevalent in ischaemic stroke survivors.
- The extent and severity of asymptomatic CAD are strongly linked to the risk of future major adverse cardiovascular events.
- Routine coronary assessment in ischaemic stroke survivors warrants further investigation for potential benefits.
Background:
Ischaemic stroke and coronary artery disease share risk factors and stroke survivors experience a high rate of cardiac events. Recent work suggests a high burden of asymptomatic coronary artery disease (CAD) in ischaemic stroke survivors. Thus, we performed this systematic review and meta-analysis to A) estimate the prevalence of CAD in ischaemic stroke survivors without known CAD and B) evaluate the association between coronary atherosclerosis and future major adverse cardiovascular events (MACE) in stroke survivors.
Patients And Methods:
We conducted a systematic review and meta-analysis according to the PRISMA statement. We included studies investigating acute ischaemic stroke or transient ischaemic attack where participants underwent anatomical assessment of all coronary arteries. For objective B) we included studies that reported an association between coronary atherosclerosis and MACE. Two reviewers used the Newcastle-Ottawa Scale to assess risk of bias. We used random-effects modelling for our analyses.
Results:
We identified 2983 studies of which 17 were included. These studies had a total of 6862 participants between 2008 and 2022. The pooled prevalence of any coronary atherosclerosis was 66.8% (95% CI 57.2%-75.1%) with substantial heterogeneity (I2 = 95.2%). The pooled prevalence of obstructive (>50%) stenosis was 29.3% with substantial heterogeneity (I2 = 91%). High-risk coronary anatomy (triple vessel disease or left main stenosis) was found in 7.0% (95% CI 4%-12%) with high heterogeneity I2 = 72%. One study examined high-risk plaques and found a prevalence of 5.9%. Five studies reported the association of coronary atherosclerosis with future MACE. The presence of obstructive CAD confers a HR of 8.0 (95% CI 1.7-37.1, p = 0.007) for future MACE.
Discussion And Conclusions:
Asymptomatic CAD is common in ischaemic stroke survivors. The presence and severity of asymptomatic CAD strongly associates with the risk of future MACE. Further evaluation of the benefits of routine coronary assessment in ischaemic stroke is warranted.
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