Coronary Calcium Score for the Prediction of Asymptomatic Coronary Artery Disease in Patients With Ischemic Stroke

The first question to ask your stroke hospital. Do they have anyone in charge of research analysis and creation of stroke interventions from such research? IF NOT, THEY ARE COMPLETELY INCOMPETENT AND HAVE NO BUSINESS BEING A STROKE HOSPITAL.

Coronary Calcium Score for the Prediction of Asymptomatic Coronary Artery Disease in Patients With Ischemic Stroke

Hye-Yeon Choi¹, Soo Jeong Shin², Joonsang Yoo^2,3, Kijeong Lee⁴, Dongbeom Song², Young Dae Kim², Hyo Suk Nam², Kyung Yul Lee², Hye Sun Lee⁵, Dong Joon Kim⁶ and Ji Hoe Heo^2,7*

• ¹Department of Neurology, Kyung Hee University College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
• ²Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
• ³Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
• ⁴Department of Neurology, College of Medicine, Eunpyeong St. Mary Hospital, Catholic University of Korea, Seoul, South Korea
• ⁵Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, South Korea
• ⁶Department of Radiology, Yonsei University College of Medicine, Seoul, South Korea
• ⁷Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea

Purpose: 

Many patients with ischemic stroke have concomitant coronary artery disease (CAD). However, it remains unclear which stroke patients should undergo evaluation for asymptomatic CAD, and which screening tools are appropriate. We investigated the role of coronary artery calcium (CAC) score as a screening tool for asymptomatic but severe CAD in acute stroke patients. We determined the selection criteria for CAC screening based on risk factors and cerebral atherosclerosis.

Materials and Methods: 

The present study included consecutive patients with acute stroke who had undergone cerebral angiography and multi-detector computed tomography coronary angiography. Severe CAD was defined as left main artery disease or three-vessel disease. Enrolled patients were randomly assigned to two sets; a set for developing selection criteria and a set for validation. To develop selection criteria, we identified associated factors with severe CAD regarding clinical factors and cerebral atherosclerosis. CAD predictability of selection criteria with the CAC score was calculated.

Results: 

Overall, 2,658 patients were included. Severe CAD was present in 360 patients (13.5%). CAC score was associated with CAD severity (P < 0.001). In the development set (N = 1,860), severe CAD was associated with age >65 years [odds ratio (95% confidence interval), 2.62 (1.93–3.55)], male sex (1.81 [1.33–2.46]), dyslipidemia (1.77 [1.25–2.61]), peripheral artery disease (2.64 [1.37–5.06]) and stenosis in the cervicocephalic branches, including the internal carotid (2.79 [2.06–3.78]) and vertebrobasilar arteries (2.08 [1.57–2.76]). We determined the combination of clinical and arterial factors as the selection criteria for CAC evaluation. The cut-off criterion was two or more elements of the selection criteria. The area under the curve (AUC) of the selection criteria was 0.701. The AUC significantly improved to 0.836 when the CAC score was added (P < 0.001). In the validation set (N = 798), the AUC of the selection criteria only was 0.661, and that of the CAC score was 0.833. The AUC of the selection criteria + CAC score significantly improved to 0.861(P < 0.001).

Conclusion: 

The necessity for CAC evaluation could be determined based on the presence of risk factors and significant stenosis of the cervicocephalic arteries. CAC evaluation may be useful for screening for severe CAD in stroke patients.

Introduction

Ischemic heart disease is the leading cause of long-term mortality in patients with stroke (1). The annual risk of myocardial infarction in patients with ischemic stroke is ~2.2% (1, 2). The presence and extent of asymptomatic stenosis in coronary angiography is strongly predictive of major cardiovascular events. Previous studies identified significant (≥50%) stenosis of the coronary artery in 20–41% of patients with stroke via autopsy, coronary angiography, or multi-detector computed tomography angiography (MDCTA) (3–7). Therefore, coronary screening may be necessary for stroke patients at high risk of coronary artery disease (CAD). However, it still remains uncertain which group of patients with stroke should undergo evaluation for asymptomatic CAD, and which evaluation tools are most appropriate for coronary screening in such patients.

Atherosclerosis is a systemic disease and CAD shares several risk factors with cerebral atherosclerosis (8). In fact, previous studies have demonstrated a significant association between CAD and atherosclerosis of the cervicocephalic arteries including the vertebrobasilar artery (VBA) and carotid arteries (4, 6, 9, 10). These findings suggest that CAD may be predicted to some extent by the presence of cerebral atherosclerosis and vascular risk factors.

Previous studies have indicated that coronary artery calcium (CAC) is superior to risk factor-based prediction of CAD and coronary events (11–14). Additionally, other studies reported that CAC scores are associated with the severity of CAD (15). In a large prospective population cohort registry, the risk of coronary events increased as the CAC score increased (12). This study aimed to investigate the role of the CAC score as a screening tool for the diagnosis of asymptomatic but severe CAD in patients with acute stroke. We also sought to determine the selection criteria for CAC screening in patients with stroke based on the presence of risk factors and cerebral atherosclerosis.

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