Published Online
on October 27, 2005

A more recent version of this article appeared on December 1, 2005

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Submitted on June 7, 2005
Revised on September 4, 2005
Accepted on September 26, 2005

Mitral Annular Calcification, Aortic Valve Sclerosis, and Incident Stroke in Adults Free of Clinical Cardiovascular Disease. The Strong Heart Study

Jorge R. Kizer MD, MSc^*; David O. Wiebers MD; Jack P. Whisnant MD; James M. Galloway MD; Thomas K. Welty MD; Elisa T. Lee PhD; Lyle G. Best MD; Helaine E. Resnick PhD, MPH; Mary J. Roman MD; and Richard B. Devereux MD

From the Departments of Medicine (J.R.K., M.J.R., R.B.D.) and Public Health (J.R.K.), Weill Medical College of Cornell University, New York, NY; Division of Cerebrovascular Diseases (D.O.W., J.P.W.), Department of Neurology, Mayo Clinic and Mayo Foundation, Rochester, Minn; University of Arizona Health Sciences Center (J.M.G.), Tucson, Ariz; Missouri Breaks Industries Research (T.K.W., L.G.B.), Timber Lake, SD; School of Public Health (E.T.L.), University of Oklahoma Health Sciences Center, Oklahoma City; and Department of Epidemiology and Biostatistics (H.E.R.), MedStar Research Institute, Washington, DC.

^* To whom correspondence should be addressed. E-mail: jok2007{at}med.cornell.edu.

Background and Purpose--Mitral annular calcification (MAC) and aortic valve (AV) sclerosis have each been linked to cardiovascular disease. Whether MAC and AV sclerosis are risk factors for stroke independent of other echocardiographic or laboratory predictors has not been established. We evaluated the relationship between MAC, AV sclerosis, and first stroke events in a population-based cohort.

Methods--Our study cohort consisted of 2723 American Indians participating in the Strong Heart Study who were free of prevalent cardiovascular disease. Participants underwent standardized clinical, echocardiographic, and laboratory evaluation, and incident stroke was ascertained using validated methods.

Results--During a median follow-up of 7 years, 86 strokes occurred. Age- and sex-adjusted incidence rates of stroke were significantly increased for MAC (rate ratio [RR], 3.12; 95% CI, 1.77 to 5.25) but not for AV sclerosis (RR, 1.15; 95% CI, 0.45 to 2.49). MAC was also associated with a reduced time to first stroke events after adjustment for clinical variables and the inflammatory markers C-reactive protein and fibrinogen (hazard ratio [HR], 2.42; 95% CI, 1.39 to 4.21) or the echocardiographic covariates left ventricular hypertrophy and left atrial enlargement (HR, 1.89; 95% CI, 1.04 to 3.41). Individuals with and without AV sclerosis showed no significant difference in stroke-free survival in unadjusted analyses (P=0.698). Crossing of the survival curves precluded multivariable analysis using Cox models.

Conclusions--In this cohort of American Indians without clinical cardiovascular disease, the presence of MAC, but not AV sclerosis, proved to be a strong risk factor for incident stroke after extensive adjustment for other predictors. Individuals exhibiting MAC may benefit from aggressive risk factor modification, but this will require further investigation.

Key words: calcium • echocardiography • heart valves • stroke

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