Cerebral embolism and complex aortic plaques: Secondary prevention
Background: After a cerebral embolic event, complex plaques in the proximal aorta constitute an important finding by transesophageal echocardiography (TEE). Yet, there is no consensus regarding its optimal treatment, and we studied the short-term outcome in this group of patients. Method: Between August 1995 and August 1998, 424 patients were examined with TEE after a suspected cerebral embolic event. We re-evaluated the 94 examinations with any plaques noticed in the proximal aorta and reviewed the medical charts for previous embolic events, diabetes, hypertension, ischemic heart disease, ECG, laboratory findings, antithrombotic treatment and outcome (mean follow-up time 19 months). Results: Of 94 patients with any plaques in the proximal aorta, 75 were complex (protruded more than 4 mm or had a mobile component), and 55 of these were finally diagnosed as having suffered cerebral embolism. After exclusion of 8 patients with atrial fibrillation, 47 patients constituted the study group. As secondary prevention, 32 and 15 patients were on antiplatelets and oral anticoagulation, respectively, at event or end of follow-up. In the antiplatelet group (A), 8 of 32 patients (25%) suffered a new cerebral embolic episode vs. none in the anticoagulant group (B) (p=0.03). Mean time to recurrent embolism was 10 months. No hemorrhagic stroke or other important bleeding occurred during follow-up. Leukocyte count was slightly higher in group A (8.7±2.4 vs. 7.2 ± 1.9× 109/L, p=0.04), no other significant difference was found between groups A and B regarding mean age (64 vs. 67 years), systolic blood pressure (171±32 vs. 166±23mmHg, p=0.60), left atrial size (17.9±4.0 vs. 19.0±5.0 cm2, p=0.42), hemoglobin conc. (143±15 vs. 140±14 g/L, p=0.53), S-cholesterol (5.9±1.5 vs. 6.5±1.2 mmol/L, p=0.23), S-triglycerides (1.9±1.0 vs. 2.0±1.1 mmol/L, p=0.70), history of diabetes, ischemic heart disease, hypertension or smoking. Conclusion: Complex plaques in the proximal aorta are frequently found in patients with cerebral embolism. Our study indicates that these patients benefit from oral anticoagulation, while treatment with antiplatelets is associated with a high incidence of recurrent embolism.