Prevalence of Systemic Atherosclerosis Burdens and Overlapping Stroke Etiologies and Their Associations With Long-term Vascular Prognosis in Stroke With Intracranial Atherosclerotic Disease
Prevalence of Systemic Atherosclerosis Burdens and Overlapping Stroke Etiologies and Their Associations With Long-term Vascular Prognosis in Stroke With Intracranial Atherosclerotic Disease
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DOI：
10.1001/jamaneurol.2017.3960
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发表时间：
2018-02-01
期刊：
影响因子：
29
通讯作者：
Amarenco, Pierre
中科院分区：
文献类型：
--
作者：
Hoshino, Takao;Sissani, Leila;Amarenco, Pierre
重要提示发生脑卒中伴颅内动脉粥样硬化性疾病（ICAD）的患者也可能在不同动脉床中伴有动脉粥样硬化和其他可能的缺血性卒中原因。然而，对这种重叠疾病的频率和预后影响知之甚少。目的描述系统性动脉粥样硬化负担和重叠卒中病因的患病率及其对经历过ICAD卒中的患者的长期预后的影响。和参与者中风和动脉粥样硬化疾病中的无症状心肌缺血研究是一项单一的-一项中心前瞻性研究，在2005年6月至2008年12月期间连续招募了405例发病10天内的急性缺血性卒中患者，并随访了4年。由于检查不完整而排除了2名患者后，本分析纳入了403名患者。主要结果和指标通过对比度增强/飞行时间磁共振血管造影、计算机断层扫描血管造影和/或经颅多普勒超声检查，将严重ICAD定义为狭窄/闭塞达到50%或以上。对动脉粥样硬化性疾病进行了系统的血管检查，包括颈动脉、主动脉和股动脉的超声检查和冠状动脉的血管造影。使用动脉粥样硬化、小血管疾病、心脏病理学、其他原因和夹层（ASCOD）分级系统评估共存的卒中病因。我们估计了主要不良心血管事件（MACE）的4年风险，包括血管性死亡，非致命性心脏事件，非致命性卒中和主要外周动脉事件。结果在403名参与者中，298名（74%）为男性，平均（SD）年龄为62.6（13.1）岁。146例（36.2%）发现明显的ICAD。与无明显ICAD的患者相比，有明显ICAD的患者更常出现主动脉弓（70 [60.9%] vs 99 [49.0%]; P = 0.04）和冠状动脉（103 [76.9%] vs 153 [63.2%]; P = 0.007）粥样硬化。在ICAD患者中，颅外颈动脉（24 [23.4%] vs 3 [9.0%]; P = 0.08;校正风险比[aHR] = 2.12）和冠状动脉（19 [29.9%] vs 8 [12.8%]; P = 0.01; aHR = 1.90）并发狭窄增加了MACE风险。此外，患有ICAD的患者也有任何心脏病理学（ASCOD等级C1-3），其MACE风险高于其他患者（等级C 0）（20 [28.2%] vs 7 [11.4%]; P = 0.01; aHR = 2.24）。相比之下，患有任何形式的小血管疾病的ICAD患者（S1-3级）的MACE风险低于没有（S 0级）（20 [17.3%] vs 6 [34.6%]; P = .05; aHR = 0.23）。结论和相关性ICAD患者通常同时存在全身性动脉粥样硬化和多种潜在的卒中机制，提示对重叠疾病的广泛评估可能允许更好的风险分层。
IMPORTANCE Patients who have experienced stroke with intracranial atherosclerotic disease (ICAD) may also have concomitant atherosclerosis in different arterial beds and other possible causes for ischemic stroke. However, little is known about the frequency and prognostic effect of such overlapping diseases.OBJECTIVES To describe the prevalence of systemic atherosclerotic burdens and overlapping stroke etiologies and their contributions to long-term prognoses among patients who have experienced stroke with ICAD.DESIGN, SETTING, AND PARTICIPANTS The Asymptomatic Myocardial Ischemia in Stroke and Atherosclerotic Disease study is a single-center prospective study in which 405 patients with acute ischemic stroke within 10 days of onset were consecutively enrolled between June 2005 and December 2008 and followed up for 4 years. After excluding 2 patients because of incomplete investigations, 403 were included in this analysis.MAIN OUTCOMES AND MEASURES Significant ICAD was defined as having 50% or greater stenosis/occlusion by contrast-enhanced/time-of-flight magnetic resonance angiography, computed tomography angiography, and/or transcranial Doppler ultrasonography. Systemic vascular investigations on atherosclerotic disease were performed with ultrasonography in carotid arteries, aorta and femoral arteries, and by angiography in coronary arteries. Coexistent stroke etiologies were assessed using the atherosclerosis, small-vessel disease, cardiac pathology, other cause, and dissection (ASCOD) grading system. We estimated the 4-year risk of major adverse cardiovascular events (MACE), including vascular death, nonfatal cardiac events, nonfatal stroke, and major peripheral arterial events.RESULTS Of 403 participants, 298 (74%) were men and the mean (SD) age was 62.6 (13.1) years. Significant ICAD was found in 146 (36.2%). Patients with significant ICAD more often had aortic arch (70 [60.9%] vs 99 [49.0%]; P = .04) and coronary artery (103 [76.9%] vs 153 [63.2%]; P = .007) atherosclerosis than those without. Among patients with ICAD, concurrent stenosis in the extracranial carotid artery (24 [23.4%] vs 3 [9.0%]; P = .08; adjusted hazard ratio[aHR] = 2.12) and the coronary artery (19 [29.9%] vs 8 [12.8%]; P = .01; aHR = 1.90) increased the MACE risk. Furthermore, patients with ICAD who also had any cardiac pathology (ASCOD grade C1-3) were at a higher MACE risk than others (grade C0) (20 [28.2%] vs 7 [11.4%]; P = .01; aHR = 2.24). By contrast, patients with ICAD with any form of small vessel disease (grade S1-3) had a lower MACE risk than those without (grade S0) (20 [17.3%] vs 6 [34.6%]; P = .05; aHR = 0.23).CONCLUSIONS AND RELEVANCE Patients with ICAD often have coexisting systemic atherosclerosis and multiple potential stroke mechanisms that affect their prognosis, suggesting that extensive evaluations of overlapping diseasesmay allow better risk stratification.