Opinion statement
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At least 20% of all ischemic strokes are cardioembolic.
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Cardiac conditions that cause cerebral embolism are classified as major or minor depending on whether the causal link has or has not been fully established between the underlying cardiac condition and the stroke.
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Atrial fibrillation, acute myocardial infarction, valvular heart disease, infective endocarditis, nonbacterial thrombotic endocarditis, and atrial myxoma are the main cardiac causes of cerebral embolism.
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Patent foramen ovale, atrial septal aneurysm, mitral valve prolapse, mitral annular calcification, calcific aortic stenosis, and mitral valve strands are cardiac conditions with a potential causal link to cerebral embolism, but until now, either they have been found to be poor predictors of recurrent stroke or their risk of recurrent stroke is unknown.
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The management of patients with a stroke of cardiac source is twofold: 1) treatment of the acute phase of stroke and 2) prophylactic treatment of recurrent thromboembolism. When possible, primary prevention of cerebral embolism should be recommended, particularly in cardiac conditions with known high risk of stroke (eg, atrial fibrillation, mitral stenosis, or presence of mechanical prosthetic heart valves).
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References and Recommended Reading
Cerebral Embolism Task Force: Cardiogenic brain embolism. Arch Neurol 1989, 46:727–743.
Wolf PA, Abbott RD, Kannel WB: Atrial fibrillation: a major contribution to stroke in elderly, the Framingham study. Arch Intern Med 1987, 147:1561–1564.
EAFT (European Atrial Fibrillation Trial) Study Group: Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet 1993, 342:1255–1262.
The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography: Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. Ann Intern Med 1998, 128:639–647. In this study of patients with AF, those with spontaneous echo contrast or thrombus in the left atrium had a risk of recurrent stroke of 7.5% per year; those with plaques of larger than 4 mm in the thoracic aorta had a risk of 12% per year; those who had both aortic plaques and left atrial echo contrast or thrombus had a risk of 20.5% per year; and those who had none of these abnormalities had a risk of 1.2% per year.
Stein PD, Alpert JS, Dalen JE, et al.: Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves. Chest 1998, 114:602S-610S. This is the report of the fifth American College of Chest Physicians consensus conference on recommendations for antithrombotic therapy in patients with mechanical and biologic prosthetic heart valves.
Salgado AV, Furlan AJ, Keys TF, et al.: Neurological complications of endocarditis: a 12-year experience. Neurology 1989, 39:173–178.
Hart RG, Foster JW, Luther MF, Kanter MC: Stroke in infective endocarditis. Stroke 1990, 21:695–700.
Boon A, Lodder J, Cheriex E, et al.: Risk of stroke in a cohort of 815 patients with calcification of the aortic valve with or without stenosis. Stroke 1996, 27:847–851.
Tunick PA, Perez JL, Kronson I: Protruding atheromas in the thoracic aorta and systemic embolization. Ann Intern Med 1991, 115:423–427.
Davila-Roman VG, Murphy SF, Nickerson NJ, et al.: Atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality. J Am Coll Cardiol 1999, 33:1308–1316.
Cabanes L, Mas JL, Cohen A, et al.: Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. Stroke 1993, 24:1865–1873.
Berthet K, Lavergne T, Cohen A, et al.: Significant association of atrial vulnerability with atrial septal abnormalities in young patients with ischemic stroke of unknown cause. Stroke 2000, 31:398–403.
Bogousslavsky J, Garazi S, Jeanrenaud X: Stroke recurrence in patients with patent foramen ovale: the Lausanne study. Neurology 1996, 46:1301–1305.
Mas JL, Zuber M: Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or TIA. French Study on Patent Foramen Ovale and Atrial Septal Aneurysm. Am Heart J 1995, 130:1083–1088.
Lee RJ, Bartzokis T, Yeoh TK: Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography. Stroke 1991, 22:734–739.
Cohen A, Tzourio C, Chauvel C, et al.: Mitral valve strands and the risk of ischemic stroke in elderly patients. Stroke 1997, 28:1574–1578.
Gilon D, Buonanno FS, Joffre MM, et al.: Lack of evidence of an association between mitral-valve prolapse and stroke in young patients. N Engl J Med 1999, 341:8–13.
Orencia AJ, Petty GW, Khandheria BK, et al.: Mitral valve prolapse and the risk of stroke after initial cerebral ischemia. Neurology 1995, 45:1083–1086.
Freed LA, Levy D, Levine RA, et al.: Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med 1999, 341:1–7.
Timsit S, Sacco R, Mohr J, et al.: Early clinical differentiation of cerebral infarction from severe atherosclerotic stenosis and cardioembolism. Stroke 1992, 23:486–491.
Collins R, MacMahon S, Flather M, et al.: Clinical effects of anticoagulant therapy in suspected acute myocardial infarction: systematic overview of randomised trials. BMJ 1996, 313:652–656.
Turpie A, Robinson J, Doyle D, et al.: Comparison of high-dose with low-dose subcutaneous heparin to prevent left ventricular mural thrombosis in patients with acute transmural anterior myocardial infarction. N Engl J Med 1989, 320:352–357.
The SCATI (Studio sulla Calciparina nell’Angina e nella Trombosi Ventricolare nell’Infarto) group: Randomised controlled trial of subcutaneous calcium-heparin in acute myocardial infarction. Lancet 1989, 2:182–186.
Kontny F, Dale J, Abildgaard U, Pedersen TR: Randomized trial of low molecular weight heparin (dalteparin) in prevention of left ventricular thrombus formation and arterial embolism after acute anterior myocardial infarction: the Fragmin in Acute Myocardial Infarction (FRAMI) Study. J Am Coll Cardiol 1997, 30(4):962–969.
Ginsberg JS, Hirsh J: Use of antithrombotic agents during pregnancy. Chest 1998, 114:524S-530S.
Stroke Prevention in Atrial Fibrillation Investigators: Adjusted-dose warfarin versus low-intensity, fixeddose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet 1996, 348:633–638.
The European Atrial Fibrillation Trial Study Group: Optimal oral anticoagulant therapy in patients with nonrheumatic atrial fibrillation and recent cerebral ischemia. N Engl J Med 1995, 333:5–10.
Stein PD, Grandison D, Hua TA, et al.: Therapeutic levels of oral anticoagulation with warfarin in patients with mechanical heart valves: review of the literature and recommendations based on international normalized ratio. Postgrad Med J 1994, 70(suppl 1):S72-S83.
Cappalleri JC, Fiore L, Brophy M, et al.: Efficacy and safety of combined anticoagulant and antiplatelet therapy versus anticoagulant monotherapy after mechanical heart-valve replacement: a meta-analysis. Am Heart J 1995, 130:547–552.
Meschengieser SS, Carlos GF, Santarelli MT, et al.: Low intensity oral anticoagulation plus low-dose aspirin versus high-intensity anticoagulation alone: a randomized trial in patients with mechanical prosthetic heart valves. J Thorac Cardiovasc Surg 1997, 113:910–916.
Coumadin Aspirin Reinfarction Study (CARS) Investigators: Randomised double-blind trial of fixed low-dose warfarin with aspirin after myocardial infarction. Lancet 1997, 350:389–396.
Collaborative overview of randomized trials of antiplatelet therapy: I. Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists’ Collaboration. BMJ 1994, 308:81–106. The Antiplatelet Trialists’ Collaboration has shown by metaanalysis that in high-risk patients (with previous vascular occlusive disease), antiplatelet agents reduce by one third the risk of nonfatal stroke.
Stroke Prevention in Atrial Fibrillation Investigators: Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: stroke prevention in atrial fibrillation II study. Lancet 1994, 343:687–691.
Petty GW, Brown RD, Whisnant JP, et al.: Frequency of major complications of aspirin, warfarin, and intravenous heparin for secondary stroke prevention. A population-based study. Ann Intern Med 1999, 130:14–22. This is a population-based study demonstrating that the complication rate with warfarin therapy is much higher than in randomized clinical trials (7.9 per 100 person-years).
Hirsh J, Dalen JE, Anderson DR, et al.: Oral anticoagulants. Mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest 1998, 114:445S-469S. This article lists the recommendations of the fifth American College of Chest Physicians consensus conference on the use of oral anticoagulants.
Eckman MH, Levine HJ, Salem DN, et al.: Making decisions about antithrombotic therapy in heart disease: decision analytic and cost-effectiveness issues. Chest 1998, 114:699S-714S.
Patrono C, Coller BS, Dalen JE, et al.: Platelet active drugs: the relationships among dose, effectiveness, and side effects. Chest 1998, 114:470S-488S. This article lists the recommendations of the fifth American College of Chest Physicians consensus conference on the use of platelet active drugs.
Tornos P, Almirante B, Mirabet S, et al.: Infective endocarditis due to Staphylococcus aureus: deleterious effect of anticoagulant therapy. Arch Intern Med 1999, 159:473–475.
Hung J, Landzberg MJ, Jenkins KJ, et al.: Transcatheter closure of patent foramen ovale for presumed paradoxical emboli: low incidence of recurrent neurologic events at intermediate term follow-up [abstract]. Circulation 1998, 98:I100.
Ugurlu BS, Dearani JA, Daly RC, et al.: Surgical patent foramen ovale closure for prevention of paradoxical embolism induced cerebrovascular events [abstract]. Circulation 1998, 98:I100.
Amarenco P, Cohen A, Tzourio C, et al.: Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 1994, 331:1474–1479.
Amarenco P, Duyckaerts C, Tzourio C, et al.: The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med 1992, 326:221–225. This case-control study showed that plaques greater than 4 mm in thickness, ulcerated plaques, and those with mobile components are more likely to be associated with stroke.
Jones EF, Kalman JM, Calafiore P, et al.: Proximal aortic atheroma: an independent risk factor for cerebral ischemia. Stroke 1995, 26:218–224.
Mittusch R, Doherty C, Wucherpfennig H, et al.: Vascular events during follow-up in patients with aortic arch atherosclerosis. Stroke 1997, 28:36–39.
The French Study of Aortic Plaques in Stroke Group: Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med 1996, 334:1216–1221.
Cohen A, Tzourio C, Bertrand B, et al.: Aortic plaque morphology and vascular events. A follow-up study in patients with ischemic stroke. Circulation 1997, 96:3838–3841. This case-control study has shown that plaques greater than 4 mm in thickness, when hypoechoic and noncalcified, are more likely to be associated with stroke.
Tunick PA, Rosenzweig BP, Katz ES, et al.: High risk for vascular events in patients with protruding aortic atheromas: a prospective study. J Am Coll Cardiol 1994, 23:1085–1090.
Dressler FA, Craig WR, Castello R, Labowitz AJ: Mobile aortic atheroma and systemic emboli: efficacy of anticoagulation and influence of plaque morphology on recurrent stroke. J Am Coll Cardiol 1998, 31:134–138.
Ferrari E, Vidal R, Chevallier T, Baudouy M: Atherosclerosis of the thoracic aorta and aortic debris as a marker of poor prognosis: benefit of oral anticoagulants. J Am Coll Cardiol 1999, 33:1317–1322.
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Vahedi, K., Amarenco, P. Cardiac causes of stroke. Curr Treat Options Neurol 2, 305–317 (2000). https://doi.org/10.1007/s11940-000-0048-4
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DOI: https://doi.org/10.1007/s11940-000-0048-4