Author: Dr Nicolas Martinez-Majander
Affiliation: Clinical Neurosciences, Department of Neurology, University of Helsinki and Department of Neurology, Helsinki University Hospital, Finland
Original Article: Cordonnier C., Lemesle G., Casolla B., et al, 2018. Incidence and determinants of cerebrovascular events in outpatients with stable coronary artery disease. European Stroke Journal. doi: 10.1177/2396987318772684

In addition to recurrent myocardial infarctions, patients with stable coronary artery disease (CAD) possess also an increased risk of ischaemic stroke. Furthermore, more efficient antithrombotic strategies may predispose to bleeding complications such as intracranial haemorrhage.

In this issue of ESJ, the authors assessed the incidence of cerebrovascular events, the relative proportion of ischaemic stroke and intracranial haemorrhage, and predictors for both in the five-year CORONOR registry.

The authors included 4184 consecutive outpatients with CAD in the prospective multicentre CORONOR registry (2010-2011). Patients had a previous myocardial infarction (>one year ago), previous coronary revascularization (>one year ago), and/or obstruction of ≥50% of the luminal diameter of at least one native coronary vessel on coronary angiography. According to the protocol, follow-ups were performed at least at two years and at five years. All cerebrovascular events were then verified using CT or MRI as well as adjudicated by two investigators blinded to each other.

The cohort consisted mainly of men (78%) with a mean age of 66.9 ± 11.5 years. Altogether 4094 (98%) patients completed the five-year clinical follow-up. The authors reported that 96 patients had an ischaemic stroke and 34 had an intracranial haemorrhage, with a cumulative incidence of 2.4% (95% CI 1.9 to 2.9) and 0.9% (95% CI 0.6 to 1.2), respectively. The overall cumulative risk for all types of cardiovascular events was 3.2% (95% CI 2.7 to 3.8). Cardiovascular event-related mortality within 30 days was 15.6% (95% CI 9.0 to 24.5) for ischaemic stroke and 45.2% (95% CI 27.3 to 64.0) for intracranial haemorrhage. Predictors of ischaemic stroke included a previous history of stroke, the absence of statin therapy at inclusion, an increasing age, and diabetes mellitus. The risk of intracranial haemorrhage was higher in older patients and in those using a combination of anticoagulant and antiplatelet therapy.

Compared to intracranial haemorrhage, the incidence of ischaemic stroke in CAD patients was significantly higher, although intracranial haemorrhage remains the most disabling form of cerebrovascular disease. Elderly patients with coronary artery disease and a history of previous stroke or diabetes have the highest risk ischaemic stroke.

The take-home message is to always remember the risk of stroke in patients with coronary artery disease. Intensify secondary prevention in patients with high risk of ischaemic stroke and give the risk of intracranial haemorrhage associated with the combination of anticoagulation and antiplatelet therapy an extra thought. The authors conclude quite fittingly:
“In stable coronary artery disease, the brain deserves attention.”

References:
Cordonnier C., Lemesle G., Casolla B., et al, 2018. Incidence and determinants of cerebrovascular events in outpatients with stable coronary artery disease. European Stroke Journal. doi: 10.1177/2396987318772684