Regular paper
Effect of treatment on the incidence of stroke and other emboli in 519 patients with severe thoracic aortic plaque

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Abstract

Severe aortic plaques seen on transesophageal echocardiography (TEE) are a high-risk cause of stroke and peripheral embolization. Evidence to guide therapy is lacking. Retrospective information was obtained regarding the occurrence of embolic events (stroke, transient ischemic attacks, or peripheral emboli) in 519 patients with severe thoracic aortic plaque seen on TEE since 1988. Treatment with statins, warfarin, or antiplatelet medications was noted. Treatment was not randomized. In a matched-paired analysis, each patient taking each class of therapy was matched for age, gender, previous embolic event, hypertension, diabetes, congestive failure, and atrial fibrillation to someone not taking that medication. Multivariate analysis was also performed. An embolic event occurred in 111 patients (21%). Multivariate analysis showed that statin use was independently protective against recurrent events (p = 0.0001). Matched analysis also showed a protective effect of statins (p = 0.0004; absolute risk reduction 17%, relative risk reduction 59%, number needed to treat [n = 6]). No protective effect was found for warfarin or antiplatelet drugs. The odds ratio for embolic events was 0.3 (95% confidence interval [CI] 0.2 to 0.6) for statin therapy, 0.7 (95% CI 0.4 to 1.2) for warfarin, and 1.4 (95% CI 0.8 to 2.4) for antiplatelet agents. Thus, there is a protective effect of statin therapy, and no significant benefit of warfarin or antiplatelet drugs on the incidence of stroke and other embolic events in patients with severe thoracic aortic plaque on TEE.

Section snippets

Patient selection:

Between 1988 and 2000, there were 1,111 patients with severe thoracic aortic plaque seen on TEE in our laboratory. Severe plaque, defined as intimal thickness ≥4 mm, was found in the aortic arch (350 patients, 31%), descending aorta (also 350 patients, 31%), or both (396 patients, 36%). Severe plaque was seen in the ascending aorta in only 10 patients (1%). The patients were in- and outpatients who were referred for TEE because of embolic events (stroke, transient ischemic attack [TIA], or

Results

The group of 519 patients was followed for an average of 34 ± 26 months (range 1 to 126). The mean follow-up times for patients who took statins (37 ± 27 months) and those who took antiplatelet drugs (36 ± 28 months) were not significantly different (p = 0.78). Patients who received warfarin were followed for 32 ± 24 months, 6 fewer months than those who received statins (p = 0.027) and 5 fewer months than patients who received antiplatelet agents (p = 0.042).

A total of 111 embolic events (21%)

Why was there no significant protective effect of warfarin?

As noted, there have been 3 reports of a treatment benefit of warfarin versus aspirin (reduction in embolic stroke) in patients with severe thoracic aortic plaque on TEE. However, these were all small studies, containing only 31, 134, and 129 patients. Moreover, very few strokes were observed, only 3, 14, and 5, respectively.

The mechanism of stroke in patients with severe aortic plaques is likely to be plaque rupture, with subsequent thromboembolism.8, 9, 10 It is likely that warfarin does not

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    Participants in the NYU Atheroma Group are listed in the Appendix.

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