Aortic Atheroma & Stroke

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What is a complex aortic arch plaque?

Thickness >4 mm

- Presence of ulcer or mobile components

- Lack of calcification

- Did you know that mobile component is usually thrombus superimposed on the plaque which has presumably ruptured?

How common you will see me?

- 2-14% of patients with stroke or peripheral embolization have aortic
atherosclerosis.

- This number might be underestimated because of what is currently seen
might be the small residual.

- 35% of patients with Afib also have aortic atheroma.

- Complex plaque is associated with higher stroke (15.8% vs 8%Vs
1.2%) (vs simple plaque vs no plaque) from SPAF III trial.

- Patients with plaque ≥4 mm have 3-4 fold higher risks of recurrent
stroke compare to <4 mm.

Look deep within plaque, you will see lipid pool, smooth muscle cell
and mononuclear cell infiltration and varying degrees of calcification.

Look at me deeply

- Look deep within plaque, you will see lipid pool, smooth muscle celland mononuclear cell infiltration and varying degrees of calcification.

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Looking for me?

- Please reach me by TEE, you will see mobile plaque at ascending and
descending aorta best by TEE.

What to do, what to do?

Dual antiplatelet therapy plus high-intensity statin therapy is
warranted for

 - Patients with stroke with complex aortic plaque

 - Or patients without stroke, but atheroma with a mobile component.

- Since simple plaque < 4 mm without a mobile component or diffuse atheromatous plaques (shaggy aorta) is controversial, Aspirin or Plavix alone with statin.

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ARCH trial

349 patients, median follow up 3.4 years, the primary event rate <3%/year.

The trial stopped early because of no funding (target was 372 per each arm) and unexpected low event rates. Vascular death was higher in warfarin group (0% vs 3.4%) (p=0.013), but this could happen by chance because the number of subjects did
not meet the numbers required to perform the first interim futility analysis.

ARCH trial

No significant in major hemorrhage complication 2.3% (DAPT) vs 3.4% (warfarin).

Warfarin has more bleeding risk, but whether DAPT is better than single antiplatelet, we can’t conclude from ARCH trial. DAPT is better than single antiplatelet…we need more studies. ☹ Stroke. 2014;45:1239-1240

 

Prognosis

Mortality is about 20% within 3 years. 20% of mortality is from stroke.