Capmany Ramón Pujadas, Ibañez Montserrat Oliveras, Pesquer Xavier Jané
Department of Cardiology, Hospital Universitari del Sagrat Cor, Address: Viladomat 288, E-08027 Barcelona, Spain.
Curr Cardiol Rev. 2010 Aug;6(3):184-93. doi: 10.2174/157340310791658712.
In many stroke patients it is not possible to establish the etiology of stroke. However, in the last two decades, the use of transesophageal echocardiography in patients with stroke of uncertain etiology reveals atherosclerotic plaques in the aortic arch, which often protrude into the lumen and have mobile components in a high percentage of cases. Several autopsy series and retrospective studies of cases and controls have shown an association between aortic arch atheroma and arterial embolism, which was later confirmed by prospectively designed studies. The association with ischemic stroke was particularly strong when atheromas were located proximal to the ostium of the left subclavian artery, when the plaque was ≥ 4 mm thick and particularly when mobile components are present. In these cases, aspirin might not prevent adequately new arterial ischemic events especially stroke. Here we review the evidence of aortic arch atheroma as an independent risk factor for stroke and arterial embolism, including clinical and pathological data on atherosclerosis of the thoracic aorta as an embolic source. In addition, the impact of complex plaques (≥ 4 mm thick, or with mobile components) on increasing the risk of stroke is also reviewed. In non-randomized retrospective studies anticoagulation was superior to antiplatelet therapy in patients with stroke and aortic arch plaques with mobile components. In a retrospective case-control study, statins significantly reduced the relative risk of new vascular events. However, given the limited data available and its retrospective nature, randomized prospective studies are needed to establish the optimal secondary prevention therapeutic regimens in these high risk patients.
在许多中风患者中，无法确定中风的病因。然而，在过去二十年中，对病因不明的中风患者使用经食管超声心动图检查发现，主动脉弓存在动脉粥样硬化斑块，这些斑块常突入管腔，且在高比例病例中具有可移动成分。多项尸检系列研究以及病例对照回顾性研究表明，主动脉弓动脉粥样硬化与动脉栓塞之间存在关联，这一关联后来得到了前瞻性设计研究的证实。当动脉粥样硬化斑块位于左锁骨下动脉开口近端、斑块厚度≥4毫米，尤其是存在可移动成分时，与缺血性中风的关联尤为强烈。在这些情况下，阿司匹林可能无法充分预防新的动脉缺血事件，尤其是中风。在此，我们回顾主动脉弓动脉粥样硬化作为中风和动脉栓塞独立危险因素的证据，包括胸主动脉粥样硬化作为栓子来源的临床和病理数据。此外，还回顾了复杂斑块（厚度≥4毫米或有可移动成分）对增加中风风险的影响。在非随机回顾性研究中，对于患有中风且主动脉弓斑块有可移动成分的患者，抗凝治疗优于抗血小板治疗。在一项回顾性病例对照研究中，他汀类药物显著降低了新血管事件的相对风险。然而，鉴于现有数据有限且具有回顾性，需要进行随机前瞻性研究来确定这些高危患者的最佳二级预防治疗方案。
