Aortic Atherosclerosis, Hypercoagulability, and Stroke. The APRIS (Aortic Plaque and Risk of Ischemic Stroke) Study

Objectives: Our goal was to assess the effect of hypercoagulability on the risk of stroke in patients with aortic plaques. Background: Atherosclerotic plaques in the aortic arch are a risk factor for ischemic stroke. Their relationship with blood hypercoagulability, which might enhance their embolic potential and affect treatment and prevention, is not known. Methods: We performed transesophageal echocardiography in 255 patients with first acute ischemic stroke and in 209 control subjects matched by age, gender, and race/ethnicity. The association between arch plaques and hypercoagulability, and its effect on the stroke risk, was assessed with a case-control design. Stroke patients were then followed prospectively to assess recurrent stroke and death. Results: Large (≥4 mm) arch plaques were associated with increased stroke risk (adjusted odds ratio [OR]: 2.4, 95% confidence interval [CI]: 1.3 to 4.6), especially when ulcerations or superimposed thrombus were present (adjusted OR: 3.3, 95% CI: 1.4 to 8.2). Prothrombin fragment F 1.2, an indicator of thrombin generation, was associated with large plaques in stroke patients (p = 0.02), but not in control subjects. Over a mean follow-up of 55.1 ± 37.2 months, stroke patients with large plaques and F 1.2 over the median value had a significantly higher risk of recurrent stroke and death than those with large plaques but lower F 1.2 levels (230 events per 1,000 person-years vs. 85 events per 1,000 person-years; p = 0.05). Conclusions: In patients presenting with acute ischemic stroke, large aortic plaques are associated with blood hypercoagulability, suggesting a role for coagulation activation in the stroke mechanism. Coexistence of large aortic plaques and blood hypercoagulability is associated with an increased risk of recurrent stroke and death.