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High-Grade Carotid Artery Stenosis and Atrial Fibrillation

Published:December 01, 2020DOI:https://doi.org/10.1016/j.amjmed.2020.10.015
      To the Editor:
      The disclosure of a higher rate of stroke among patients with the association of nonvalvular atrial fibrillation and peripheral vascular disease

      Vitalis A, Shantsila A, Proietti M, et al. Peripheral arterial disease in patients with atrial fibrillation: the AFFIRM study. Am J Med. [In press.] doi.org/ 10.1016/j.amjmed.2020.08.026

      is entirely predictable given the fact that Kanter et al
      • Kanter MC
      • Tegeler CH
      • Pearce LA
      • et al.
      Carotid stenosis in patients with atrial fibrillation. Prevalence, risk factors, and relationship to stroke in the Stroke Prevention in Atrial Fibrillation Study.
      have shown that, among patients with nonvalvular atrial fibrillation, high-grade carotid artery stenosis (a risk factor for stroke)
      • Rothwell PM
      Prediction and prevention of stroke in patients with symptomatic carotid stenosis: the high-risk period and the high-risk patient.
      had a prevalence of 12% among men aged >70 years, and a prevalence of 11% among women of that age group. Furthermore, in their systematic review of 9 studies (2611 patients) reporting presumed pathophysiological stroke mechanisms in patients with atrial fibrillation, Katsi et al
      • Katsi V
      • Georgiopoulos G
      • Skafida A
      • et al.
      Noncardioembolic stoke in patients with atrial fibrillation.
      showed that 11%-24% of patients with the association of stroke and nonvalvular atrial fibrillation have high-grade (>50% stenosis) carotid artery stenosis.
      Some stroke patients with nonvalvular atrial fibrillation have high-grade carotid artery stenosis ipsilateral to the cerebral infarct, as was the case in 15 of the 25 stroke patients evaluated by Chang et al.
      • Chang Y-J
      • Ryu S-J
      • Lin S-K
      Carotid artery stenosis in ischemic stroke patients with nonvalvular atrial fibrillation.
      In view of the above observations,
      • Kanter MC
      • Tegeler CH
      • Pearce LA
      • et al.
      Carotid stenosis in patients with atrial fibrillation. Prevalence, risk factors, and relationship to stroke in the Stroke Prevention in Atrial Fibrillation Study.
      • Rothwell PM
      Prediction and prevention of stroke in patients with symptomatic carotid stenosis: the high-risk period and the high-risk patient.
      • Katsi V
      • Georgiopoulos G
      • Skafida A
      • et al.
      Noncardioembolic stoke in patients with atrial fibrillation.
      • Chang Y-J
      • Ryu S-J
      • Lin S-K
      Carotid artery stenosis in ischemic stroke patients with nonvalvular atrial fibrillation.
      it would be informative to ascertain what proportion (if any) of the patients studied by Vitalis et al

      Vitalis A, Shantsila A, Proietti M, et al. Peripheral arterial disease in patients with atrial fibrillation: the AFFIRM study. Am J Med. [In press.] doi.org/ 10.1016/j.amjmed.2020.08.026

      had high-grade carotid artery stenosis.
      The association of high-grade carotid artery stenosis, nonvalvular atrial fibrillation, and stroke has profound therapeutic implications. In a review of 1594 patients who had undergone carotid endarterectomy for symptomatic carotid artery stenosis, Ugurlucan et al
      • Ugurlucan M
      • Akay MT
      • Erdinc I
      • Ozras DM
      • Conkbayir C
      • Aslim E
      • et al.
      Anticoagulation strategy in patients with atrial fibrillation after carotid endarterectomy.
      identified 165 patients with concomitant atrial fibrillation who had been managed with the combination of warfarin (to mitigate the risk of cardioembolic stroke) and aspirin (to mitigate the risk of recurrence of atherothrombotic stroke). In that cohort the international normalized ratio was maintained at 2-3, and the aspirin dose was confined to 100 mg/day. In the follow-up period of a mean of 64.4 months, 3 patients died from intracranial hemorrhage, and 3 others “required exploration against bleeding.”
      • Ugurlucan M
      • Akay MT
      • Erdinc I
      • Ozras DM
      • Conkbayir C
      • Aslim E
      • et al.
      Anticoagulation strategy in patients with atrial fibrillation after carotid endarterectomy.
      Direct oral anticoagulants mitigate the risk of intracranial haemorrhage.
      • Douros A
      • Renoux C
      • Yin H
      • Filion KB
      • Suissa S
      • Azoulay L
      Concomitant use of direct oral anticoagulants with antiplatelet agents and the risk of major bleeding in patients with nonvalvular atrial fibrillation.

      References

      1. Vitalis A, Shantsila A, Proietti M, et al. Peripheral arterial disease in patients with atrial fibrillation: the AFFIRM study. Am J Med. [In press.] doi.org/ 10.1016/j.amjmed.2020.08.026

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        Prediction and prevention of stroke in patients with symptomatic carotid stenosis: the high-risk period and the high-risk patient.
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