Medicina

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM
Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease
A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of CardiovascularAnesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons and Society for Vascular Medicine. Endorsed by the North American Society for Cardiovascular Imaging
Journal of the American College of Cardiology Vol. 55, No. 14, 2010:e27-e129; originally published online Mar 16, 2010
This information is current as of February 28,2012
11. AORTIC ARCH AND THORACIC AORTIC
ATHEROMA AND ATHEROEMBOLIC DISEASE
11.1. RECOMMENDATIONS FOR AORTIC ARCH
AND THORACIC AORTIC ATHEROMA AND
ATHEROEMBOLIC DISEASE
CLASS IIa
1. Treatment with a statin is a reasonable option for patients with aortic arch atheroma to reduce the risk of stroke. (540) (Level of Evidence: C)
CLASS IIb
1. Oral anticoagulation therapy with warfarin (INR 2.0 to3.0) or antiplatelet therapy may be considered in stroke patients with aortic arch atheroma 4.0 mm or greater to prevent recurrentstroke. ( Level of Evidence: C)
11.2. Clinical Description
Aortic arch atheroma is a risk factor for ischemic stroke based on autopsy (541,542), TEE (543–548), and intraoperative ultrasonographic studies (549)(Figure 35). In particular, plaques 4 mm or greater inthickness proximal to the origin of the left subclavian artery are associated with stroke and constitute one third of patients with otherwise unexplained stroke (542). These patients, even on antiplatelet therapy, carry a risk of recurrent ischemic stroke as high as 11% at 1 year, and the risk of a new vascular event (ischemic stroke, MI, peripheral event, and vascular death) is 20%, 36%, and 50% at1, 2, and 3 years, respectively (550). The RR of new ischemic stroke was 3.8 (95% CI 1.8 to 7.8, P0.002), and that of new vascular events was 3.5 (95% CI 2.1 to 5.9, P<0.001), independent of carotid stenosis, atrial fibrillation, peripheral artery disease, or other risk factors (550). Otherstudies showed that aortic arch plaques were independent predictors of recurrent strokes, MI and vasculardeath 551–553). Patients with noncalcified plaques were at higher risk for recurrent vascular events (554).
Regarding the natural history of aortic arch atheroma, Sen et al (555) noted progression in 29% and regression (defined as an increase or decrease in plaque thickness by 1 grade or greater, respectively) in 9%. Montgomery et al (556) reported 30 patients with moderate-to-severe aortic plaquenoted on initial bi/multiplanar TEE as part of a workup for cardiac or an embolic event. Over a mean of 1 year, progression was reported in 23% and regression in 10%. Pistavos et al (557)used monoplanar TEE in 16 patients with familial hypercho-lesterolemia taking pravastatin to show progression in 19% and regression in 38% over 2 years. Geraci and Weinberger (558), using supraclavicular B-modeultrasonography of the proximal aortic arch in 89 patients evaluated for transient neurologic symptom, noted a progression rate of 19% and a regression rate of 18% over a mean of 7.7 months (range 3 to 18 months). Sen et al (559) confirmed that in patients with stroke/TIA, aortic arch atheroma progression over 12 months is associated with more vascular events
11.3. Risk Factors for the developmentof aortic atheroma include age, sex, heredity, hypertension, diabetes mellitus, hyperlip-idemia, sedentary lifestyle, smoking, and endothelial dys-function. Other factors include elevated levels of inflamma-tory markers (i.e., serum C-reactive protein), homocysteine, or lipoprotein (560,561). Risk factors for embolic complica-tions include inflammation, shear forces of hypertension, plaque...