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Cerebrovascular disease and risk of stroke

Submitted by Dr. Yasser Mokhtar, MD. Dept. of internal medicine. School of medicine, University of South Dakota.


Stroke is a loss of cerebral function with symptoms lasting >24 hrs or death due to vascular disease


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  Cerebral circulation
The internal Medicine Lounge

2. Cardiac diseases

Cardiac diseases have been clearly associated with an increased risk of ischemic stroke particularly atrial fibrillation, valvular heart disease, myocardial infarction, coronary artery disease, congestive heart failure, electrocardiographic evidence of left ventricular hypertrophy and perhaps mitral valve prolapse.

Atrial fibrillation (AF)

This is the most potential cardiac source of embolism to the brain. AF is usually non-rheumatic in developed countries. Both non-rheumatic and more so rheumatic AF have been associated with stroke from postmortem (Hinton et al., 1977) case control (Kempster et al., 1988) and cohort studies (Flegel et al., 1987). AF even without valvular heart disease is strongly correlated with stroke, especially embolic stroke (Wolf et al., 1983). AF prevalence is very closely related to age so that most strokes caused by AF are in the very elderly, where the proportion attributed to AF is highest (Wolf et al., 1991). Some of the association must be coincidental because AF can be caused by coronary heart disease and hypertensive heart disease both of which may be associated with stroke by mechanisms other than embolism from the fibrillating left atrium (Davies et al., 1987). In the Framingham study, AF was a strong predictor of stroke with nearly a five-fold increased risk of stroke. In those with coronary heart disease, or cardiac failure, AF doubled the stroke risk in males and tripled the risk in females. With coexisting valvular disease, AF had an even greater impact on the relative risk of stroke. Left ventricular dysfunction and left atrial size determined by echocardiography were also predictors of increased thromboembolic risk (Wolf et al., 1991). 

Coronary artery disease

Independent of age coronary artery disease (myocardial infarction or angina) is clearly associated with stroke. The evidence comes from postmortem (Stemmerman et al., 1984), case control (Woo et al., 1991), and cohort studies (Kannel et al., 1983). Data suggest that most of this association is causal (i.e. embolism from the left ventricular thrombus complicating myocardial infarction) rather than due to the coincidence of atheroma in coronary and cerebral circulation in the same (predisposed) individuals (Dexter et al., 1987).

Cardiac failure is a further risk factor (Kannel et al., 1983).

ECG abnormalities reflecting hypertension or coronary heart disease are, not surprisingly, risk factors for stroke (Knutsen et al., 1988 and Shaper et al., 1991).

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