Brain Natriuretic Peptide and Particular Left Ventricle Segment Asynergy Associated with Cardioembolic Stroke from Old Myocardial Infarction

https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.02.003Get rights and content

Background

It is important to determine the usage of anticoagulants by defining the actual risk of cardioembolic stroke in patients with old myocardial infarction. In the present study, we aimed to more precisely evaluate the risks of each segment associated with cardioembolic stroke using a 16-segment model. The usage of the plasma brain natriuretic peptide (BNP) associated with cardioembolic stroke was also evaluated in comparison with a left ventricle ejection fraction less than 40%.

Methods

There were a total of 190 ischemic stroke patients who had premorbid myocardial infarction. The study included a total of 143 ischemic stroke patients with old myocardial infarction who were available for evaluation and excluded patients with atrial fibrillation or acute myocardial infarction. Their left ventricle wall motion abnormality and the level of plasma BNP at their admission were analyzed.

Results

Hypertension and a plasma BNP level of 206.9 pg/mL or higher, determined from the receiver operating characteristic curve, were independently associated with cardioembolic stroke (χ2 = 35.6, R2 = .30, P < .001). Adjusting for these factors, statistically independent high risk was observed at the basal–inferior, basal–inferolateral, mid-anterior, mid-anteroseptal, apical–anterior, and apical–septal left ventricles.

Conclusion

High plasma BNP levels and left ventricular wall motion abnormalities in the segments perfused with left anterior descending coronary artery or right coronary artery show a high risk for cardioembolic stroke in patients with old myocardial infarction. Considering these factors, it could be possible to more precisely define the risk of cardioembolic stroke and to perform appropriate antithrombotic treatments in old myocardial infarction patients.

Introduction

Myocardial infarction is a disease under the spectrum of atherothrombosis, but it is also a possible cause of cardioembolism resulting from left ventricular wall motion abnormality. Visible left ventricular thrombus is frequently detected in acute myocardial infarction in the anterior (33.8%-54.1%) compared to the inferior region (0%-4.7%) based on observational studies before the advent of thrombolysis and percutaneous coronary intervention.1, 2, 3, 4 According to the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, an anticoagulant is recommended for preventing left ventricular thrombus in patients with anterior ST-segment elevation myocardial infarction and left ventricle ejection fraction less than 40%.5 These guidelines also recommend warfarin treatment (prothrombin time–international normalized ratio [PT-INR], 2-3) for several months in those patients followed by the discontinuation of warfarin treatment thereafter. The incidences of myocardial infarction and stroke were 1.44% and 1.38%/year in patients with established cardiovascular disease.6 Stroke occurs more frequently than myocardial infarction in patients with established coronary artery disease, especially in Asia and Europe.6 There could be a potent risk of cardioembolic stroke even in patients with old myocardial infarction, especially in patients with inferior myocardial infarction. It is important to determine the usage of anticoagulants by defining the actual risk of cardioembolic stroke in each patient.

In the present study, we aimed to more precisely evaluate the risks of each segment that is associated with cardioembolic stroke using a 16-segment model.7 Usage of the plasma brain natriuretic peptide (BNP) level in association with cardioembolic stroke is also evaluated in comparison with left ventricle ejection fraction.

Section snippets

Methods

In the Brain Attack Center Ota Memorial Hospital, 2590 patients with acute ischemic stroke were admitted from January 2012 to December 2014. The study protocol was governed by the guidelines of the national government based on the Helsinki Declaration revised in 1983 and was approved by the Institutional Research and Ethics Committee of our hospital.

All patients underwent magnetic resonance imaging, magnetic resonance angiography of the cranial and carotid arteries, electrocardiogram, and

Results

Among the acute ischemic stroke patients, 190 patients had premorbid myocardial infarction. There were 33 patients with atrial fibrillation and 6 patients with an onset of myocardial infarction within 6 months before ischemic stroke onset. Additionally, 8 patients had no transthoracic echocardiography evaluation. Excluding these patients, 143 patients were available for evaluation. Left ventricular wall motion abnormality (≥akinesis), which was described as a high-risk cardiac source for

Discussion

In the present study, the clinical features of cardioembolic stroke due to old myocardial infarction were evaluated. The patients with cardioembolic stroke had high plasma BNP levels at their admission. Additionally, a high plasma BNP level was an independent factor for differentiating cardioembolic stroke from noncardioembolic infarction compared to the left ventricle ejection fraction in the patients with old myocardial infarction. Additionally, the prevalence of left ventricular wall motion

Acknowledgments

We would like to show our sincere appreciation to Ms. Tomoko Fukushima (Brain Attack Center Ota Memorial Hospital) for her data management support. We also thank Dr. Shiro Nozaki, MD, PhD, FACC (Nozaki Clinic of Cardiology, Takamatsu, Japan), for his meaningful discussions.

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Grant support: This study was supported in part by research grants from Japan Society for the Promotion of Science KAKENHI (Grant Number 23590598, 15K08615), the Japan Science and Technology Agency (AS242Z02592P), Bristol-Myers Squibb, the Smoking Research Foundation, and the Tsuchiya Foundation.

Disclosures: Dr. Hosomi reports an honorarium from Mochida Pharmaceutical Co., Ltd., which is outside the scope of the submitted work. Prof. Matsumoto reports grants from Mochida Pharmaceutical Co., Ltd., Otsuka Pharmaceutical, and Daiichi Sankyo Co., Ltd., and an honoraria from Sanofi K.K., Bayer Health Care, Otsuka Pharmaceutical, Daiichi Sankyo Co., Ltd., Boehringer Ingelheim, and Sumitomo Dainippon Pharma Co., Ltd., which are outside the scope of the submitted work.

Authors' contributions: Naohisa Hosomi, Masaru Kuriyama, and Masayasu Matsumoto contributed to the study design, data analysis, data interpretation, and manuscript construction. Takeshi Yoshimoto, Yuhei Kanaya, Shuichiro Neshige, Naoyuki Hara, Takahiro Himeno, Ryuhei Kono, Shinichi Takeshima, Yutaka Shimoe, Kazuhiro Takamatsu, and Taisei Ota contributed to the data collection. Tomoko Ota, Yoshinori Miyamoto, and Kotaro Yasuda contributed to the diagnosis of myocardial infarction.

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