Progress in Cerebrovascular Disease Management of Cerebral Embolism of Cardiac Origin

Tbe cardiac conditions most commonly associated with cerebral embolism are rheumatic heart disease (RHD), atherosclerotic heart disease (myocardlal infarction and atrial arrhythmias) and other kinds of nonvalvular atrial fibrillation (AF). Tbe natural history of cerebral embolism from these cardiac sources is reviewed. Virtually all rheumatic hearts producing emboll hare mitral stenosis, but not all of them are in AF. Of patients with RHD, 10-20% will experience a systemic embolus, and approximately half will hare a recurrence, usually early. Of patients with a myocardial infarction, 5-12% will have a clinically apparent systemic embolus, and one-third to one-half have a recurrence, usually early. As many as 10-20% of patients with nonrheumatic AF have a systemic embolus. Anticoagulation reduces systemic embolism to 10-20% of the natural incidence in RHD, and it reduces embollc recurrences to 10-20% of tbe natural recurrence rate. Anticoagulation diminishes tbe incidence of emboll In myocardial Infarction to 25% of the natural Incidence. It is not known what effect anticoagulation has on the incidence of embolism hi nonrbeumatic AF. Tbe data regarding the effect of valvulotomy and prosthetic valve placement in RHD are briefly reviewed. Recommendations are made for tbe use and timing of anticoagulation based on the available data.