Predicting Asymptomatic Coronary Artery Disease in Patients With Ischemic Stroke and Transient Ischemic Attack

Coronary heart disease (CHD) is usually considered a significant cause of morbidity and mortality in patients who have had a stroke or a transient ischemic attack (TIA). Although recurrent strokes occur more commonly than cardiac events over the long term after stroke, cardiac events still account for a greater proportion of mortality. Identifying severe occult coronary artery stenosis, in particular those with left main trunk or 3-vessel disease, may help to improve prevention of cardiac events in stroke/ TIA patients. The prevalence of severe (≥50% reduction in diameter) occult coronary artery stenosis has been reported to be between 18% and 38% in patients with stroke or TIA and no previous history of CHD. We recently showed that in these patients traditional vascular risk factors, assessed individually or through the Framingham Risk Score (FRS), and the severity of cervicocephalic atherosclerosis are strongly and independently associated with severe coronary artery stenosis detected by 64-section CT. These associations have been confirmed in other studies. The aim of this study was to derive and validate a simple prediction score for severe occult coronary artery stenosis in stroke/ TIA patients. Background and Purpose—Identifying occult coronary artery stenosis may improve secondary prevention of stroke patients. The aim of this study was to derive and validate a simple score to predict severe occult coronary artery stenosis in stroke patients. Methods—We derived a score from a French hospital–based cohort of consecutive patients (n=300) who had an ischemic stroke or a transient ischemic attack and no previous history of coronary heart disease (Predicting Asymptomatic Coronary Artery Disease in Patients With Ischemic Stroke and Transient Ischemic Attack [PRECORIS] score) and validated the score in a similar Korean cohort (n=1602). In both cohorts, severe coronary artery stenosis was defined by the presence of at least 1 ≥50% coronary artery stenosis as detected by 64-section CT coronary angiography. Results—A 5-point score (Framingham Risk Score–predicted 10-year coronary heart disease risk [≥20%=3; 10–19%=1; <10%=0] and cervicocephalic artery stenosis [≥50%=2; <50%=1; none=0]) was predictive of occult ≥50% coronary artery stenosis risk in the derivation cohort (C-statistic=0.77 [0.70–0.84]) and in the validation cohort (C-statistic=0.66 [0.63–0.68]). The predictive ability of the score was even stronger when only ≥50% left main trunk disease or 3-vessel disease were considered (C-statistic=0.83 [0.74–0.92] and 0.70 [0.66–0.74] in derivation and validation cohorts, respectively). The prevalence of occult ≥50% coronary artery stenosis and ≥50% left main trunk or 3-vessel disease increased gradually with the PRECORIS score, reaching 44.2% and 13.5% in derivation cohort and 49.8% and 12.8% in validation cohort in patients with a PRECORIS score ≥4. Conclusions—The PRECORIS score can identify a population of stroke or transient ischemic attack patients with a high prevalence of occult severe coronary artery stenosis. (Stroke. 2014;45:82-86.)