Prevalence, Prognosis, Diagnosis, and Treatment

The results of recent multicenter studies of stroke prevention are encouraging. Carotid endarterectomy is highly beneficial for patients with recent transient ischemic attacks (TIA) or nondisabling stroke and ipsilateral high-grade stenosis (70-99%); ticlopidine significantly lowers the risk of stroke in patients with TIA or minor stroke compared with aspirin or placebo,' and coumadin and aspirin are effective for preventing stroke in patients with nonrheumatic atrial fibrillation. However, if long-term benefits of medical or surgical therapy for cerebrovascular disease are to be achieved, coronary artery disease (CAD), the major cause of death in stroke patients, must be identified and treated effectively. Although strategies for evaluating and treating symptomatic CAD in patients with stroke are well established, this is not true of asymptomatic CAD. Therefore, a detailed cardiovascular evaluation is rarely incorporated into the management of patients with cerebrovascular disease and without symptoms of CAD. Accumulating evidence suggests that asymptomatic CAD is common in patients with cerebrovascular diseaseand that the prognosis of a subset of patients with asymptomatic CAD is poor.Furthermore, preliminary data from nonrandomized studies suggest that the prognosis of patients with asymptomatic 3-vessel or left main CAD is improved after coronary artery bypass surgery. In this article we review available data on the prevalence and prognosis of asymptomatic CAD in patients with cerebrovascular disease and suggest possible diagnostic and therapeutic strategies for management of asymptomatic CAD in these patients.