Shahrivari, Mahan

Introduction: Malignancy represents an important subgroup of embolic stroke of undetermined source (ESUS). We aim to compare infarct features, potential embolic sources, and long-term outcomes in ESUS patients with and without malignancy. Methods: In this pre-specified secondary analysis of the Cardiac Abnormalities in Stroke Prevention and Recurrence (CASPR) retrospective cohort study, active cancers were identified by site investigators and adjudicated as malignant if they were non-squamous or non-basal cell skin cancers. We compared the prevalence of various potential embolic sources (e.g., patent foramen ovale, left ventricular dysfunction, post-stroke atrial fibrillation) among patients with and without malignancy. The risk of recurrent stroke, major bleeding, or death was evaluated using adjusted Cox proportional hazards models, accounting for age, sex, vascular risk factors, competing potential embolic sources, and initial treatment with anticoagulation versus non-anticoagulant (e.g., antiplatelet) regimen. Results: Of the 2201 patients followed over a median of 564 days, 236 (10.7%) were diagnosed with cancer at the time of stroke. Patients with malignancy were older, more frequently hypertensive and did not differ with regards to prevalence of specific infarct patterns or potential cardiac embolic sources. No difference was observed in the composite outcome of recurrent stroke, major bleeding, or death (adjusted HR 1.02, 95% CI, 0.71-1.46). Age (adjusted HR per year 1.02, 95% CI, 1.01-1.03), baseline stroke severity (adjusted HR 1.03 per NIHSS point, 95% CI, 1.01-1.05), prior stroke (adjusted HR 1.68, 95% CI, 1.38-2.05), and multi-territorial infarct pattern (adjusted HR 1.67, 95% CI, 1.33-2.08) were significantly associated with this composite outcome, but anticoagulation was not. There was a nominally lower rate of major bleeding with malignancy (adjusted HR 0.45, 95% CI, 0.19-1.04), a significantly higher rate of death (adjusted HR 1.58, 95% CI, 1.09-2.30), but no significant difference in recurrent ischemic stroke (p=0.31). Conclusions: Patients with malignancy and ESUS had higher mortality but did not differ in recurrent stroke risk or major bleeding when compared to patients without malignancy. Anticoagulation was not independently associated with better outcomes. Further analysis of infarct topology and risk factors may better identify patients for whom anticoagulation may benefit.

Introduction: Clinical outcomes of FFR-guided PCI have been superior to those of angiographically guided PCI, with or without prior cardiac stress testing. Based on these findings, we hypothesized that the accuracy of stress testing is inferior to that of FFR in determining the physiologic significance of angiographic coronary artery disease. Method: To that end, we studied 243 consecutive patients who underwent coronary angiography and FFR assessment between September 2010 and April 2013 at Mayo Clinic, Florida. Out of this group, we excluded 143 patients due to absence of stress testing in the preceding 6 months. We assessed demographics, coronary risk factors, symptoms, stress test variables, angiographic data, and FFR measurements. FFR values ≤0.80 were considered to be positive for ischemia. We evaluated the diagnostic performance of stress testing vs. FFR. Result: Out of the 100 patients included in the study, FFR was measured in the Left Main coronary artery in 3(3%), in the Left Anterior Descending artery (LAD) in 67(67%), in the left circumflex territory in 11(11%), in the Right Coronary Artery (RCA) in 18(18%). The diagnostic performance of stress testing vs. FFR is summarized in the table, with regards to presence of ischemia in any vascular territory and with regards to a specific vascular territory. Conclusion: Compared to FFR, cardiac stress testing has reasonable NPV but poor PPV in determining the presence of absence of overall ischemia in a given patient. Most concerning, however, is that stress testing has poor PPV and NPV when used to determine the site of ischemia in a specific vascular territory.