Prevalence of Potential Risk Factors for Stroke Assessed by Transesophageal Echocardiography and Carotid Ultrasonography: The SPARC Study

doi:10.4065/74.9.862

Mayo Clinic Proceedings

Volume 74, Issue 9, September 1999, Pages 862-869

https://doi.org/10.4065/74.9.862 Get rights and content

Objectives

The SPARC (Stroke Prevention: Assessment of Risk in a Community) study was designed to identify risk factors for stroke and cardiovascular disease using transesophageal echocardiography and carotid ultrasonography. This protocol was undertaken to establish a cohort in which putative risk factors for stroke were identified so that subsequent follow-up could discern the roles these risk factors play in stroke incidence.

Subjects and Methods

This was a prospective, population-based study. A randomly selected cohort comprised 1475 Olmsted County, Minnesota, residents aged 45 years or older, of whom 588 agreed to participate. Transesophageal echocardiography and carotid ultrasonography were used for evaluation of the subjects. Prevalences of various cardiovascular and cerebrovascular conditions were determined.

Results

Transesophageal echocardiography was successfully completed in 581 subjects. The prevalence (±SE) of patent foramen ovale was 25.6% (±1.9%), and that of atrial septal aneurysm was 2.2% (±0.6%). The prevalence of aortic atherosclerosis increased with age and was most common in the descending aorta, particularly in subjects 75 to 84 years old. The prevalence of strands on native valve was 46.4% (±2.2%). Carotid ultrasonography data for 567 participants revealed minimal atherosclerotic disease. Most subjects had minimal or mild carotid occlusive disease. The prevalence of moderate (50%-79%) and severe (80%-99%) stenosis was 7.7% (±1.1%) and 0.3% (±0.2%), respectively.

Conclusions

This prospective study defines the prevalence of multiple potential cardiovascular and cerebrovascular risk factors, providing population-based data for ongoing follow-up of the risk of stroke.

Section snippets

METHODS

The resources of the Rochester Epidemiology Project³¹ were used to enumerate the Ohnsted County, Minnesota, population. These data were obtained primarily from medical records at Mayo Clinic and the Olmsted Medical Center, documenting all medical contacts by residents of the population. The number of individuals so identified in any 3-year span for the age-group of interest exceeded the corresponding figures interpolated from the decennial census and state demographics; this observation

Cohort Description

A random sample of 1475 Olmsted County residents was selected. The majority of subjects (98%) were of white, non-Hispanic origin. Of these, 230 were ineligible, and 636 participated in the home interview, 48 of whom refused to undergo TEE. TEE was performed successfully in 581 (99%) of the 588 participants. The reasons for no TEE data in the other 7 were failed intubation in 2, inadequate image quality due to large diaphragmatic hernia in 2, relative contraindication because of severe left

DISCUSSION

This study provides, for the first time to our knowledge, data on uniformly collected cardiovascular and cerebro-vascular abnormalities in a large population-based sample. Knowledge of the prevalence of putative risk factors in a general population is essential to the understanding of their significance in the disease state. This study overcomes the selection bias of literature published to date, assessing stroke risk in small samples of subjects who have already experienced the end point or

ACKNOWLEDGMENTS

We are indebted to Lori A. Reese for assistance with patient recruitment; to Ronald H. May and Sara L. Osborn for technical assistance; to Elizabeth E. Worrall and Dixie R. Long for their assistance with data analyses; and to Deborah M. Pluth for typing the manuscript.

REFERENCES (46)

AC Pearson et al.
Superiority of transcsophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology
J Am Coit Cardiol
(1991)
MW Webster et al.
Patent foramen ovale in young stroke patients
Lancet
(1988)
A Chenzbraun et al.
Biplane transesophageal echocardiography in the diagnosis of patent foramen ovale
J Am Soc Echocardiogr
(1993)
FP Job et al.
Comparison of transcranial contrast Doppier sonography and transesophageal contrast echocardiography for the detection of patent foramen ovale in young stroke patients
Am J Cardiol
(1994)
EF Jones et al.
Evidence that patent foramen ovale is not a risk factor for cerebral ischemia in the elderly
Am J Cardiol
(1994)
JJ Lynch et al.
Prevalence of right-to-left atrial shunting in a healthy population: detection by Valsalva maneuver contrast echocardiography
Am J Cardiol
(1984)
BD Lewis et al.
Current applications of duplex and color Doppler ultrasound imaging: carotid and peripheral vascular system
Mayo Clin Proc
(1989)
JP Whisnant et al.
Comparison of case ascertainment by medical record linkage and cohort follow-up to determine incidence rates for transient ischcmic attacks and stroke
J Clin Epidemiol
(1990)
JB Seward et al.
Biplanar transesophageal echocardiography: anatomic correlations, image orientation, and clinical applications
Mayo Clin Proc
(1990)
JB Seward et al.
Multiplane transesophageal echocardiography: image orientation, examination technique, anatomic correlations, and clinical applications
Mayo Clin Proc
(1993)

BK Khandheria et al.

Transesophageal echocardiography

Mayo Clin Proc

(1994)

PC Hanley et al.

Diagnosis and classification of atrial septal aneurysm by two-dimensional echocardiography: report of 80 consecutive cases

J Am Coll Cardiol

(1985)

DG Karalis et al.

Recognition and embolie potential of intraaortic atherosclerotic debris

J Am Coll Cardiol

(1991)

LJ Melton

History of the Rochester Epidemiology Project

Mayo Clin Proc

(1996)

PT Hagen et al.

Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts

Mayo Clin Proc

(1984)

RS Freedberg et al.

Valve strands are strongly associated with systemic embolization: a transesophageal echocardiographic study

J Am Coll Cardiol

(1995)

American Heart Association

Cerebral Embolism Task Force

Cardiogenic brain embolism

Arch Neural

(1986)

FA DcRook et al.

Transesophageal echocardiography in the evaluation of stroke

Ann Intern Med

(1992)

P Lechat et al.

Prevalence of patent foramen ovale in patients with stroke

N Fngl J Med

(1988)

T Hofmann et al.

Echo-cardiographic evaluation of patients with clinically suspected arterial cmboli

Lancet

(1990)

WJ Chen et al.

The frequency of patent foramen ovale in patients with ischemic stroke: a trans esophageal echocardiogeaphic study

J Formas MedAssoc

(1991)

M Di Tullio et al.

Patent foramen ovale as a risk factor for cryptogenic stroke

Ann Intern Med

(1992)

Cited by (364)

Cerebrovascular disease in surgical patients
2024, Perioperative Care and Operating Room Management
It is well established that patients with a personal history of a cerebrovascular accident (stroke or transient ischemic attack) are at increased risk for perioperative cardiovascular complications, including recurrent stroke. Although the individual patient risk for perioperative stroke is typically low, the overall prevalence is significant, appears to be increasing, and has the potential for devastating complications including death. The perioperative provider must not only be knowledgeable of the elevated risk for patients with a history of stroke undergoing surgery, but also be familiar with perioperative risk reduction strategies. This article provides a general overview of cerebrovascular disease in surgical patients with much of the content being presented at the 2023 Perioperative Medicine Summit in Orlando, Florida.
Cardiovascular Outcomes and Readmissions of Atrial Fibrillation Among Patent Foramen Ovale Occluder Device Recipients: A Propensity Matched National Readmission Study
2024, Current Problems in Cardiology
Patent foramen ovale (PFO) occluder devices are increasingly utilized in minimally invasive procedures used to treat cryptogenic stroke. Data on the impact of Atrial Fibrillation (AF) among PFO occluder device recipients are limited. The Nationwide Readmissions Database was queried between 2016 and 2019 to identify PFO patients with and without AF. The 2 groups were compared using propensity score matching (PSM) and multivariate regression models. The outcomes included in-hospital mortality, acute kidney injury (AKI), Mechanical circulatory support use (MCS), Cardiogenic shock (CS), acute ischemic stroke, bleeding, and other cardiovascular outcomes. Statistical analysis was performed using STATA v. 17. Out of 6508 Weighted hospitalizations for PFO occluder device procedure over the study period, 877 (13.4%) had AF compared to 5631 (86.6%) who did not. On adjusted analysis, PFO with AF group had higher rates of MCS (PSM, 4.5% vs 2.2 %, P value = 0.011) and SCA (PSM, 7.6% vs 4.6 %, P value = 0.015) compared to PFO with no AF. There was no statistically significant difference in the rate of in-hospital mortality (PSM, 5.4% vs 6.4 %, P value = 0.39), CS (PSM, 8.3% vs 5.9 %, P value = 0.075), AKI (PSM, 32.4% vs 32.3 %, P value = 0.96), bleeding (PSM, 2.08% vs 1.3%, P value = 0.235) or the readmission rates among both cohorts. Additionally, AF was associated with higher hospital length of stay (9.5 ± 13.2 vs 8.2 ± 24.3 days, P-value = 0.012) and total cost ($66,513 ± $80,922 vs $52,013±$125,136, 0.025, P-value = 0.025) compared to PFO without AF. AF among PFO occluder device recipients is associated with increased adverse outcomes, including MCS use and SCA, with no difference in mortality and readmission rates among both cohorts. Long-term follow-up needs further studies.
Cardiac Masses Discovered by Echocardiogram; What to Do Next?
2023, Structural Heart
Cardiac tumors are rare conditions, typically diagnosed on autopsy, but with the advancement of imaging techniques they are now encountered more frequently in clinical practice. Echocardiography is often the initial method of investigation for cardiac masses and provides a quick and valuable springboard for their characterization. While some cardiac masses can be readily identified by echocardiography alone, several require incorporation of multiple data points to reach diagnostic certainty. Herein, we will provide an overview of the main clinical, diagnostic, and therapeutic characteristics of cardiac masses within the framework of their location.
Embolic Stroke of Undetermined Source: Current Perspectives on Diagnosis, Investigations, and Management
2023, Canadian Journal of Cardiology
In 2014, Hart et al. introduced the concept of “embolic stroke of undetermined source” (ESUS) to the clinical-research stroke community. The hypothesis underlying the development of the ESUS construct was that this potentially heterogenous group of stroke mechanisms were largely thromboembolic, and would thus benefit from anticoagulation over antiplatelet for secondary prevention. Since then, 2 large clinical trials have shown that, to date, there is not a clear uniform antithrombotic strategy for secondary prevention after ESUS as it was originally broadly defined. However, this work has yielded valuable information about the patient phenotypes that experience ESUS strokes, as well as hypothesis-generating substudies that have given rise to the next generation of secondary prevention trials aimed at more personalized approaches for different suspected mechanisms of embolic stroke. In parallel with the evolution of ESUS, several studies aimed at screening for atrial fibrillation in the secondary stroke prevention population have generated additional questions about the mechanistic relevance of atrial fibrillation detected after stroke, and how this should inform poststroke workup, and secondary prevention strategies. Herein, we provide a synthesis of the current understanding surrounding the patient phenotypes that experience ESUS strokes, and previous, ongoing, and anticipated clinical trials that will guide earlier and later secondary prevention strategies and poststroke cardiac investigations.
En 2014, Hart et ses collaborateurs ont introduit le concept d’« accident vasculaire cérébral embolique de source indéterminée » (embolic stroke of undetermined source ou ESUS) dans le domaine de la recherche clinique sur les accidents vasculaires cérébraux (AVC). Selon l’hypothèse sous-tendant le concept, l’ESUS était probablement attribuable à des mécanismes hétérogènes essentiellement thromboemboliques. Conséquemment, un traitement anticoagulant paraissait préférable à un traitement antiplaquettaire en prévention secondaire de cette forme d’AVC. Depuis lors, deux essais cliniques de grande envergure ont montré qu’il n’existe à ce jour aucune stratégie antithrombotique claire et cohérente en matière de prévention secondaire de l’ESUS, au sens large de la définition princeps. Néanmoins, les travaux effectués ont fourni de précieux renseignements sur les phénotypes des patients qui subissent un ESUS. Ils ont aussi donné lieu à des sous-études permettant de formuler des hypothèses qui sont à l’origine de la prochaine génération d’essais en prévention secondaire axés sur des approches plus personnalisées des différents mécanismes présumés de l’AVC embolique. Parallèlement à l’évolution du concept d’ESUS, plusieurs études centrées sur le dépistage de la fibrillation auriculaire en contexte de prévention secondaire des AVC ont soulevé d’autres questions sur l’importance de la fibrillation auriculaire détectée après un AVC relativement aux mécanismes en jeu et sur sa portée au regard du bilan post-AVC et des stratégies de prévention secondaire. Nous présentons ici une synthèse de la compréhension actuelle des phénotypes des patients qui subissent un ESUS. Nous résumons aussi les essais cliniques passés, en cours et à venir qui orienteront les stratégies de prévention secondaire et les investigations cardiaques post-AVC à court et à plus long terme.
Percutaneous suture-based patent foramen ovale closure: A state-of-the-art review
2023, Trends in Cardiovascular Medicine
Percutaneous closure of a patent foramen ovale (PFO), a common variation of interatrial septum anatomy, is a commonly performed procedure in the catheterization laboratory to reduce the risk of recurrent stroke in selected patients and to treat other PFO-related syndromes. In the last twenty years, disc-based devices have represented the armamentarium of the interventional cardiologist; recently, suture-based devices have become an attractive alternative, despite limited data regarding their long-term performance. The present review gives an overview of the current evidence regarding suture-based PFO closure, the device's characteristics, the echocardiographic evaluation of the PFO anatomy, and recommendations for patient selection. A detailed procedural guide is then provided, and potential complications and future developments in the field are discussed.
Patent foramen ovale and perioperative stroke in noncardiac surgery: a systematic review and meta-analysis
2022, British Journal of Anaesthesia
Patent foramen ovale (PFO) is associated with perioperative stroke in noncardiac surgery. The magnitude of this association was assessed in a systematic review and meta-analysis.
Electronic databases were searched up to June 2022 for studies assessing the association between patent foramen ovale and perioperative stroke in adult patients undergoing noncardiac surgery. The primary analysis was limited to studies reporting effect estimates adjusted for significant clinical confounders. We calculated the adjusted odds ratio (aOR) and 95% confidence interval (CI).
We included nine retrospective and two prospective observational studies, including 21 257 082 patients. The presence of a patent foramen ovale was independently associated with stroke at 30 days after surgery (aOR=6.68 [95% CI: 3.51–12.73]; P<0.001) and at longest follow-up available (aOR=7.36 [95% CI: 3.56–15.21]; P<0.001). The odds of stroke at 30 days varied according to surgical specialty: neurosurgery (aOR=4.52 [95% CI: 3.17–6.43]), vascular surgery (aOR=7.15 [95% CI: 2.52–20.22]), thoracic surgery (aOR=10.64 [95% CI: 5.97–18.98]), orthopaedic surgery (aOR=11.85 [95% CI: 5.38–26.08]), general surgery (aOR=14.40 [95% CI: 10.88–19.06]), and genitourinary surgery (aOR=17.28 [95% CI: 10.36–28.84]).
The presence of a patent foramen ovale is associated with a large and consistent increase in odds of stroke across all explored surgical settings. Prospective trials should further explore this association by systematically assessing patent foramen ovale and stroke prevalence and identifying a specific population at risk. This is crucial for the elaboration of prevention plans and may improve perioperative outcomes.

View all citing articles on Scopus

: This study was supported in part by research grants NS 06663 and AR 30582 from the United States Public Health Service.

View full text

Original ArticlePrevalence of Potential Risk Factors for Stroke Assessed by Transesophageal Echocardiography and Carotid Ultrasonography: The SPARC Study

Objectives

Subjects and Methods

Results

Conclusions

Section snippets

METHODS

Cohort Description

DISCUSSION

ACKNOWLEDGMENTS

J Am Coit Cardiol

Lancet

J Am Soc Echocardiogr

Am J Cardiol

Am J Cardiol

Am J Cardiol

Mayo Clin Proc

J Clin Epidemiol

Mayo Clin Proc

Mayo Clin Proc

Mayo Clin Proc

J Am Coll Cardiol

J Am Coll Cardiol

Mayo Clin Proc

Mayo Clin Proc

J Am Coll Cardiol

Cardiogenic brain embolism

Arch Neural

Transesophageal echocardiography in the evaluation of stroke

Ann Intern Med

Prevalence of patent foramen ovale in patients with stroke

N Fngl J Med

Echo-cardiographic evaluation of patients with clinically suspected arterial cmboli

Lancet

The frequency of patent foramen ovale in patients with ischemic stroke: a trans esophageal echocardiogeaphic study

J Formas MedAssoc

Patent foramen ovale as a risk factor for cryptogenic stroke

Ann Intern Med

Original Article
Prevalence of Potential Risk Factors for Stroke Assessed by Transesophageal Echocardiography and Carotid Ultrasonography: The SPARC Study