Aortic Arch Calcification Observed on Chest X-Ray May Serve as an Independent Predictor for Recurrent Stroke

Çakan, Fahri; Sunal, Asli Sert; Adar, Adem; Onalan, Orhan

doi:10.36660/abc.20230805i

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Origianl Article • Arq. Bras. Cardiol. 121 (7) • June 2024 • https://doi.org/10.36660/abc.20230805i copy

Aortic Arch Calcification Observed on Chest X-Ray May Serve as an Independent Predictor for Recurrent Stroke

Authorship SCIMAGO INSTITUTIONS RANKINGS

Central Illustration
: Aortic Arch Calcification Observed on Chest X-Ray May Serve as an Independent Predictor for Recurrent Stroke

Abstract

Background

Despite advances in diagnostic and treatment modalities, there is a need for predictive markers for recurrent strokes.

Objectives

This study aimed to investigate the relationship between aortic arch calcification (AAC) and stroke recurrence in stroke patients during a one-year follow-up.

Methods

All stroke patients who experienced their first event were evaluated for participation in the study. Patients who experienced recurrent strokes during the one-year follow-up were recorded. AAC was assessed by chest radiography. Based on the occurrence of recurrent strokes the patients were divided into two groups. AAC was classified into four categories according to its degree, and the presence of AAC was included in the statistical analysis. The relationship between AAC and recurrent stroke was assessed using a receiver operating characteristic curve. A significance level of <0.05 was deemed acceptable for all statistical analyses.

Results

A total of 203 patients were included in the study (46.8% female, mean age 69±12.3). Recurrent stroke was detected in 49 patients. AAC, hypertension, and atrial fibrillation were more frequent in patients with recurrent stroke. Patients with recurrent stroke had a lower glomerular filtration rate and a higher red cell distribution width (RDW). In multivariate regression analysis, AAC (hazard ratio [HR], 3.544; 95% CI:1.653-7.598, p=0.001) and RDW (HR,1.214; 95% CI:1.053-1.400, p=0.008) were identified as independent predictors of recurrent stroke.

Conclusion

The presence of AAC (≥ grade 1) and RDW were found to be significantly associated with the development of recurrent stroke within one year. These findings may have prognostic significance in the follow-up of stroke patients.

Thoracic Aorta; Stroke; Erythrocytes

Highlights

• Recurrent stroke is an important cause of morbidity and mortality.

• AAC is an important clinical marker of vascular disease burden.

• AAC on chest radiography can be a key factor in recurrent strokes.

• RDW has been shown to be an effective indicator of recurrent stroke.

Characteristic	Total (n=203)	Non-recurrent Stroke (n=154)	Recurrent Stroke (n=49)	p
Gender (Female), n (%)	95 (46.8%)	72 (46.8%)	23 (46.9%)	0.556
Age (year)	69 (±12.3)	68.4 (±12.6)	71.1 (±11.2)	0.231
Weight (kg)	75 (15)	76 (15)	75 (14)	0.964
Height (cm)	165 (12)	166 (12)	165 (16)	0.935
BMI (kg/m2)	27.1 (5.1)	27.0 (5.5)	27.1 (4.0)	0.958
BSA (m2)	1.87 (±0.17)	1.87 (±0.17)	1.86 (±0.17)	0.941
Hypertension, n (%)	156 (77.2%%)	110 (71.4%)	46 (93.9%)	0.001
Diabetes Mellitus, n (%)	75 (36.9%)	53 (34.4%)	22 (44.9%)	0.125
Coronary Artery Disease, n (%)	42 (20.7%)	30 (19.5%)	12 (24.5%)	0.286
Chronic Kidney Disease, n (%)	10 (4.9%)	7 (4.5%)	3 (6.1%)	0.45
Hyperlipidemia, n (%)	97 (47.8%)	73 (47.4%)	24 (49%)	0.488
Cigarette, n (%)	57 (28.1%)	41 (26.6%)	16 (32.7%)	0.26
Alcohol, n (%)	19 (9.4%)	15 (9.7%)	4 (8.2%)	0.497
Renin-Angiotensin System Inhibitor, n (%)	122 (60.1%)	84 (54.5%)	38 (77.6%)	0.003
Statin, n (%)	119 58.6%)	91 (59.1%)	28 (57.1%)	0.468
Calcium Channel Blocker, n (%)	61 (30%)	42 (27.3%)	19 (38.8%)	0.09
Beta-Blocker, n (%)	76 (37.4%)	54 (35.1%)	22 (44.9%)	0.143
Insulin, n (%)	17 (8.4%)	12 (7.8%)	5 (10.2%)	0.392
Anticoagulant, n (%)	34 (16.7%)	20 (13%)	14 (28.6%)	0.012
Fibrate, n (%)	3 (1.4%)	1 (0.6%)	2 (4.1%)	0.145
Antiplatelet, n (%)	78 (38.8%)	58 (37.7%)	20 (40.8%)	0.433
Acetylsalicylic Acid, n (%)	61 (30%)	108 (70.1%)	34 (69.4%)	0.527
Oral Antidiabetic, n (%)	62 (30.5%)	43 (27.9%)	19 (38.8%)	0.105
Atrial Fibrillation, n (%)	42 (20.7%)	34 (22.1%)	15 (30.6%)	0.042
CHA₂DS₂-VASc Score	4 (1)	4 (2)	5 (2)	<0.001
Aortic Arch Calcification
0	98 (48.3%)	86 (55.8%)	12 (24.5%)	<0.001
1	71 (35%)	49 (31.8%)	22 (44.9%)
2	31 (15.3%)	17 (11%)	14 (28.6%)
3	3 (1.5%)	2 (1.3%)	1 (2.0%)
≥1	105 (51.7%)	68 (44.1%)	37 (75.5%)	<0.001
≥2	24 (16.7%)	19 (12.3%)	15 (30.6%)	0.004
Bamford Classification
LACS, n(%)	59 (29.1%)	49(31.2%)	10(20.4%)
PACS, n(%)	83 (40.9%)	55(35.7%)	28(57.1%)
POCS, n(%)	46 (22.7%)	38(24.7%)	8(16.3%)	0.118
TACS, n(%)	14 (6.9%)	11(7.1%)	3(6.1%)
TOAST Classification
Large Artery Atherosclerosis, n (%)	54 (26.6%)	37 (24.0%)	17 (34.7%)
Lacunar, n (%)	42 (20.7%)	28 (18.2%)	14 (28.6%)
Cardioembolism, n (%)	20 (9.9%)	17 (11.0%)	3 (6.1%)
Other, n (%)	5 (2.5%)	3 (1.9%)	2 (4.0%)	0.138
Undetermined, n (%)	81 (39.9%)	68 (44.1%)	13 (26.5%)
Modified Rankin Scale	2 (3)	1 (3)	2 (2)	0.021
NIH Stroke Scale	3 (5)	3 (4)	5 (7)	0.047

Parameters	Non-recurrent Stroke	Recurrent Stroke	p
Laboratory parameters
Glucose (mg/dL)	111 (50)	117 (40)	0.541
GFR (mL/min/1.73 m²)	85 (23)	77 (33)	0.018
Alanine Aminotransferase (U/L)	15 (11)	15 (18)	0.737
Aspartate Aminotransferase (U/L)	18 (8)	18 (13)	0.372
Sodium (mEq/L)	140 (3)	140 (5)	0.657
Potassium (mEq/L)	4.3 (±0.5)	4.3 (±0.5)	0.768
Triglyceride (mg/dL)	135 (98)	128 (74)	0.916
Total cholesterol (mg/dL)	186 (±44.4)	178 (±51)	0.185
Low-density lipoprotein (mg/dL)	111 (±37.3)	108 (±41.4)	0.561
High-density lipoprotein (mg/dL)	42 (18)	42 (16)	0.632
White Blood Cell (n, x10³⁾	8.15 (±2.44)	8.20 (±2.87)	0.924
Hemoglobin (g/dL)	13.0 (±2)	12.5 (±2.3)	0.112
Platelet (n, x103)	233 (96)	249 (84)	0.052
PDW (%)	16.7 (±2.6)	16.5 (±2.5)	0.509
Plateletcrit (%)	0.22 (0.07)	0.24 (0.09)	0.047
Neutrophil (n, x10³⁾	4.75 (2.22)	4.60 (2.88)	0.881
Lymphocyte (n, x10³⁾	2.05 (±0.69)	1.95 (±0.86)	0.141
RDW (fL)	15.2 (2.1)	16.3 (3.8)	0.001
Free T3 (ng/L)	2.45 (0.64)	2.37 (0.80)	0.261
Free T4 (ng/dL)	1.02 (0.20)	1.03 (0.22)	0.528
TSH (mIU/L)	1.36 (1.32)	1.33 (1.28)	0.885
Echocardiographic parameters
Left Ventricular End-Diastolic Diameter (mm)	44 (4)	44 (4)	0.4
Left Ventricular End-Systolic Diameter (mm)	29 (4)	29 (4)	0.691
Left Ventricular Ejection Fraction (%)	59.88 (6.3)	59.6 (8.2)	0.75
Left Ventricular Mass (gr)	203.05 (69)	207.28 (67)	0.949
Left Ventricular Mass Index (gr/m²)	109.49 (31.7)	109 (38.1)	0.991
Relative Wall Thickness	0.54 (±0.07)	0.55 (±0.07)	0.574
Aortic Diameter (mm)	33.46 (±3.9)	33.49 (±4.3)	0.908
Interventricular Septal Thickness (mm)	12 (2)	13 (3)	0.36
Posterior Wall Thickness (mm)	12 (2)	12 (2)	0.563
Left Atrial Diameter (mm)	36 (5)	37 (4)	0.275
Estimated Pulmonary Artery Pressure (mmHg)	9 (15.8)	16 (17.8)	0.009
Aortic Regurgitation (≥moderate), n (%)	2 (1.3)	3 (6.1)	0.058
Mitral Regurgitation (≥moderate), n (%)	4 (2.6)	3 (6.1)	0.363
Tricuspid Regurgitation (≥moderate), n (%)	6 (3.9)	2 (4.1)	0.616
Left Ventricular Geometry
Concentric Hypertrophy	82 (53.2)	26 (53.1)
Concentric Remodeling	64 (41.6)	21 (42.9)	0.991
Eccentric Hypertrophy	4 (2.6)	1 (2)
Normal Geometry	4 (2.6)	1 (2)

Parameter	Univariate analysis		Multivariate analysis
Parameter	β	p	β	p	Hazard Ratio (95% CI)
Hypertension	1.239	0.130
Atrial Fibrillation	-0.286	0.751
Aortic Arch Calcification (≥1)	1.260	0.007	1.265	0.001	3.544 (1.653 - 7.598)
Glomerular Filtration Rate	-0.008	0.432
Estimated Pulmonary Artery Pressure	0.015	0.190
NIH Stroke Scale	-0.041	0.567
Modified Rankin Scale	0.201	0.398
Anticoagulant	0.863	0.174
RAS Inhibitor	0.259	0.621
CHA₂DS₂-VASc Score	-0.128	0.564
RDW	0.135	0.070	0.194	0.008	1.214 (1.053- 1.400)
Aortic Regurgitation	2.270	0.097	2.376	0.066	10.766 (0.857 - 135.171)
Constant	-4.652	0.004

AUC	p	95% CI	Sensitivity	Specificity	PPV	NPV
0.657	0.001	0.572 - 0.742	0.755	0.558	33.33%	87.76%

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