Stroke associated with myocardial infarction

Ravindra Kumar Garg MD (Dr. Garg of King George's Medical University in Lucknow, India, has no relevant financial relationships to disclose.)
Steven R Levine MD, editor. (Dr. Levine of the SUNY Health Science Center at Brooklyn has received honorariums from Genentech for service on a scientific advisory committee and a research grant from Genentech as a principal investigator.)
Originally released April 10, 1995; last updated May 14, 2017; expires May 14, 2020

Overview

Acute myocardial infarction is associated with a low but significant risk of stroke. A relationship between unrecognized myocardial infarction and the risk of stroke has been suggested. Most strokes complicating acute myocardial infarction in patients not receiving thrombolysis are cardioembolic. Stroke in patients with acute myocardial infarction adversely affects the outcome. In patients with coronary artery disease, stroke is also associated with a marked increase in risk of other vascular events like myocardial infarction or stroke (including both ischemic and hemorrhagic stroke), in addition to the risk of death. New-onset atrial fibrillation in patients with acute myocardial infarction not only increases the risk of ischemic stroke, but also enhances the risk of mortality. Thrombolysis-related intracerebral hemorrhage markedly increases the risk of death and disability. Common locations of intracranial hemorrhage are intracerebral, subdural, subarachnoid, and intraventricular. It is extremely important to identify stroke-prone patients after myocardial infarction and to institute appropriate preventive measures. It has been demonstrated that early coronary revascularization diminishes the risk of ischemic stroke with acute myocardial infarction. The risk of stroke has decreased during recent years. Percutaneous coronary intervention, fibrinolysis, acetylsalicylic acid, statins, and P2Y12 inhibitors are predictors of reduced risk of stroke. Ticagrelor, a platelet aggregation inhibitor, significantly further reduces the risk of stroke when added to low-dose aspirin in patients with prior myocardial infarction. In this article, the author has provided the latest information available on this subject.

Key points

 

• Stroke can complicate the course of acute myocardial infarction.

 

• Ischemic strokes are the predominant type of stroke seen in non-ST-segment elevation acute myocardial infarction.

 

• Most ischemic strokes complicating acute myocardial infarction are cardioembolic.

 

• Intracerebral hemorrhage can occur after thrombolysis for acute myocardial infarction.

 

• Development of stroke is one of the major reasons for mortality after coronary artery bypass operations.

 

• Acute myocardial infarction is also an important medical complication of ischemic stroke.

 

• Aspirin, anticoagulants, and early coronary revascularization diminish the risk of ischemic stroke with acute myocardial infarction.

Historical note and terminology

Since the early 19th century, several authors have noted the occurrence of mural thrombi complicating acute myocardial infarction. Virchow postulated that 3 factors predispose patients to thrombosis: (1) injury of the vascular endothelial or endocardial surface, (2) circulatory stasis, and (3) a generalized hypercoagulant state (Virchow 1856). He reported occlusion of arteries in the brain by thrombi, which seemed to have originated in the heart, and named this phenomenon "embolism" (from the Greek word for “plug”).

Gordinier suggested that the sudden arterial plugging of the vessels of the brain, viscera, or extremities indicates involvement of a branch of the left coronary, whereas signs of pulmonary infarct suggest involvement of the right coronary or its branches (Gordinier 1924). Blumer was among the first to extensively discuss the importance of embolism as a complication of cardiac infarction. He stated that mural thrombi are common following cardiac infarction, and that fragments may detach and produce embolic phenomena (Blumer 1937).

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