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  • Updated 03.18.2021
  • Released 04.10.1995
  • Expires For CME 03.18.2024

Stroke associated with myocardial infarction

Introduction

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. An analysis of a total 11,622,528 American patients of acute myocardial infarction recorded 183,896 (1.6%) concomitant acute ischemic stroke. Out of 1,842,529 acute ST-elevation myocardial infarction patients, 22,268 (1.2%) had concomitant acute ischemic stroke. Similarly, out of a total 11,622,528 acute myocardial infraction, 23,422 (0.2%) patients had simultaneous intracranial hemorrhage. 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. There is a significantly increased risk of vascular dementia after myocardial infarction. The risk is much more in patients who have experienced stroke after myocardial infarction. It is extremely important to identify stroke-prone patients after myocardial infarction and to institute appropriate preventive measures. Increased ticagrelor (a platelet aggregation inhibitor) usage in the management of acute myocardial infarction has led to a decreased incidence of ischemic stroke. In some preliminary reports, cangrelor infusion has also shown promise. 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 1 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 (87). 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 (30). 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 (14).

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