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Meta-Analysis Comparing the Frequency of Carotid Artery Stenosis in Patients With Atrial Fibrillation and Vice Versa

Published:October 13, 2020DOI:https://doi.org/10.1016/j.amjcard.2020.10.017
      Atrial fibrillation (AF) and carotid stenosis (CS) can coexist and this association has been reported to result in a higher risk of stroke than attributed to either condition alone. Here we aimed to summarize the data on the association of CS and AF. MEDLINE and Embase were searched to identify all published studies providing relevant data through February 27, 2020. Random-effects meta-analysis method was used to pool estimates of prevalence. Heterogeneity was assessed by mean I-squared statistic. Forty-eight studies were included, 20 reporting on the prevalence of carotid disease in a pooled population of 49,070 AF patients, and 28 on the prevalence of AF in a total of 2,288,265 patients with carotid disease. The pooled prevalence of CS in AF patients was 12.4% (95% confidence interval [CI] 8.7 to 16.0, I2 93%; n = 3,919), ranging from 4.4% to 24.3%. The pooled prevalence of carotid plaque was 48.4% (95% CI 35.2 to 61.7, I2 = 99%; n = 4292). The prevalence of AF in patients with CS was 9.3% (95% CI 8.7 to 10.0, I2 99%; n = 2,286,518), ranging from 3.6% to 10.0%. This prevalence was much higher (p <0.001) in patients undergoing carotid artery stenting (12.7%, 95% CI 11.3 to 14.02, I2 38.3%) compared with those undergoing carotid endarterectomy (6.9%, 95% CI 8.3 to 10.4, I2 94.1%). There was no difference in AF prevalence between patients with CS, with and without previous cerebrovascular event (p >0.05). In conclusion, AF and CS frequently coexist, with about one in ten patients with AF having CS, and vice versa. In addition, nonstenotic carotid disease is present in about half of AF patients. These findings have important implications for AF screening in patients with CS, stroke prevention, and the opportunities to intervene on common risk factors.
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      References

      1. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016.
        Lancet. 2017; 390: 1151-1210
        • Wolf PA
        • Abbott RD
        • Kannel WB
        Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.
        Stroke. 1991; 22: 983-988
        • Krishnamurthi RV
        • Ikeda T
        • Feigin VL
        Global, regional and country-specific burden of ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage: a systematic analysis of the Global Burden of Disease Study 2017.
        Neuroepidemiology. 2020; 54: 171-179
        • Flaherty ML
        • Kissela B
        • Khoury JC
        • Alwell K
        • Moomaw CJ
        • Woo D
        • Khatri P
        • Ferioli S
        • Adeoye O
        • Broderick JP
        • Kleindorfer D
        Carotid artery stenosis as a cause of stroke.
        Neuroepidemiology. 2013; 40: 36-41
        • Lehtola H
        • Airaksinen KEJ
        • Hartikainen P
        • Hartikainen JEK
        • Palomäki A
        • Nuotio I
        • Ylitalo A
        • Kiviniemi T
        • Mustonen P
        Stroke recurrence in patients with atrial fibrillation: concomitant carotid artery stenosis doubles the risk.
        Eur J Neurol. 2017; 24: 719-725
        • Chang YJ
        • Ryu SJ
        • Lin SK
        Carotid artery stenosis in ischemic stroke patients with nonvalvular atrial fibrillation.
        Cerebrovasc Dis. 2002; 13: 16-20
        • Hoy D
        • Brooks P
        • Woolf A
        • Blyth F
        • March L
        • Bain C
        • Baker P
        • Smith E
        • Buchbinder R
        Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement.
        J Clin Epidemiol. 2012; 65: 934-939
        • Higgins JP
        • Thompson SG
        Quantifying heterogeneity in a meta-analysis.
        Stat Med. 2002; 21: 1539-1558
        • Qureshi AI
        • Chaudhry SA
        • Qureshi MH
        • Suri MF
        Rates and predictors of 5-year survival in a national cohort of asymptomatic elderly patients undergoing carotid revascularization.
        Neurosurgery. 2015; 76: 34-40
        • Riera-Vázquez R
        • Lozano-Vilardell P
        • Manuel-Rimbau E
        • Juliá-Montoya J
        • Corominas-Roura C
        • Merino-Mairal OA
        Carotid endarterectomy in high-risk patients.
        Angiologia. 2006; 58: 287-294
        • Rong X
        • Yang W
        • Garzon-Muvdi T
        • Ye X
        • Caplan JM
        • Colby GP
        • Coon AL
        • Tamargo RJ
        • Huang J
        Risk factors associated with ipsilateral ischemic events following carotid endarterectomy for carotid artery stenosis.
        World Neurosurg. 2016; 89: 611-619
        • Roussopoulou A
        • Lazaris A
        • Tsivgoulis G
        • Krogias C
        • Moulakakis K
        • Georgiadis GS
        • Kakisis JD
        • Zompola C
        • Faissner S
        • Palaiodimou L
        • Theodorou A
        • Hummel T
        • Safouris A
        • Matsota P
        • Zervas P
        • Triantafyllou S
        • Voumvourakis C
        • Lazarides M
        • Geroulakos G
        • Vasdekis SN
        Risk of perioperative neck hematoma in TIA and non-disabling stroke patients with symptomatic carotid artery stenosis undergoing endarterectomy within 14 days from cerebrovascular event.
        J Neurol Sci. 2020; 409116590
        • Shah Z
        • Masoomi R
        • Thapa R
        • Wani M
        • Chen J
        • Dawn B
        • Rymer M
        • Gupta K
        Optimal medical management reduces risk of disease progression and ischemic events in asymptomatic carotid stenosis patients: a long-term follow-up study.
        Cerebrovasc Dis. 2017; 44: 150-159
        • Siddiq F
        • Adil MM
        • Malik AA
        • Qureshi MH
        • Qureshi AI
        Effect of carotid revascularization endarterectomy versus stenting trial results on the performance of carotid artery stent placement and carotid endarterectomy in the United States.
        Neurosurgery. 2015; 77: 726-732
        • Stanziale SF
        • Marone LK
        • Boules TN
        • Brimmeier JA
        • Hill K
        • Makaroun MS
        • Wholey MH
        Carotid artery stenting in octogenarians is associated with increased adverse outcomes.
        J Vasc Surg. 2006; 43: 297-304
        • Tedesco MM
        • Coogan SM
        • Dalman RL
        • Haukoos JS
        • Lane B
        • Loh C
        • Penkar TS
        • Lee JT
        Risk factors for developing postprocedural microemboli following carotid interventions.
        J Endovasc Ther. 2007; 14: 561-567
        • Tsialtas D
        • Bolognesi MG
        • Assimopoulos S
        • Volpi R
        • Bolognesi R
        Electrocardiographic and echocardiographic features in patients with major arterial vascular disease assigned to surgical revascularization.
        Acta Cardiol. 2019; 74: 501-507
        • Tu JV
        • Wang H
        • Bowyer B
        • Green L
        • Fang J
        • Kucey D
        Risk factors for death or stroke after carotid endarterectomy: observations from the Ontario Carotid Endarterectomy Registry.
        Stroke. 2003; 34: 2568-2573
        • Watanabe M
        • Chaudhry SA
        • Adil MM
        • Alqadri SL
        • Majidi S
        • Semaan E
        • Qureshi AI
        The effect of atrial fibrillation on outcomes in patients undergoing carotid endarterectomy or stent placement in general practice.
        J Vasc Surg. 2015; 61: 927-932
        • Chen CY
        • Weng WC
        • Wu CL
        • Huang WY
        Association between gender and stoke recurrence in ischemic stroke patients with high-grade carotid artery stenosis.
        J Clin Neurosci. 2019; 67: 62-67
        • Keyhani S
        • Madden E
        • Cheng EM
        • Bravata DM
        • Halm E
        • Austin PC
        • Ghasemiesfe M
        • Abraham AS
        • Zhang AJ
        • Johanning JM
        Risk prediction tools to improve patient selection for carotid endarterectomy among patients with asymptomatic carotid stenosis.
        JAMA Surg. 2019; 154: 336-344
        • Choi JH
        • Pile-Spellman J
        • Brisman JL
        US nationwide trends in carotid revascularization: hospital outcome and predictors of outcome from 1998 to 2007.
        Acta Neurol Scand. 2014; 129: 85-93
        • Dharmasaroja PA
        • Intharakham K
        Risk factors for carotid stenosis in Thai patients with ischemic stroke/TIA.
        Angiology. 2010; 61: 789-792
        • Díaz-Pérez J
        • Parrilla G
        • Espinosa de Rueda M
        • Cabrera-Maqueda JM
        • García-Villalba B
        • Alba-Isasi MT
        • Morales A
        • Zamarro J
        Mechanical thrombectomy in acute stroke due to carotid occlusion: a series of 153 consecutive patients.
        Cerebrovasc Dis (Basel, Switzerland). 2018; 46: 132-141
        • Doig D
        • Turner EL
        • Dobson J
        • Featherstone RL
        • de Borst GJ
        • Brown MM
        • Richards T
        Incidence, impact, and predictors of cranial nerve palsy and haematoma following carotid endarterectomy in the international carotid stenting study.
        Eur J Vasc Endovasc Surg. 2014; 48: 498-504
        • Pucite E
        • Slisers M
        • Miglane E
        • Krievins D
        • Dadzite J
        • Krievina I
        Health-related quality of life among patients with severe carotid disease.
        Cerebrovasc Dis. 2016; 41: 238
        • Colussi G
        • Zuttion F
        • Bais B
        • Dolso P
        • Valente M
        • Gigli GL
        • Gasparini D
        • Sponza M
        • Catena C
        • Sechi LA
        • Cavarape A
        Pre-procedural statin use is associated with improved long-term survival and reduced major cardiovascular events in patients undergoing carotid artery stenting: a retrospective study.
        J Clin Med. 2018; 7: 286
        • Telman G
        • Sprecher E
        • Kouperberg E
        Carotid disease in acute ischemic stroke patients of Northern Israel.
        Acta Neurol Scand. 2012; 126: 398-403
        • Giri J
        • Parikh SA
        • Kennedy KF
        • Weinberg I
        • Donaldson C
        • Hawkins BM
        • McCormick DJ
        • Jackson B
        • Armstrong EJ
        • Ramchand P
        • White CJ
        • Jaff MR
        • Rosenfield K
        • Yeh RW
        Proximal versus distal embolic protection for carotid artery stenting: a national cardiovascular data registry analysis.
        JACC Cardiovasc Interv. 2015; 8: 609-615
        • Willeit K
        • Pechlaner R
        • Egger G
        • Weger S
        • Oberhollenzer M
        • Willeit J
        • Kiechl S
        Carotid atherosclerosis and incident atrial fibrillation.
        Arterioscler Thromb Vasc Biol. 2013; 33: 2660-2665
        • Kapral MK
        • Wang H
        • Austin PC
        • Fang J
        • Kucey D
        • Bowyer B
        • Tu JV
        Sex differences in carotid endarterectomy outcomes: results from the Ontario Carotid Endarterectomy Registry.
        Stroke. 2003; 34: 1120-1125
        • Keyhani S
        • Madden E
        • Cheng EM
        • Bravata DM
        • Halm E
        • Austin PC
        • Ghasemiesfe M
        • Abraham AS
        • Zhang AJ
        • Johanning JM
        Risk prediction tools to improve patient selection for carotid endarterectomy among patients with asymptomatic carotid stenosis.
        JAMA Surg. 2019; 154: 336-344
        • Mazzaccaro D
        • Modafferi A
        • Malacrida G
        • Nano G
        Assessment of long-term survival and stroke after carotid endarterectomy and carotid stenting in patients older than 80 years.
        J Vasc Surg. 2019; 70: 522-529
        • Mudra H
        • Staubach S
        • Hein-Rothweiler R
        • Segerer M
        • Strohm H
        • Weber H
        • Ledwoch J
        Long-term outcomes of carotid artery stenting in clinical practice.
        Circ Cardiovasc Interv. 2016; 9e003940
        • Ogata T
        • Inoue T
        • Okada Y
        Outcome of 312 Japanese patients with carotid endarterectomy and factors associated with cardiovascular events–a single-center study in Japan.
        J Stroke Cerebrovasc Dis. 2014; 23: 529-533
        • Paciaroni M
        • Inzitari D
        • Agnelli G
        • Caso V
        • Balucani C
        • Grotta JC
        • Sarraj A
        • Sung-Il S
        • Chamorro A
        • Urra X
        • Leys D
        • Henon H
        • Cordonnier C
        • Dequatre N
        • Aguettaz P
        • Alberti A
        • Venti M
        • Acciarresi M
        • D'Amore C
        • Zini A
        • Vallone S
        • Dell'Acqua ML
        • Menetti F
        • Nencini P
        • Mangiafico S
        • Barlinn K
        • Kepplinger J
        • Bodechtel U
        • Gerber J
        • Bovi P
        • Cappellari M
        • Linfante I
        • Dabus G
        • Marcheselli S
        • Pezzini A
        • Padovani A
        • Alexandrov AV
        • Shahripour RB
        • Sessa M
        • Giacalone G
        • Silvestrelli G
        • Lanari A
        • Ciccone A
        • De Vito A
        • Azzini C
        • Saletti A
        • Fainardi E
        • Orlandi G
        • Chiti A
        • Gialdini G
        • Silvestrini M
        • Ferrarese C
        • Beretta S
        • Tassi R
        • Martini G
        • Tsivgoulis G
        • Vasdekis SN
        • Consoli D
        • Baldi A
        • D'Anna S
        • Luda E
        • Varbella F
        • Galletti G
        • Invernizzi P
        • Donati E
        • De Lodovici ML
        • Bono G
        • Corea F
        • Sette MD
        • Monaco S
        • Riva M
        • Tassinari T
        • Scoditti U
        • Toni D
        Intravenous thrombolysis or endovascular therapy for acute ischemic stroke associated with cervical internal carotid artery occlusion: the ICARO-3 study.
        J Neurol. 2015; 262: 459-468
        • Rizos T
        • Horstmann S
        • Dittgen F
        • Täger T
        • Jenetzky E
        • Heuschmann P
        • Veltkamp R
        Preexisting heart disease underlies newly diagnosed atrial fibrillation after acute ischemic stroke.
        Stroke. 2016; 47: 336-341
        • Shibazaki K
        • Kimura K
        • Iguchi Y
        • Aoki J
        • Sakai K
        • Kobayashi K
        Plasma brain natriuretic peptide predicts death during hospitalization in acute ischaemic stroke and transient ischaemic attack patients with atrial fibrillation.
        Eur J Neurol. 2011; 18: 165-169
        • Yang PS
        • Pak HN
        • Park DH
        • Yoo J
        • Kim TH
        • Uhm JS
        • Kim YD
        • Nam HS
        • Joung B
        • Lee MH
        • Heo JH
        Non-cardioembolic risk factors in atrial fibrillation-associated ischemic stroke.
        PLoS One. 2018; 13e0201062
        • Shang L
        • Zhao Y
        • Shao M
        • Sun H
        • Feng M
        • Li Y
        • Zhou X
        • Tang B
        The association of CHA2DS2-VASc score and carotid plaque in patients with non-valvular atrial fibrillation.
        PLoS One. 2019; 14e0210945
        • Siegler JE
        • Thon JM
        • Woo JH
        • Do D
        • Messé SR
        • Cucchiara B
        Prevalence of nonstenotic carotid plaque in stroke due to atrial fibrillation compared to embolic stroke of undetermined source.
        J Stroke Cerebrovasc Dis. 2019; 28104289
        • Akanksha WG
        • Paramdeep K
        • Gagandeep S
        • Rajinder B
        • Birinder SP
        • Monika S
        • Shavinder S
        • Clarence JS
        • Shweta JV
        • Sharma M
        • Jeyaraj DP
        Clinical features, risk factors, and short-term outcome of ischemic stroke, in patients with atrial fibrillation: data from a population-based study.
        Ann Indian Acad Neurol. 2017; 20: 289-293
        • Kanter MC
        • Tegeler CH
        • Pearce LA
        • Weinberger J
        • Feinberg WM
        • Anderson DC
        • Gomez CR
        • Rothrock JF
        • Helgason CM
        • Hart RG
        Carotid stenosis in patients with atrial fibrillation. Prevalence, risk factors, and relationship to stroke in the Stroke Prevention in Atrial Fibrillation Study.
        Arch Intern Med. 1994; 154: 1372-1377
        • Paciaroni M
        • Agnelli G
        • Ageno W
        • Caso V
        • Corea F
        • Lanari A
        • Alberti A
        • Previdi P
        • Fedele M
        • Manina G
        • Vedovati C
        • Venti M
        • Billeci AM
        • Batta M
        • Galli L
        • Silvestrelli G
        Risk factors for cerebral ischemic events in patients with atrial fibrillation on warfarin for stroke prevention.
        Atherosclerosis. 2010; 212: 564-566
        • Proietti M
        • Calvieri C
        • Malatino L
        • Signorelli S
        • Corazza GR
        • Perticone F
        • Vestri AR
        • Loffredo L
        • Davì G
        • Violi F
        • Basili S
        Relationship between carotid intima-media thickness and non valvular atrial fibrillation type.
        Atherosclerosis. 2015; 238: 350-355
        • Chen LY
        • Leening MJ
        • Norby FL
        • Roetker NS
        • Hofman A
        • Franco OH
        • Pan W
        • Polak JF
        • Witteman JC
        • Kronmal RA
        • Folsom AR
        • Nazarian S
        • Stricker BH
        • Heckbert SR
        • Alonso A
        Carotid intima-media thickness and arterial stiffness and the risk of atrial fibrillation: The Atherosclerosis Risk in Communities (ARIC) Study, Multi-Ethnic Study of Atherosclerosis (MESA), and the Rotterdam Study.
        J Am Heart Assoc. 2016; 5e002907
        • Benbir G
        • Uluduz D
        • Ince B
        • Bozluolcay M
        Atherothrombotic ischemic stroke in patients with atrial fibrillation.
        Clin Neurol Neurosurg. 2007; 109: 485-490
        • Bogousslavsky J
        • Van Melle G
        • Regli F
        • Kappenberger L
        Pathogenesis of anterior circulation stroke in patients with nonvalvular atrial fibrillation: the Lausanne Stroke Registry.
        Neurology. 1990; 40: 1046-1050
        • Cho DH
        • Choi JI
        • Choi J
        • Kim YG
        • Oh SK
        • Kook H
        • Lee KN
        • Shim J
        • Park SM
        • Shim WJ
        • Kim YH
        Impact of carotid atherosclerosis in CHA2DS2-VASc-based risk score on predicting ischemic stroke in patients with atrial fibrillation.
        Korean J Intern Med. 2020; https://doi.org/10.3904/kjim.2019.099
        • Deguchi I
        • Hayashi T
        • Ohe Y
        • Kato Y
        • Fukuoka T
        • Maruyama H
        • Horiuchi Y
        • Sano H
        • Nagamine Y
        • Tanahashi N
        CHADS2 score/CHA2 DS2 -VASc score and major artery occlusion in cardioembolic stroke patients with nonvalvular atrial fibrillation.
        Int J Stroke. 2014; 9: 576-579
        • Fox KAA
        • Velentgas P
        • Camm AJ
        • Bassand JP
        • Fitzmaurice DA
        • Gersh BJ
        • Goldhaber SZ
        • Goto S
        • Haas S
        • Misselwitz F
        • Pieper KS
        • Turpie AGG
        • Verheugt FWA
        • Dabrowski E
        • Luo K
        • Gibbs L
        • Kakkar AK
        Outcomes associated with oral anticoagulants plus antiplatelets in patients with newly diagnosed atrial fibrillation.
        JAMA Netw Open. 2020; 3e200107
        • Kochar A
        • Hellkamp AS
        • Lokhnygina Y
        • Jones WS
        • Becker RC
        • Berkowitz SD
        • Breithardt G
        • Fox KAA
        • Halperin JL
        • Hankey GJ
        • Mahaffey KW
        • Nessel CC
        • Singer DE
        • Piccini JP
        • Patel MR
        Efficacy and safety of rivaroxaban compared with warfarin in patients with carotid artery disease and nonvalvular atrial fibrillation: insights from the ROCKET AF trial.
        Clin Cardiol. 2018; 41: 39-45
        • Lip GY
        • Nieuwlaat R
        • Pisters R
        • Lane DA
        • Crijns HJ
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation.
        Chest. 2010; 137: 263-272
        • Alkhouli M
        • Friedman PA
        Ischemic stroke risk in patients with nonvalvular atrial fibrillation: JACC review topic of the week.
        J Am Coll Cardiol. 2019; 74: 3050-3065
        • Goyal M
        • Singh N
        • Marko M
        • Hill MD
        • Menon BK
        • Demchuk A
        • Coutts SB
        • Almekhlafi MA
        • Ospel JM
        Embolic stroke of undetermined source and symptomatic nonstenotic carotid disease.
        Stroke. 2020; 51: 1321-1325
        • Kamtchum-Tatuene J
        • Noubiap J
        • Wilman A
        • Saqqur M
        • Shuaib A
        • Jickling G
        High-risk plaques and risk of stroke in asymptomatic carotid stenosis.
        JAMA Neurol. 2020; e202658
        • Ntaios G
        • Papavasileiou V
        • Milionis H
        • Makaritsis K
        • Manios E
        • Spengos K
        • Michel P
        • Vemmos K
        Embolic strokes of undetermined source in the Athens stroke registry: a descriptive analysis.
        Stroke. 2015; 46: 176-181
        • January CT
        • Wann LS
        • Calkins H
        • Chen LY
        • Cigarroa JE
        • Cleveland Jr., JC
        • Ellinor PT
        • Ezekowitz MD
        • Field ME
        • Furie KL
        • Heidenreich PA
        • Murray KT
        • Shea JB
        • Tracy CM
        • Yancy CW
        2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
        J Am Coll Cardiol. 2019; 74: 104-132