Catheterization and Cardiovascular Interventions

Volume 84, Issue 3 pp. 479-485

Valvular and Structural Heart Diseases

Association of ischemic stroke, hormone therapy, and right to left shunt in postmenopausal women

Nancy C. Greep MD,

Nancy C. Greep MD

Department of Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, California

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David S. Liebeskind MD,

David S. Liebeskind MD

Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California

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Rubine Gevorgyan MD,

Rubine Gevorgyan MD

Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, California

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Tam Truong MD,

Tam Truong MD

University of Arizona, Sarver Heart Center, Tucson, Arizona

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Bennett Cua MD,

Bennett Cua MD

Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut

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Chi-Hong Tseng PhD,

Chi-Hong Tseng PhD

Department of Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, California

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David W. Dodick MD,

David W. Dodick MD

Department of Neurology, Mayo Clinic, Scottsdale, Arizona

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Bart M. Demaerschalk MD,

Bart M. Demaerschalk MD

Department of Neurology, Mayo Clinic, Scottsdale, Arizona

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David E. Thaler MD,

David E. Thaler MD

Department of Neurology, Tufts University, Boston, Massachusetts

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Jonathan M. Tobis MD,

Corresponding Author

Jonathan M. Tobis MD

Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, California

Correspondence to: Jonathan Tobis, M.D., Director of Interventional Cardiology, Factor Building B- 976 CHS, PO Box 951717, Los Angeles, CA 90095-1717. E-mail: [email protected]Search for more papers by this author

Nancy C. Greep MD,

Nancy C. Greep MD

Department of Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, California

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David S. Liebeskind MD,

David S. Liebeskind MD

Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California

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Rubine Gevorgyan MD,

Rubine Gevorgyan MD

Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, California

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Tam Truong MD,

Tam Truong MD

University of Arizona, Sarver Heart Center, Tucson, Arizona

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Bennett Cua MD,

Bennett Cua MD

Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut

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Chi-Hong Tseng PhD,

Chi-Hong Tseng PhD

Department of Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, California

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David W. Dodick MD,

David W. Dodick MD

Department of Neurology, Mayo Clinic, Scottsdale, Arizona

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Bart M. Demaerschalk MD,

Bart M. Demaerschalk MD

Department of Neurology, Mayo Clinic, Scottsdale, Arizona

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David E. Thaler MD,

David E. Thaler MD

Department of Neurology, Tufts University, Boston, Massachusetts

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Jonathan M. Tobis MD,

Corresponding Author

Jonathan M. Tobis MD

Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, California

First published: 12 February 2014

https://doi.org/10.1002/ccd.25431

Citations: 1

Conflict of interest: Nothing to report.

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Abstract

Background

Postmenopausal hormone therapy (HT) increases the risk of venous thrombosis and ischemic stroke.

Objectives

We postulated that HT might increase the risk of ischemic stroke by promoting venous clots that travel to the brain through a right to left shunt (RLS).

Methods

A total of 2,389 records were studied. After eliminating the premenopausal patients, and those with TIAs and non-ischemic strokes, the medical records of 1846 postmenopausal women hospitalized at four institutions for ischemic stroke were reviewed to identify those who had undergone an adequate study to assess for RLS. The proportion of women with a shunt in users and non-users of HT was compared in stroke patients and in a reference population consisting of postmenopausal women undergoing elective cardiac catheterization.

Results

There were 363 (20%) records that had complete data and were included in the analysis. A shunt was more prevalent in patients with a cryptogenic stroke than in patients with a stroke of known cause (55/88 (63%) vs. 53/275 (19%), P < 0.001). In patients with a stroke of known cause, the frequency of a shunt was similar to that in reference women 31/136 (23%), and the proportion of women with a shunt was similar in non-users and current users of HT (14% vs. 20%, P = 0.40). However, among patients with a cryptogenic stroke, the prevalence of a shunt was 1.5 times higher in current users than non-users of HT (82% vs. 56%, P = 0.04).

Conclusions

Supporting Information

REFERENCES

1 Wassertheil-Smoller S, Hendrix SL, Limacher M, et al. Effect of estrogen plus progestin on stroke in postmenopausal women: The Women's Health Initiative: A randomized trial. JAMA 2003; 289: 2673–2684.
10.1001/jama.289.20.2673
CAS PubMed Web of Science® Google Scholar
2 Hendrix SL, Wassertheil-Smoller S, Johnson KC, et al. Effects of conjugated equine estrogen on stroke in the Women's Health Initiative. Circulation 2006; 113: 2425–2434.
10.1161/CIRCULATIONAHA.105.594077
CAS PubMed Web of Science® Google Scholar
3 Canonico M, Plu-Bureau G, Lowe GD, Scarabin PY. Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: Systematic review and meta-analysis. BMJ 2008; 336: 1227–1231.
10.1136/bmj.39555.441944.BE
PubMed Web of Science® Google Scholar
4 Sacco RL, Ellenberg JH, Mohr JP, et al. Infarcts of undetermined cause: The NINCDS Stroke Data Bank. Ann Neurol 1989; 25: 382–390.
10.1002/ana.410250410
CAS PubMed Web of Science® Google Scholar
5 Meier B, Lock JE. Contemporary management of patent foramen ovale. Circulation 2003; 107: 5–9.
10.1161/01.CIR.0000046073.34261.C1
PubMed Web of Science® Google Scholar
6 Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988; 318: 1148–1152.
10.1056/NEJM198805053181802
CAS PubMed Web of Science® Google Scholar
7 Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP. Effect of medical treatment in stroke patients with patent foramen ovale: Patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002; 105: 2625–2631.
10.1161/01.CIR.0000017498.88393.44
PubMed Web of Science® Google Scholar
8 Dowson A, Mullen MJ, Peatfield R, et al. Migraine Intervention With STARFlex Technology (MIST) trial: A prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation 2008; 117: 1397–1404.
10.1161/CIRCULATIONAHA.107.727271
PubMed Web of Science® Google Scholar
9 Zito C, Dattilo G, Oreto G, et al. Patent foramen ovale: Comparison among diagnostic strategies in cryptogenic stroke and migraine. Echocardiography 2009; 26: 495–503.
10.1111/j.1540-8175.2008.00852.x
CAS PubMed Web of Science® Google Scholar
10 Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute stroke treatment. Stroke 1993; 24: 35–41.
10.1161/01.STR.24.1.35
PubMed Web of Science® Google Scholar
11 National Stroke Association. Available at: http://www.stroke.org/site/PageServer?pagename=RISK. (Accessed on February 20, 2014).
Google Scholar
12 Teague SM, Sharma MK. Detection of paradoxical cerebral echo contrast embolization by transcranial Doppler ultrasound. Stroke 1991; 22: 740–745.
10.1161/01.STR.22.6.740
CAS PubMed Web of Science® Google Scholar
13 Rosenbaum PR. The case-only odds ratio as a causal parameter. Biometrics 2004; 60: 233–240.
10.1111/j.0006-341X.2004.00154.x
PubMed Web of Science® Google Scholar
14 Hagen PT, Scholz DG, Edwards WD. 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; 59: 17–20.
10.1016/S0025-6196(12)60336-X
CAS PubMed Web of Science® Google Scholar
15 Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: A report from the American Heart Association. Circulation 3;125: e2–e220.
Google Scholar
16 Handke M, Harloff A, Olschewski M, Hetzel A, Geibel A. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med 2007; 357: 2262–2268.
10.1056/NEJMoa071422
CAS PubMed Web of Science® Google Scholar
17 Heiss G, Wallace R, Anderson GL, et al. Health risks and benefits 3 years after stopping randomized treatment with estrogen and progestin. JAMA 2008; 299: 1036–1045.
10.1001/jama.299.9.1036
CAS PubMed Web of Science® Google Scholar
18 LaCroix AZ, Chlebowski RT, Manson JE, et al. Health outcomes after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy: A randomized controlled trial. JAMA 2011; 305: 1305–1314.
10.1001/jama.2011.382
CAS PubMed Web of Science® Google Scholar
19 Lobo RA, Clarkson TB. Different mechanisms for benefit and risk of coronary heart disease and stroke in early postmenopausal women: A hypothetical explanation. Menopause 2011; 18: 237–240.
Web of Science® Google Scholar
20 Thaler DE, Saver JL. Cryptogenic stroke and patent foramen ovale. Curr Opin Cardiol 2008; 23: 537–544.
10.1097/HCO.0b013e32831311bd
PubMed Web of Science® Google Scholar
21 Aggarwal K, Jayam VK, Meyer MA, Nayak AK, Nathan S. Thrombus-in-transit and paradoxical embolism. J Am Soc Echocardiogr 2002; 15: 1021–1022.
10.1067/mje.2002.121279
PubMed Web of Science® Google Scholar
22 Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: A meta-analysis of case-control studies. Neurology 2000; 55: 1172–1179.
10.1212/WNL.55.8.1172
CAS PubMed Web of Science® Google Scholar
23 Khairy P, O'Donnell CP, Landzberg MJ. Transcatheter closure versus medical therapy of patent foramen ovale and presumed paradoxical thromboemboli: A systematic review. Ann Intern Med 2003; 139: 753–760.
10.7326/0003-4819-139-9-200311040-00010
PubMed Web of Science® Google Scholar
24 Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366: 991–999.
10.1056/NEJMoa1009639
CAS PubMed Web of Science® Google Scholar
25 Carroll JD, Saver JL, Thaler DE, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013; 368: 1092–1100.
10.1056/NEJMoa1301440
CAS PubMed Web of Science® Google Scholar
26 Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368: 1083–1091.
10.1056/NEJMoa1211716
CAS PubMed Web of Science® Google Scholar
27 Capodanno D, Milazzo G, Vitale L, et al. Updating the evidence on patent foramen ovale closure versus medical therapy in patients with cryptogenic stroke: A systematic review and comprehensive meta-analysis of 2,303 patients from three randomised trials and 2,231 patients from 11 observational studies. EuroIntervention. 2013 Jul 24. pii: 20130608-03. [Epub ahead of print].
Google Scholar
28 Renoux C, Dell'aniello S, Garbe E, Suissa S. Transdermal and oral hormone replacement therapy and the risk of stroke: A nested case–control study. BMJ 2010; 340: c2519.
10.1136/bmj.c2519
PubMed Web of Science® Google Scholar
29 Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991; 151: 933–938.
10.1001/archinte.1991.00400050081016
CAS PubMed Web of Science® Google Scholar
30 Stein PD, Beemath A, Olson RE. Obesity as a risk factor in venous thromboembolism. Am J Med 2005; 118: 978–980.
10.1016/j.amjmed.2005.03.012
PubMed Web of Science® Google Scholar
31 Marchione P, Ghiotto N, Sances G, et al. Clinical implications of patent foramen ovale in migraine with aura. Funct Neurol 2008; 23: 201–205.
PubMed Web of Science® Google Scholar

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Volume84, Issue3

01 September 2014

Pages 479-485

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Association of ischemic stroke, hormone therapy, and right to left shunt in postmenopausal women

Abstract

Background

Objectives

Methods

Results

Conclusions

Supporting Information

REFERENCES

Citing Literature

References

Information

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Association of ischemic stroke, hormone therapy, and right to left shunt in postmenopausal women

Abstract

Background

Objectives

Methods

Results

Conclusions

Supporting Information

REFERENCES

Citing Literature

References

Related

Information