Review Article| Volume 425, 117444, June 15, 2021

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Stroke risk associated with carotid and aortic atherosclerosis in patients with atrial fibrillation: A systematic review

Published:April 10, 2021DOI:


      • Carotid atherosclerosis is associated with an increased risk of stroke in patients with atrial fibrillation (AF).
      • Aortic plaque alone does not predict incident ischemic stroke in patients with AF.
      • Carotid intima-media thickness and characteristics of carotid and aortic plaques might improve stroke prediction in patients with AF.
      • The benefit of these imaging features in improving stroke prediction in patients with AF needs to be evaluated.



      This review aimed to summarize the evidence on the risk of thromboembolism associated with carotid and aortic atherosclerosis in patients with AF, and the potential impact of their inclusion in current stroke risk stratification scores.


      MEDLINE, Web of Science and EMBASE were systematically searched to identify all published studies providing relevant data through 28 February 2021.


      We identified 10 eligible studies. There was high heterogeneity across studies, precluding a meta-analysis. Carotid stenosis was not associated with incident ischemic stroke in three prospective studies, including the SPAF II trial and the ROCKET-AF trial. An association between carotid stenosis and thromboembolism was found in two studies, with a potential reporting bias due to their retrospective design. The evidence suggesting that carotid plaque predicts stroke or transient ischemic attack in AF patients were more consistent in the four studies evaluating this association. The inclusion of carotid plaque and carotid intima-media thickness (cIMT) into stroke risk stratification tools for AF patients improved their performance. Data on the association of aortic plaque with thromboembolism is scarce in patients with AF. The two studies reporting on this association suggest that aortic plaque alone does not predict incident ischemic stroke.


      Available data suggest an association of carotid atherosclerosis with the risk of stroke and transient ischemic attack in patients with AF. Future studies should evaluate whether incorporating cIMT and characteristics of carotid and aortic plaques into scoring systems would improve stroke prediction and prevention in patients with AF.


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