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CLINICAL RESEARCH: MYOCARDIAL INFARCTION AND STROKE

Young Adult Myocardial Infarction and Ischemic Stroke

The Role of Paradoxical Embolism and Thrombophilia (The YAMIS Study)

Sanjay Sastry, MBChB, MRCP^_*, Graham Riding, FRCS^_*, Julie Morris, MSc, David Taberner, FRCP, FRCPath, Nicola Cherry, MD, PhD, FRCP, Anthony Heagerty, MD, FRCP, FMedSci^|| and Charles McCollum, FRCS, MD^_*,_*

^_* Academic Surgery Unit, South Manchester University Hospital, Manchester, United Kingdom
Department of Medical Statistics, South Manchester University Hospital, Manchester, United Kingdom
Thrombosis Reference Centre, South Manchester University Hospital, Manchester, United Kingdom
^|| Department of Medicine, Manchester Royal Infirmary, Manchester, United Kingdom
Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada

Manuscript received September 8, 2005; revised manuscript received February 27, 2006, accepted February 28, 2006.

^_* Reprint requests and correspondence: Prof. Charles N. McCollum, Academic Surgery Unit, South Manchester University Hospital, Southmoor Road, Manchester, M23 9LT, United Kingdom. (Email: cnmcc{at}man.ac.uk).

OBJECTIVES: We aimed to investigate the frequency of venous-to-arterial circulation shunts (v-aCS), usually caused by patent foramen ovale (PFO), and thrombophilia in young adults suffering myocardial infarction (MI) and ischemic stroke (IS) and matched healthy control subjects.

BACKGROUND: The cause of MI and IS in young adults is often uncertain, and paradoxical embolism might be more frequent than previously thought.

METHODS: Young adults (ages 16 to 39 years) surviving MI (n = 101) and IS (n = 101) between 1993 and 1998 were matched by age and gender to 202 control subjects from the same general practitioner practices. The v-aCS were detected by transcranial Doppler after intravenous microbubble ultrasound contrast; "significant" v-aCS (15 microbubble emboli) correlated with PFO on transesophageal echocardiography. A "major" v-aCS was >50 microbubbles spontaneously or >10 microbubbles spontaneously with >80 after provocation. Venous blood was taken for a thrombophilia screen.

RESULTS: Myocardial infarction, more frequent in men, was associated with the usual cardiovascular risk factors. More women suffered IS, which was associated only with migraine and hypertension. Neither "significant" nor "major" v-aCS were associated with MI. "Major" v-aCS was found in 24 (25%) IS cases compared with 12 (12%) control subjects (odds ratio 2.80, 95% confidence interval 1.21 to 6.84; p = 0.016). Thrombophilia was not significantly associated with either MI or IS.

CONCLUSIONS: Only "major" v-aCS were associated with stroke in young adults. Closure of smaller v-aCS might not be justified.

Abbreviations and Acronyms   APCr = activated protein C resistance   CI = confidence interval   GP = general practitioner   ICD = International Classification of Diseases   IS = ischemic stroke   MI = myocardial infarction   OR = odds ratio   PFO = patent foramen ovale   TCD = transcranial Doppler   TOE = transesophageal echocardiography   v-aCS = venous-to-arterial circulation shunt

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