Speakers. 2015, American Heart Association 1

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Speakers Lee Schwamm, MD, FAHA Executive Vice Chairman of Neurology, Massachusetts General Hospital Director, Stroke Service and Medical Director, MGH TeleHealth,

Smith, MD, MPH, FRCPC, FAHA Associate Professor, Dept of Clinical Neurosciences, Radiology and Community Health Sciences Member, Hotchkiss Brain Institute Cumming

1 Speakers Lee Schwamm, MD, FAHA Executive Vice Chairman of Neurology, Massachusetts General Hospital Director, Stroke Service and Medical Director, MGH TeleHealth, Massachusetts General Hospital Director, Partners TeleStroke Center, Massachusetts General Hospital Chair, Get With The Guidelines-Stroke Committee Eric Edward Smith, MD, MPH, FRCPC, FAHA Associate Professor, Dept of Clinical Neurosciences, Radiology and Community Health Sciences Member, Hotchkiss Brain Institute Cumming School of Medicine, University of Calgary Medical Director, Cognitive Neurosciences Clinic Stroke Neurologist, Calgary Stroke Program 2015, American Heart Association 1

2 2015, American Heart Association 2

3 Cryptogenic Stroke Incidence in the U.S. 2015, American Heart Association 3

Sec of Defense Donald Rumsfeld Briefing the Press on Cryptogenic Stroke Reports that say that something hasn't happened are always interesting to me, because as we know, there are known knowns; there

4 Sec of Defense Donald Rumsfeld Briefing the Press on Cryptogenic Stroke Reports that say that something hasn't happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns the ones we don't know we don't know. And if one looks throughout the history of our country and other free countries, it is the latter category that tend to be the difficult ones Defense.gov News Transcript: DoD News Briefing Secretary Rumsfeld United States Department of Defense (defense.gov) 4

5 What is a Cryptogenic Stroke?

6 Cerebrovascular Disease: Stroke Subtypes Ischemic Stroke (85%) Hemorrhagic Stroke (15%) Atherothrombotic Cerebrovascular Disease (20%) Cryptogenic (30%)? Intracerebral Hemorrhage (70%) Lacunar (25%) (small vessel disease) Cardioembolic (20%) Subarachnoid Hemorrhage (30%) AHA Heart and Stroke Statistics

7 Stroke Classification Systems: TOAST Large Artery Atherosclerosis* Cardioembolism* (high and medium risk sources) Small Vessel Occlusion* Stroke of Other Determined Etiology* Stroke of Undetermined Etiology 2 or more causes identified Negative Evaluation Incomplete Evaluation *possible or probable depending on ancillary tests Amerenco et al. Cerebrovac Dis

8 Stroke Classification Systems: NINDS Stroke Databank Atherothrombosis Tandem Arterial Pathology Cardiac Embolism Lacune Unusual Cause Infarction of Undetermined Cause Amerenco et al. Cerebrovac Dis

9 Stroke Classification Systems: Oxford Community Stroke Project (OCSP) Total Anterior Circulation (TAC) Partial Anterior Circulation (PAC) Lacunar (LAC) Posterior Circulation (POC) Stroke Type is amended as a final letter I for infarct S for syndrome prior to imaging or if indeterminate Bamford et al. Lancet 1991; 337:1521 9

10 Stroke Classification Systems: Causative Classification of Stroke E.M. Arsava et al. Neurology 2010;75:

11 Definition of Cryptogenic Stroke 2013, American Heart Association 11

12 Stroke Diagnosis: Can I Buy a Vowel? Stroke Diagnosis: Can I Buy a Vowel? L C N C A D I E M C C R Y O G N L A G E A R T Y STROKE TYPE 12

cavity termed a lacune within the subcortical white matter and in the

13 In a Patient with AF and Prior Lacunes, is this a Cryptogenic Stroke? An illustration of coronal cross section of the brain showing a small cavity termed a lacune within the subcortical white matter and in the territory of perforating arteries. (A) acute DWI SVI, (B) chronic lacune on DWI MRI 13

14 Is Stroke in a Young Patient with a PFO Cryptogenic? Ay. Stroke. 1998; 29: D.J. Beacock, j.euje

15 Two approaches Round up the usual suspects Call in the Crime Scene Investigators (CSI)

17 AHA Stroke Guidelines for Secondary Prevention Extracranial Vascular Imaging It is important to evaluate the extracranial vasculature after the onset of acute cerebral ischemia (stroke or TIA) to aid in the determination of the mechanism of the stroke and thus potentially to prevent a recurrence Antiplatelet Therapy Oral administration of aspirin (initial dose is 325 mg) within 24 to 48 hours after stroke onset is recommended for treatment of most patients. Anticoagulation Therapy Anticoagulation is recommended for high risk cardioembolic sources Young patients with cryptogenic TIA or stroke and PFO should be evaluated for lower extremity or pelvic venous thrombosis, which would be an indication for anticoagulation PFO For patients with a cryptogenic ischemic stroke or TIA and a PFO without evidence for DVT, available data do not support a benefit for PFO closure (Class III; Level of Evidence A). Kernan. Stroke 2014

18 Monitoring and Detection Strategies Telemetry Holter monitoring MCOT ICM/PCM 4/4/ , American Heart Association 18

19 Detection of Occult AF Approximately 10% of patients with acute ischemic stroke or TIA will have new AF detected during their hospital admission In stroke or TIA patients with an indication for a pacemaker, interrogation of the device identified a 28% incidence of occult AF during 1 year A similar rate of occult AF has been reported among high-risk, non-stroke patients with implantable cardiac rhythm devices Occult AF detected during pacemaker interrogation in stroke-free patients or mixed populations is associated with increased risk for stroke

20 Dussault. Circ Arrhythm Electrophysiol Jan 31. Detecting AF after IS or TIA: Systematic Review and Meta-Analysis Prospective studies (n=31) reporting proportion of new AF diagnosed using ECG-monitoring for >12 hr in patients with recent stroke or TIA were analyzed Longer duration of monitoring was associated with an increased detection of AF when examining monitoring time as a continuous variable (p<0.001 for meta-regression analysis) or as 72 hours vs. 7 days vs. 3 months (5.1% vs. 15% vs. 29%) Significant heterogeneity within studies was detected for both groups ( 72 hr: I 2 = 91%; 7 d: I 2 = 75%) When assessing the odds of AF detection in the 3 randomized controlled trial, there was a 7.26 increased odds of AF detection with long-term monitoring (95% CI [ ]; p<0.001)

21 Crystal AF: Detection Rates: 36 months 30% v 3% Estimated rate of detection in ICM arm was 30.0% vs 3.0% in control arm Sanna T ; NEJM 2014;370;2478

22 Predictors of AF in the Cryptogenic Stroke Population Univariate Predictors of Atrial Fibrillation Age (>65 years) Gender (male) Race (white) BMI (per kg/m^3) Index Event (stroke) Modified Rankin Score CHADS2 Score PR Interval (per 10ms) Diabetes Hypertension Congestive Heart Failure PFO (present) p<0.01 p<0.01 p< p< Hazard Ratio AF Less Likely AF More Likely Variable HR (95% CI) p-value Age (per 10 years) 1.91 (1.31, 2.80) PR interval (per 10 ms) On PR-lengthening medication 1.17 (1.02, 1.35) 0.02 Off PR-lengthening medication 1.58 (1.32, 1.90) < Assar M, Passman R:; ESC 2014

23 New Statements and Guidelines and Their Relevance for Stroke Performance Measurement 4/4/ , American Heart Association 23

24 2013, American Heart Association 24

25 New 2015 Scientific Statement

26 Major New Recommendations in 2015 Statement Two prior warnings/relative contraindications where treated is now recommended based on pooled RCT evidence in subgroups: Old age. Severe stroke. Many clinical scenarios where tpa is reasonable or may be considered. Implication: clinical judgement required, also reasonable to NOT give tpa based on physician judgement of risk:benefit ratio (which should be documented).

27 Exclusion and Relative Exclusion Criteria 2013, American Heart Association 27

28 4/4/ , American Heart Association 28

29 Statin Prescribed at Discharge New Reporting measure: Statin Prescribed at Discharge Includes removal of two exclusion criteria: (a) No documented prior cholesterol reducing therapy and (b) LDL <100 A documented reason for not prescribing a statin at discharge continues to be an exclusion for the measure population. 2013, American Heart Association 29

30 Patient Management Tool Updates 2013, American Heart Association 30

31 Stroke Etiology 2013, American Heart Association 31

32 Stroke Diagnostic Tests and Interventions Discharge Tab 2013, American Heart Association 32

33 Configurable Measure Report: Ischemic Stroke Etiology 40% 35% 30% 25% 20% 15% 10% 5% 23% 34% 21% 6% 16% Of the first 3947 cases, 68% in had no stroke etiology documented 0% Large-artery atherosclerosis (e.g., carotid or basilar artery stenosis) Cardioembolism (e.g., atrial fibrillation/flutter, prosthetic heart valve, recent MI) Small-vessel occlusion (e.g., Subcortical or brain stem lacunar infarction <1.5 cm) Stroke of other determined etiology (e.g., dissection, vasculopathy, hypercoagulable or hematologic disorders Cryptogenic Stroke (Stroke of undetermined etiology) Among 2680 entered, 16% were cryptogenic 2013, American Heart Association 33

34 Documented exclusions or relative exclusions for not initiating IV thrombolytic 2013, American Heart Association 34

35 Previous contraindications and warnings moved to Historic Tab 2013, American Heart Association 35

36 Thank you for attending this review of the Get With the Guidelines-Stroke PMT Update and for your participation in the Get With the Guidelines program For PMT questions and assistance please contact the GWTG Helpdesk at , American Heart Association 36

What the general cardiologist should know about arrhythmia Stroke prevention in AF" Peter Ammann Kantonsspital St. Gallen

What the general cardiologist should know about arrhythmia Stroke prevention in AF" Peter Ammann Kantonsspital St. Gallen What the cardiologist should know about arrhythmia and stroke are there real low