FORAME OVALE PERVIO E ICTUS CRIPTOGENETICO: Dimensione del problema. Roberto Mantovan, MD, PhD U.O. Cardiologia Ospedale M.

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1 FORAME OVALE PERVIO E ICTUS CRIPTOGENETICO: Dimensione del problema Roberto Mantovan, MD, PhD U.O. Cardiologia Ospedale M. Bufalini - Cesena

2 FORAME OVALE PERVIO ICTUS CRIPTOGENETICO

3 FORAME OVALE PERVIO ICTUS CRIPTOGENETICO

Patent foramen ovale J Cardiol. 2010 September The frequency of patent foramen ovale (PFO) in the general population has been estimated to be 15% to 35%.

4 Patent foramen ovale J Cardiol September The frequency of patent foramen ovale (PFO) in the general population has been estimated to be 15% to 35%. Example of PFO detection by transthoracic echocardiography (TTE) with contrast injection. Microbubbles are visualized filling the right-sided chambers and into the left atrium (LA) and left ventricle (LV). Lorem ipsum dolor sit amet, sed legendos consetetur cu. Ex eripuit eruditi vix, per vocent delicata persecuti te 4

8 Causality and Cryptogenic Stroke

9 Patent Foramen Ovale, Subclinical Cerebrovascular Disease and ischemic Stroke in a Population-Based Cohort Marco R. Di Tullio et al J Am Coll Cardiol July 2; 62(1): Results A PFO was present in 164 participants (14.9%). Over a mean follow up of years, 111 ischemic strokes occurred (10.1%), 15 (9.2%) in the PFO + and 96 (10.3%) in the PFO groups. Conclusions In this community-based cohort, PFO was not associated with an increased risk of clinical stroke or subclinical cerebrovascular disease. Lorem ipsum dolor sit amet, sed legendos consetetur cu. Ex eripuit eruditi vix, per vocent delicata persecuti te 9

10 Recurrent Stroke and Patent Foramen Ovale A Systematic Review and Meta-Analysis Stroke. 2014;45: The frequency of patent foramen ovale (PFO) in the general population has been estimated to be 15% to 35%. To evaluate if the presence of PFO is associated with an increased risk of recurrent stroke Patients with stroke with PFO did not have a higher risk of the combined outcome of recurrent stroke/transient ischemic attack (risk ratio=1.18; 95% confidence interval= ; P =0.43) or in the incidence of recurrent strokes (risk ratio =0.85; 95% confidence interval= ; P =0.37) in comparison with stroke patients without PFO. Lorem ipsum dolor sit amet, sed legendos consetetur cu. Ex eripuit eruditi vix, per vocent delicata persecuti te 10

11 Recurrent Stroke and Patent Foramen Ovale A Systematic Review and Meta-Analysis Stroke. 2014;45: Risk of recurrent stroke or transient ischemic attack (A) and risk of recurrent stroke (B) in patients with patent foramen ovale (PFO) compared with patients without PFO. ASA indicates atrial septal aneurysm; CI, confidence interval; TCD, transcranial Doppler; and TEE, transesophageal echocardiography. Lorem ipsum dolor sit amet, sed legendos consetetur cu. Ex eripuit eruditi vix, per vocent delicata persecuti te 11

12 Recurrent Stroke and Patent Foramen Ovale A Systematic Review and Meta-Analysis Stroke. 2014;45: Risk of recurrent stroke or transient ischemic attack (A) and risk of recurrent stroke (B) in patients with moderate or large shunt size compared with patients with small shunt size. PFO size was not associated with the risk of recurrent stroke or transient ischemic attack. Lorem ipsum dolor sit amet, sed legendos consetetur cu. Ex eripuit eruditi vix, per vocent delicata persecuti te 12

13 Recurrent Stroke and Patent Foramen Ovale A Systematic Review and Meta-Analysis Stroke. 2014;45: Conclusions Our findings indicate that medically treated patients with PFO do not have a higher risk for recurrent cryptogenic cerebrovascular events, compared with those without PFO. No relation between the degree of PFO and the risk of future cerebrovascular events was identified. Lorem ipsum dolor sit amet, sed legendos consetetur cu. Ex eripuit eruditi vix, per vocent delicata persecuti te 13

14 In pts with CS or TIA, PFO closure with a device did not offer grater benefit than medical therapy alone

and major bleeding (panel B) in patients with PFO

15 Am J Cardiol 2015;115:837e 843 antiplatelet versus anticoagulant recurrent stroke and/or TIA (panel A) and major bleeding (panel B) in patients with PFO receiving antiplatelet versus anticoagulant therapy.

16 PFO closure vs anticoagulant Am J Cardiol 2015;115:837e 843 recurrent stroke and/or TIA (panel A), major bleeding (panel B), and cumulative incidence of recurrent stroke and/or TIA or major bleeding (panel C) in patients undergoing percutaneous PFO closure or receiving anticoagulant therapy.

17 FORAME OVALE PERVIO ICTUS CRIPTOGENETICO

18 Cryptogenic stroke accounts for 23% to 40% of patients, more frequent in younger patients.

Cryptogenic Stroke (Stroke. 2009;40:1195-1203.) Cardioembolism (20%) and cervicocerebral artery dissection (15%) were the most frequent etiologic subgroups.

19 Cryptogenic Stroke (Stroke. 2009;40: ) Cardioembolism (20%) and cervicocerebral artery dissection (15%) were the most frequent etiologic subgroups. whereas frequency of undetermined etiology (33%) decreased along aging. Subclinical infarcts were surprisingly common in the young. Lorem ipsum dolor sit amet, sed legendos consetetur cu. Ex eripuit eruditi vix, per vocent delicata persecuti te 19

20 Cryptogenic Stroke Lorem ipsum dolor sit amet, sed legendos consetetur cu. Ex eripuit eruditi vix, per vocent delicata persecuti te 20

21 Stroke. 2014;45: The issue of cryptogenic stroke is a relevant one for several reasons. First, prognosis high risks of recurrence have been reported after cryptogenic stroke or transient ischemic attack (TIA). Second, perception because no distinctive treatment is often recommended in patients with cryptogenic stroke, physicians and patients may otherwise not take adherence to prescribed treatments Third, advanced diagnostic techniques. Lorem ipsum dolor sit amet, sed legendos consetetur cu. Ex eripuit eruditi vix, per vocent delicata persecuti te 21

22 Cryptogenic Stroke in Clinical Trials

23 Challenges in the Diagnosis of Cryptogenic Stroke Stroke. 2014;45: Patients diagnosed with a cryptogenic stroke may have evidence of a mild degree of stenosis in vessels corresponding to the area of symptomatic vascular brain injury Another challenge with properly excluding the diagnosis of cryptogenic stroke is that the cause of stroke may be transitory or spontaneously reversible, i.e. paradoxical AF is more prevalent than persistent AF in patients with stroke/tia Finally, the actual cause of a stroke may be inadequately investigated or ignored, such as paradoxical or aortogenic embolism and intravascular coagulopathy approximately one third of discovered PFOs are likely to be incidental and hence not benefit from closure Aortic arch atheroma (AAA) is commonly observed in the elderly Cancer and ischemic stroke 23

24 How should we diagnose Cryptogenic Stroke? Sensitive Neuroimaging MRI Diffusion-Weighted Imaging Complete Neurovascular imaging Extracranial and intracranial circulation Complete Cardiac Evaluation TTE and TEE, with contrast, including aortic arch Prolonged, continuous cardiac monitoring Evaluation for Thrombophilia Vascular Neurologist to exclude rare causes

25 Advanced Diagnostic Techniques in Cryptogenic Stroke Stroke. 2014;45: Diffusion-weighted imaging (DWI) and coronary computed tomographic angiographic (CTA) findings of patients with paradoxical and aortogenic embolism. DWIs show multiple small scattered cortical infarcts on cerebral cortex in patients with both paradoxical and aortogenic embolism Single cortico/subcortical lesions and multiple bilateral lesions in the anterior and posterior circulation on DWI have been associated with cardiac embolic sources, whereas multiple unilateral lesions in the anterior circulation have been linked with arterogenic embolism, such as atherosclerosis or dissection.

Advanced Diagnostic Techniques in Cryptogenic Stroke: Lesion Pattern Analysis Stroke. 2014;45:1186-1194 1.

26 Advanced Diagnostic Techniques in Cryptogenic Stroke: Lesion Pattern Analysis Stroke. 2014;45: DWI infarct pattern: embolic versus deep and large versus small scattered. 2. DWI infarct distribution: 1 vascular territory involved. 3. Past stroke on history or fluidattenuated inversion recovery image: the same side versus different territory.

27 How should we diagnose Cryptogenic Stroke? Sensitive Neuroimaging MRI Diffusion-Weighted Imaging Complete Neurovascular imaging Extracranial and intracranial circulation Complete Cardiac Evaluation TTE and TEE, with contrast, including aortic arch Prolonged, continuous cardiac monitoring Evaluation for Thrombophilia Vascular Neurologist to exclude rare causes

28 How should we diagnose Cryptogenic Stroke? Sensitive Neuroimaging MRI Diffusion-Weighted Imaging Complete Neurovascular imaging Extracranial and intracranial circulation Complete Cardiac Evaluation TTE and TEE, with contrast, including aortic arch Prolonged, continuous cardiac monitoring Evaluation for Thrombophilia Vascular Neurologist to exclude rare causes

29 Advanced Monitoring for AF Detection Stroke. 2014;45: )

30 In-Hospital and brief Monitoring for Detection of AF in Patients with Cryptogenic Stroke The detection of AF from ECG after ischemic strke or TIA is estimated 2-4%, Conversely Continuous Cardiac Monitoring (24-72 h) detect new AF in up to ,5% of patients

31 Outpatient Detection of AF in Patients with Cryptogenic Stroke 31

32 CRYptogenic STroke and underlying AtriaL Fibrillation (CRYSTAL AF): Long-Term Follow-Up Results Rod S. Passman, MD, Johannes Brachmann, MD, Ph.D. Carlos Morillo, MD, Tommaso Sanna, MD, Richard Bernstein, MD, Ph.D., Vincenzo Di Lazzaro, MD, Hans-Christoph Diener, MD, Ph.D., Marilyn Rymer, MD, Frank Beckers, Ph.D, Tyson Rogers, M.S., Paul Ziegler, M.S. for the Crystal AF Investigators

33 Objectives of CRYSTAL-AF Assess whether a long-term cardiac monitoring strategy with an insertable cardiac monitor (ICM) is superior to standard monitoring for the detection of AF in patients with cryptogenic stroke Determine the proportion of patients with cryptogenic stroke that are subsequently found to have AF Determine actions taken after patient is diagnosed with AF

34 Key Inclusion/Exclusion Criteria Inclusion: 40 years of age Cryptogenic stroke (or clinical TIA), with infarct seen on MRI or CT, within the previous 90 days; and no mechanism (including AF) determined after: 12-lead ECG Minimum of 24-hour ECG monitoring (e.g. Telemetry, Holter) Transesophageal echocardiography (TEE) CTA or MRA of head and neck to rule out arterial source Screening for hypercoagulable states in patients <55 years old Exclusion: History of AF or Atrial Flutter Permanent indication or contraindication for anticoagulation Indication for pacemaker or implantable cardioverter defibrillator

followed remotely MRI conditional 3 year device longevity Automatic AF detection algorithm Cardiac monitoring performed

35 Comparison of Monitoring Strategies Continuous Monitoring Arm: Insertion of REVEAL XT Standard Monitoring Arm Minimally invasive outpatient procedure Local anesthetic and no leads or fluoroscopy minute procedure Device can be followed remotely MRI conditional 3 year device longevity Automatic AF detection algorithm Cardiac monitoring performed according to local standards, after mandated testing completed Symptoms consistent with AF were evaluated by study physicians

36 Study Endpoints Primary: AF Detection Rates at 6 Months Secondary: AF Detection Rates at 12 Months Change in Use of Oral Anticoagulant (OAC) Drugs

37 Patient Flow

38 Sanna T. N Engl J Med 2014; 370: Primary Endpoint: AF at 6 Months At 6 months AF was detected in 8.9% in the ICM group compared with 1.4% in controls (19 vs 3 pts.) Median time to AF detection: 41 d, 74% asymptomatic

39 Sanna T. N Engl J Med 2014; 370: Secondary Endpoint: AF at 12 Months At 12 months AF was detected in 12.4% in the ICM group compared with 2.0% in controls (29 vs 4 pts.) Median time to AF detection: 84 d, 79% asymptomatic

40 Sanna T. N Engl J Med 2014; 370: CRYSTAL AF: AF at 3 Years At 3 years AF was detected in 30.0% in the ICM group compared with 3.0% in controls (42 vs 5 pts.)

41 Sanna T. N Engl J Med 2014; 370: CRYSTAL AF: Conclusion AF monitoring with an ICM is superior to conventional follow-up in cryptogenic stroke pts. Time ICM (%) Control (%) Hazard Ratio P 6 months months years AF was mostly asymptomatic and paroxysmal so unlikely to be detected by non continuous monitoring

42 Circ Arrhythm Electrophysiol. 2015;8:

43 Circ Arrhythm Electrophysiol. 2015;8: Extending electrocardiographic monitoring from 24 hours to 30 days increased the proportion of patients diagnosed with atrial fibrillation from 4.38% to 15.2%.

Circ Arrhythm Electrophysiol. 2015;8:263-269.

44 Circ Arrhythm Electrophysiol. 2015;8: Longer duration of electrocardiographic monitoring after cryptogenic stroke is associated with a greater detection of AF. These findings support recent changes in guidelines recommending extended electrocardiographic monitoring after cryptogenic stroke.

45 Advanced diagnostic technologies may reduce the proportion of patients diagnosed with cryptogenic stroke Stroke. 2014;45:

46 Conclusioni La presenza di un PFO non sembra aumentare il rischio di TIA/stroke L ictus criptogenetico non è sempre determinato da un PFO, anche se incidentalmente diagnosticato Le cause di ictus criptogenetico devono essere attentamente indagate per escludere : Altre cause ateroembliche Coagulopatie/neoplasie Come cardiologi siamo particolarmente coinvolti nella valutazione, oltre che del PFO, di una possibile presenza di Fibrillazione Atriale Un prolungato monitoraggio elettrocardiografico dovrebbe essere raccomandato dopo un Ictus/TIA criptogenetico 46

Θα πρέπει να αναζηηείηαι η παροσζία ζιωπηλής κολπικής μαρμαρσγή ζε αζθενείς με κρσπηογενές εγκεθαλικό επειζόδιο; Ποιά είναι η καλύηερη μέθοδος;

Θα πρέπει να αναζηηείηαι η παροσζία ζιωπηλής κολπικής μαρμαρσγή ζε αζθενείς με κρσπηογενές εγκεθαλικό επειζόδιο; Ποιά είναι η καλύηερη μέθοδος; Νικόλαος Φραγκάκης Λέκηορας Καρδιολογίας, FESC Ιπποκράηειο