EANS ESC Council on Stroke joint session Venice, October 2017 Cardiovascular complica/ons a1er stroke Wolfram Doehner, PD, PhD Center for Stroke Research Berlin & Department of Cardiology, Campus Virchow Charité Universitätsmedizin Berlin, Germany
CV involvement in Stroke - the need for joined efforts CV Risk profile Atrial fibrilla/on Hypertension Atherosklerosis Myocardial infarcqon MyocardiQs EndocardiQs LV Aneurysm Chronic heart failure Valvular disease Valve replacement Overt foramen ovale Stroke Post Stroke CV Complica/on All of the above (secondary prevenqon) Cardiopulm. funcqon Arrhythmias inadequate RR regulaqon Cardiac / vascular re- embolism Myocardial InfarcQon CHF exacerbaqon Thrombosis Widimsky P et al Eur Heart J 2017
Acute Stroke Stroke The cardiologic input Acute care Emergency Dept. vital status adequate rhythm adequate BP adequate breathing immediate Diagnos/cs cerebral damage cause of stroke Immediate Therapy neurological Tx cardiac Tx Subacute care Stroke Unit / ICU Complica/ons Arrhythmias BP episodes Troponin? CV comorbidiqes EndocardiQs Heart failure Risk profile AF, HTN, CAD, CHF Lipidaemia chronic care Nursing home, Home CV comorbidi/es CV risk factors Sec. Preven/on con/nued monitoring and therapy
Acute Stroke Stroke The cardiologic input Acute care Emergency Dept. vital status adequate rhythm adequate BP adequate breathing immediate Diagnos/cs cerebral damage cause of stroke Immediate Therapy neurological Tx cardiac Tx Subacute care Stroke Unit / ICU Complica/ons Arrhythmias BP episodes Troponin? CV comorbidiqes EndocardiQs Heart failure Risk profile AF, HTN, CAD, CHF Lipidaemia Neurologist Cardiologist CV monitoring 100% addiqonal cv Dx
Doehner et al EJHF 2017 in revision Cerebro- cardic signaling a1er Stroke Stroke (insular cortex involvement) Inflammatory response Sympatho-vagal imbalance Central immunodepression Systemic cytocine overflow Cathecolamine levels Arterial baroreflex Coronary plaque instability Intracellular calcium overload Myocardial necrosis variability instability Myocardial injury Ventricular/atrial strain Acute coronary syndrome Strain related cardiomyopathy Ventricular Arrhythmia Atrial fibrillation
Cardiac complica/ons a1er acute ischaemic stroke } } } } Arrhythmias ventricular arrhythmias atrial fibrillaqon BP control hypertensive crisis hypotension Acute ischaemic event Troponin? CV comorbidiqes heart failure valve disease chronic ischaemic CAD } EndocardiQs previous endocardiqs risk profile current sings of endocardiqs
Cardiac complica/ons a1er acute ischaemic stroke N=200 In hospital mortality ager stroke: 8% (CV complicaqons second leading cause of death) Wira CR et al., West J Emerg Med 2011
Elevated troponin in acute stroke - relevant or not? CirculaQon 2016 PaQents with acute ischaemic stroke: n= 2123 Elevated Troponin: 13.7% of paqents Elevated Tropinin with culprit coronary lesion: 1 out of 4 paqents (24%) Conclusion: Elevated ctn levels are common ager stroke Cardiac troponin alone poorly predicts ACS in acute stroke Monitoring dynamic change of ctn Combine biomarker signal with clinical / ECG / other findings
Cryptogenic stroke: DetecQon of Atrial FibrillaQon 7 days 3 years 12.5% 30% DetecQon rate (%) AF detected (% of paqents) Monitoring- Intervall [d] Monitoring- Intervall [months] Stahrenberg et al., Stroke 2010; 41:2884-2888 Sanna T et al. NEJM 2014
Cryptogenic stroke è ESUS Embolic Stroke of Unknown Source ESUS criteria: 20 % of all strokes Not lacunar (CT or MRI) No atheroscl. Stenosis 50% in the supplying arteries Imaging CT or MRI CT / MR angio duplex US cervical + transcranial No major- risk cardioembolic source of embolism Precordial echocardiography 12 lead ECG ECG monitoring 24h No other specific cause idenqfied (e.g. arteriqs, dissecqon, migraine/vasospasm, drug misuse) New Data to come (2018): RESPECT ESUS, NAVIGATE ESUS Hart RG et al. Lancet Neurol 2014
InfecQve endocardiqs: Source and complicaqon of stroke
Diagnosis of infec/ve endocardi/s (IE) Duke Criteria DefiniQve IE pathologic proof Likely IE clinical signs Unlikely IE no clinical signs Major criteria: (1) posiqve blood cultures - 2 blood cultures drawn 12 hours apart - 3 or most of 4 or more separate blood cultures, 1 hour from first to last (2) evidence of endocardial involvement - posiqve echocardiogram for infecqve endocardiqs (TOE) Minor criteria (1) predisposing heart condiqon / iv drug use (2) fever : 38 C (3) vascular phenomena (4) immunologic phenomena (5) microbiologic evidence (6) SuggesQve echocardiography findings Stroke IE likely: 2 major or 1 major + 3 minor or 5 minor
Echocardiography - which type for what? TTE Trans- thoracic echo Trans- esophageal echo TOE long distance short distance lower resoluqon very high soluqon no definite exclusion of thrombus definite exclusion of thrombus LV, LA diameter, volume wall thickness LA auricle thrombus LV EF patent voramen ovale Regional contracqlity (apex) endocardi/s valve funcqon (global) detailed valve funcqon TTE TOE
Heart Failure risk factor of thrombembolic stroke Large LV size Low (global) contracqlity Hyp- / akineqc LV segements Aneurysm Low LV blood flow
Heart failure and stroke - a high risk popula/on In pa/ents with HF... (A) stroke is more likely higher stroke incidence (B) stroke is more severe (C) stroke complicates HF worse funcqonal outcome higher mortality, HF progression HF mortality
Cardiac cause of death a1er stroke Stroke = high risk for subsequent cardiovascular death mortality (%) 100 80 60 40 Cause of death First stroke Recurrent stroke Cardiac death 20 0 < 30 Tage 30d 6 Mon. 6 Mon. 1 J. 1 3 Jahre 3 5 Jahre 30d 0.5y 1y 1-3y 3-5y years Hankey et al Stroke 2000
ESCardio.org / Councils / Council- on- Stroke Avend the Stroke council s Heart & Brain - workshop 19. - 20. January 18 Prague Thank you wolfram.doehner@charite.de