By Christian Boehme
Twitter: @chris7ianb
Cardioembolism and Heart-Brain Interactions
The first day of ESOC 2024 in Basel held mild temperatures and a little morning drizzle as Mira Katan (Basel, Switzerland) and Peter Schellinger (Minden, Germany) served as chairs of this commencing early morning session.
Ashkan Shoamanesh of the McMaster University in Hamilton, Canada presented APIXABAN FOR STROKE PREVENTION IN PATIENTS WITH SUBCLINICAL ATRIAL FIBRILLATION AND PRIOR STROKE: INSIGHTS FROM THE ARTESIA TRIAL. The ARTESIA trial showed that apixaban reduced stroke and systemic embolism in patients with SCAF (subclinical AF) but increased major bleeding complications. To identify the patients with the most likely benefit, the study group examined the effect of apixaban in patients with or without previous stroke/TIA. The study showed that patients with device-detected SCAF and a history of stroke/TIA are at substantially higher risk of stroke or systemic embolism. The absolute risk reduction using apixaban was 6.2% (NNT=16) in the group with previous events compared to 1.1% (NNT=91) for patients without ischemic cerebrovascular history. Also, apixaban treatment was associated with a RRR of 74% in disabling or fatal stroke in patients with prior stroke/TIA. Therefore, the study recommends apixaban in stroke secondary prevention in these patients.
Alexander Benz, also from Hamilton, Canada presented PREDICTORS OF STROKE IN PATIENTS WITH RHEUMATIC HEART DISEASE-ASSOCIATED ATRIAL FIBRILLATION – RESULTS FROM THE INVICTUS TRIAL. He commenced with the striking difference in prevalence of rheumatic heart disease globally, with a markedly higher prevalence in South East Asia, Sub-Saharan Africa and Latin America, where most study centers were located. The aim of the study was to explore risk factors for stroke or systemic embolism in patients with AF secondary to rheumatic heart disease. The INVICTUS trial recruited over 4,500 patients with rheumatic heart disease-related AF with a follow up of 3 years. During follow-up, 3.8% had a stroke or systemic embolism translating to 1.2 events per 100 patient-years. Predictors for the endpoint were higher age, diabetes, prior stroke/TIA or systemic embolism, vascular disease, and moderate-to-severe mitral stenosis. Furthermore, results showed only a modest risk discrimination for the CHADDS-VASC Score in patients with rheumatic disease-associated AF.
Edip Gurol from the MGH, USA presented RISK SCORES AND BRAIN MRI MARKERS IN DISTINGUISHING ISCHEMIC FROM HEMORRHAGIC STROKE RISK AMONG ATRIAL FIBRILLATION PATIENTS: THE NEURO-AFIB STUDY. Edip points out the doubt of the risk-differentiating capabilities of CHA2DS2-VASC- and HAS-BLED scores in recent research regarding bleeding risk and stroke risk in patients with non-valvular AF. In roughly 6,000 patients, the study found cerebral microbleeds, cortical superficial siderosis and moderate-to-severe leukaraiosis were commonly found among ICH patients compared to ischemic stroke patients. On the other hand, lacunar infarcts and chronic non-lacunar infarcts were more commonly found in ischemic stroke patients. Edip concludes that precise measures of AF burden can provide a better assessment of ischemic stroke risk. Furthermore, chronic MRI findings should be incorporated into risk scores and their predictive value for ischemic and hemorrhagic stroke should be investigated in prospective studies to select the proper prevention strategies in AF patients.
Gerrit Grosse from Hannover, Germany presented PRIOR ANTICOAGULATION IS LINKED TO A DECREASED RISK OF HAEMORRHAGIC TRANSFORMATION IN ACUTE STROKE. The PRODAST study included over 10,000 prospective multicenter stroke patients with AF and focused on use of antithrombotic monotherapy at the time of the event. The study showed that patients under antithrombotic treatment had lower stroke volumes with a more pronounced effect for dOACs and VKA compared to antiplatelet treatment. Also, the risk of hemorrhagic transformation was lower in patients using dOACs and VKA. In contrast, the use of antiplatelets pre-stroke slightly increased the risk of hemorrhagic transformation. Gerrit concludes that breakthrough-ischemic strokes despite OAC are less severe (-2.5 NIHSS points), smaller (-23 mL) and have lower odds for hemorrhagic transformation (5% vs. 10%) than ischemic strokes without previous use of OAC.
Isra Hatab from Graz, Austria presented THE ROLE OF NT-PROBNP FOR ATRIAL FIBRILLATION DETECTION AFTER ISCHEMIC STROKE: A TIME-DEPENDENT RELATIONSHIP. The study goal was to validate a pre-researched cut-off of NT-proBNP and its time-dependent association for AF detection after stroke in a large prospective cohort. The study showed that an NT-proBNP cut-off of >505 pg/ml might be an accurate discriminator for early in-hospital AF-detection with a high NPV of 97%. Interestingly, in-hospital detected AF after stroke was associated with major atherosclerotic cardiovascular events.
Jeffrey Saver from UCLA, USA presented DEVICE CLOSURE OF PATENT FORAMEN OVALE IN PATIENTS >60 YEARS WITH ISCHEMIC STROKE: RESULTS FROM U.S. MEDICARE BENEFICIARIES. In patients with ischemic stroke within 6 months and PFO as well as >60 years of age, within 3 years of follow-up, PFO closure showed a RRR of recurrent ischemic stroke of 38% (translating to a NNT=33) compared to 59% in age <60 years as seen in RCTs. Also, the rate of safety endpoints i.e. punction site complications and new AF were low. Jeffrey concludes that in properly selected patients >60 years of age, PFO closure may be beneficial in reducing recurrent stroke risk with a low incidence of adverse events.
Shan Sui Nio from Amsterdam, Netherlands closed the session with a presentation on LEFT ATRIAL DIVERTICULA DETECTED ON CARDIAC CT IN ACUTE ISCHEMIC STROKE PATIENTS ARE ASSOCIATED WITH STROKE RECURRENCE. Left atrial diverticula is an outpouching of the left atrial wall which might increase the risk of stroke and is quite prevalent in cardiac CT. The study investigated the frequency of detection, baseline characteristics and outcomes in stroke patients. In this single-center prospective study, left atrial diverticula were detected in 30% of acute ischemic stroke patients on cardiac CT and these patients had a higher rate of ischemic stroke recurrence. But on the contrary, patients with left atrial diverticula had a better functional outcome after two years of follow-up. The reason behind these findings are interesting and warrant further research.
