ESOC 2018 Session Highlight – AF and Cardioembolic Stroke

This interesting session, Chaired by Christian Gerloff and Svetlana Lorenzano, covered the most relevant updates on AF and cardioembolic stroke pointing out take-home messages oriented to the clinical practice.

First speaker of the session, Dr. Holswilder from Leiden (The Netherlands) presented results on a single-center study aiming to evaluate the implications for therapeutic management of cardiac CTA in the diagnostic work up of patients presenting with TIA or ischemic stroke. CTA allowed to detect cardioembolic risk sources in 31% of patients and changed therapeutic management in 7% of ischemic stroke patients.

The second speaker, Dr. Dávalos from Barcelona (Spain) reported on methods for detecting paroxysmal AF in patients with TIA or acute ischemic stroke without history of AF or AF at admission ECG. The Stroke Risk Analysis was used for automated analysis of continuous ECG monitoring prolonged up to a total time of 7 days. The study results showed us that this technology allows to increase the rate of paroxysmal AF detection compared with standard continuous ECG monitoring in stroke units and improves the prediction of the risk to develop AF during the full time monitoring. The only concern is represented by the low positive predictive value although this diagnostic tool resulted to have a good specificity and negative predictive value and a fair sensitivity.

Four other speakers focused on oral anticoagulant treatment of patients with stroke and AF. In particular:

– Dr. Ximénez-Carrillo showed us that patients with acute ischemic stroke previously treated with direct oral anticoagulant presented more often TIA, less symptomatic hemorrhagic transformation and a shorter duration of hospital stay compared to those treated with warfarin prior to the index stroke. Moreover, the last are more frequently shifted to direct oral anticoagulant for long-term stroke secondary prevention;

– Dr. Diener from Essen (Germany) presented results from the GLORIA-AF Registry Program -a prospective, global registry of patients with newly diagnosed AF with and without prior stroke- and confirmed the safety and efficacy of dabigatran, in terms of lower rates of major bleeding and stroke, for these patients in clinical practice.

– Dr Yiin from Oxford (United Kingdom) reported on the important public health issue of under-treatment of AF that is a major risk factor for ischemic stroke. Indeed, the presented population-based study showed us that 1-in-3 incident ischemic stroke are related to AF due partly to continuing low rates of pre-morbid anticoagulation in patients with known prior AF.

– Dr. Altavilla from Perugia (Italy) focused on the difference in clinical profile and outcome (composite outcome: stroke, TIA, symptomatic systemic embolism, symptomatic cerebral bleeding and major extra-cerebral bleeding at 90 days) between patients with acute ischemic stroke and non-valvular AF bridged with low-molecular weighted heparin at full dose before starting oral anticoagulant and those non-bridged. The first group had a higher incidence of early ischemic stroke recurrence and hemorrhagic transformation, independently from the type of oral anticoagulants.

The last two speakers provided highlights on the challenging management of patients with potentially PFO-related stroke. Interestingly,

–  Dr. Khales from Aarau (Switzerland) found in the presented study that in patients with cryptogenic stroke and PFO, the stroke recurrence risk is driven by both PFO-related and -unrelated factors. Right-to-left shunt, atrial septal aneurysm along with age bear the highest population attributable risk.

– Dr. Turc from Paris (France) reported on a systematic review of randomized trials and a sequential meta-analysis comparing either PFO closure, anticoagulant or antiplatelet therapy to prevent stroke recurrence in patients with PFO-related stroke. PFO closure was confirmed to be superior to antithrombotic therapy despite an increased risk of atrial fibrillation.