ESOC 2018: Stroke and Heart Joint ESO – ESC Session

One of the highlights of today’s program was the joint session of ESO and ESC (European Society of Cardiology, European Heart Association).  For the second year this joint session is now included in the ESOC program as a key event of the collaboration between the two European Societies. The continued scientific exchange and educational collaboration between cardiologists and strokeologists is essential to further improve comprehensive patient care and to advance novel treatment options.

From the many topics of concerning cardiac involvement in stroke primary or secondary prevention, diagnostics, monitoring and treatment; several highly relevant topics were selected for presentation in this year’s session.

Simona Sacco (Italy) discussed that cardiac complications are among the most relevant complications in acute stroke and are among the main aspects of stroke unit care. The range of complications vary from mild asymptomatic conditions to severe fatal complications and include ECG abnormalities, brady- and tachyarrhythmias, neurogenic stress cardiomyopathy, Takotsubo cardiomyopathy, and myocardial infarction. Hence adequate monitoring of cardiac functions (cardiac contractility, heart rate and rhythm), vascular regulation (blood pressure) and cardiac diagnostic workup (echocardiography, cardio-MR, and if needed coronary angiography) are essential components of involvement of cardiac expertise in stroke treatment.

Lucas v Boersma (Netherlands) talked about left atrial appendage occlusion, which is likely to become a valuable tool for stroke prevention, mainly in patients with possible contraindications for oral anticoagulation such as ICH on anticoagulation treatment. He was one of the main investigators of the prospective EWOLUTION study and demonstrated the safety, clinical benefit and cost-effectiveness of this procedure in preventing stroke in these patients.

Jean Louis Mas (France) presented recent results about Patent Foramen Ovale (PFO) and stroke. Prof Mas discussed that randomized clinical trials have shown that transcatheter closure of PFO is associated with a 64% lower risk of stroke recurrence compared with antithrombotic treatment alone. This is a step forward that will benefit many patients. Patients with some PFO characteristics (e.g. associated atrial septal aneurysm or PFO with large shunt) appear to benefit most from the procedure. Whether new oral anticoagulants are as effective as PFO closure is not known and should be assessed in a randomized clinical trial. Any therapeutic decision regarding PFO and stroke should be taken by a multidisciplinary team including neurologists or stroke specialists and cardiologists.

Simon Jung (Switzerland) reviewed data about the meaning of Troponin elevation after stroke, being due to heart or brain disease or both in some situations. In his speech, Dr Jung showed that, heart disease can cause stroke, but that also stroke can cause heart disease. Particularly high sensitive Troponin T (hsTnT) elevation is a stroke prognostic marker in stroke patients and is associated with severe stroke and insular location, but can also be associated with impairment of renal function and ECG changes. The importance of following the dynamics of hsTnT levels was also mentioned.

Isabelle van Gelder (Netherlands), closed this interesting joint stroke-heart session with talking about EKG monitoring after stroke of unknown source by using e.g. insertable monitors. Recent data, using long term monitoring in patients with ESUS shows  that AF is detected in a high proportion of patients and that more AF episodes also can be seen several days/weeks/months after stroke. That AF should be diagnosed before starting anticoagulation in ESUS patients was recently confirmed by the NAVIGATE ESUS trial, showing no benefit of rivaroxaban over aspirin in ESUS patients without prior confirmation of AF. Long term ECG monitoring seems essential to improve outcome of patients with ESUS.