By Dr. Inna Lutsenko, ESO Social Media and PR Committee
Chairs: Marta Rubiera (Spain) and Wolfram Döhner (Germany)
How can I see inside the heart? The basics of POCUS assessment in neurologist’s hands
Theodoros Karapanayiotides from Greece opened the session of collaborative Symposium the ESO and the European Society of Cardiology. He started his talk with an introduction of “POCUS” – point of care ultrasound, a portable device, which does not make neurologists depend on the radiology department in the cases when an immediate ultrasound diagnosis is necessary. With a POCUS a patient may be scanned while in an ambulance on the way to an emergency room or even in remote areas. The advantage of the POCUS is its availability in neurological departments. POCUS is not a full cardiac examination, a semi qualitative, but permits to estimate the left/right ventricle size in the parasternal long axis. Common pathologies, which might be diagnosed with a POCUS are
- heart failure with an enlargement of the left atrium in a four chamber view, confirming with the global hypokinesia of the left atrium,
- “ballooning deformation of the heart” – Takotsubo cardiomyopathy when heart changes its shape in the so called “octopus trap”
- Constrictive cardiomyopathy with a total collapse of left ventricle,
- apical left ventricular thrombus
- aortic arch in suprasternal view, where large atheromas could be detected in the ascending and descending aorta,
- and even the distensibility and diameter of vena cava with central venous pressure could be measured.
POCUS is not used though for the PFO diagnostics, in these cases we should refer the patient to a cardiologist with the use of the transesophageal ultrasound. Theodoros Karapanayiotides concluded that POCUS is not intended for full investigation of cardiogenic/cryptogenic stroke, but this is an extension/complement to physical examination, which could provide rapid answers to specific questions.
Troponin elevation in acute stroke: when to worry when to wait
Jan Scheitz from Germany started his talk with a clinical case with a 77 years old female, having a right MCA syndrome with NIHSS 7 and onset-to-admission time 12 hours. She had diabetes, her vital signs were normal and ECG was unspecific and troponin was elevated in admission (hs-c TnT 70 ng/L (5-times ↑ URL). The question was raised whether it is an acute myocardial infarction and how to proceed. Jan Scheitz reminded us that troponin is a special biomarker for the condition of the heart contraction and it could reflect any heart pathology, such as myocardial damage and necrosis. High sensitivity troponin helps us to reveal the heart changes in the general population.
What do we have if we look closely at the patients with elevated troponin level before sending the patient to the CT lab? In the The TRoponin ELevation in Acute Ischemic Stroke (TRELAS) Study which was done in Charite, Berlin, among 2,123 consecutive acute ischemic stroke patients prospectively screened at two tertiary hospitals, 13.7% had cTn elevation (>50ng/l). Further studies are needed to clinically identify the minority of patients with AIS and angiographic evidence of a culprit lesion. In a case of the elevated troponin level in acute ischemic steroke Jan recommends as a first step to differentiate acute or chronic myocardial injury. In case of an acute stroke (hs-cTn ↑ (> 99th Percentile) we should suspect stroke-associated myocardial injury.
Characteristics associated with post-stroke troponin elevation:
- Older age, burden of cardiovascular risk factors,
- Chronic kidney disease,
- Presence of structural and coronary heart disease:
- History of CAD, AFIB, Heart Failure
- Correlates with LF-EF, WMA, ECG (QT c time, repolarization changes)
- Stroke severity, embolic infarct pattern, stroke lesion site.
To summarize: neurologists should differentiate acute and chronic injury and for this to lead serial troponin measurements. In case of chronic myocardial injury, re-stratify vascular risk profile and perform (outpatient) cardiac assessment. In acute myocardial injury – establish cause in a timely manner. Use conventional risk schemes and cardiac imaging to stratify risk of type 1 myocardial infarction.
What the heart hides: How to perform basic and advanced cardiac monitoring in your stroke unit
In his presentation, Martin Köhrmann from Germany underlined that cardiac monitoring includes: evaluation of biomarkers (CHD, CAD, MI), evaluation of structural changes and function (heart ultrasound), evaluation of vasculature if needed and evaluation of electric changes (ECG). Stroke Arrhythmia Monitoring Database (SAMBA) was a prospective, monocentric study with 641 patients from the Stroke Unit. Daily standardized rhythm analysis of acquired ECG data was done. SAMBA consisted of several substudies: SAMBA-SR: detection of Arrhythmias (Kurka et al. Stroke; Kallmunzer et al. Stroke; Seifert et al. J Neuol), SAMBA-AF: detection of atrial fibrillation (Kallmunzer et el.; Stroke), SAMBA HR: clinical impact of heart rate dynamics (Kallmunzer et al.; J Stroke Cerebrovasc Dis.) and Impact on Early Repolarization Pattern (Bobinger et al.; Clin Res Cardiol).
Standardized Algorithm for ECG analysis should include:
- 24-h spectrum of HR dynamics
- Identification of drops and raises > 20/min
- Changes in width of spectrum
- Tachycardia > 120/min and Bradycardia < 40/min
- Automatically detected arrhythmias and alarms
Arrhythmia after Stroke:
- 25% of all patients have relevant arrhythmia
- 24% of these are clinically evident
- 77% direct therapeutic consequences (1 CPR, 13 pacemaker/ICD, medication)
- Tachycardic > bradycardic
- Clearly time dependent after stroke
- Predictors: Age, NIHSS on admission.
Biomarkers of Cardiac and Vascular Thrombogenicity and Stroke Risk
Presented by Magnus Bäck, Sweden
Several mechanisms take part in a cardiac thrombogenicity: endothelial dysfunction, vasoconstriction, thrombosis, inflammation, smooth muscle proliferation, biomarkers of inflammation: IL-6, CCRP, n-3, PUFA, coagulation and platelet aggregation with elevated D-dimers, fibrinogen, etc. Biomarkers can also distinguish the source of thrombus.
Left atrium thrombogenicity can be evaluated by ultrasound monitoring. Cardiac thrombogenicity can be systemic. In the center is inflammation that can help to distinguish cardiac and vascular thrombogenicity.
CRP is higher in non-cardioembolic cases. Omega-3-fatty acids in atherosclerosis can be biomarkers for inflammation. DHA fatty acids decreased the risk of ischemic stroke. DPA decreases the risk of cardioembolic stroke.
Stroke prevention in cardiac interventions: TAVI, ablations.
Presented by Jan Kovac, United Kingdom
Heart interventions which coil lead to the acute brain injury are mechanical thrombectomy (pivotal, but not limited to), LAA Closure, embolic protection for Cardiac Interventions and ablations. Postulated Mechanism is the reduction of the left atrial appendage blood flow from dysrhythmia. AF slows LAA blood flow and disrupts laminar flow. More complex LAA internal characteristics such as “cauliflower” morphology puts even low CHA2DS2 – VASc score AF patients at significantly higher embolic risk than the simpler chicken wing or windsock morphologies. There are 90% nonvalvular atrial fibrillation related emboli detected in left atrial appendage closure. Most of the atrial fibrillation comes from the left atrial appendage.
Can pulmonary vein isolation (PVI, AF Ablation) prevent Stroke?
Historical studies such as AFFIRM/RACE showed no difference in risk of stroke between rate and rhythm control strategies for AF. There are multiple observational studies demonstrating a reduced incidence of stroke post-ablation (Bunch et al./Korean National Health Insurance Service (NHIS) database). Meta-analyses also supported the reduced stroke risk post ablation (although in the majority of studies included, anticoagulation was continued post-ablation). Randomized Prospective studies demonstrated that there is no randomized prospective data to suggest ablation is associated with a reduction in risk of stroke (CABANA trial). There are several ongoing studies LAA vs NOACs: CHAMPION – AF clinical trial, PFO trial.
Heart Brain Interventionist 2022 (And Beyond):
- Cardiology is moving beyond boundaries of heart disease
- Stroke is often related to heart conditions
- Stroke prevention and treatment is multidisciplinary
- Several New Skills required for all specialties
- Cooperation and pathway access requires collaboration of all stakeholders
- Important issue of training quality and outcome control
- Stroke Specialist – Referrer, Gate Keeper and Quality Controller!