By: Thomas Meinel, Rustam Al-Shahi Salman
ESO European Stroke Science Workshop 2023
Session 2: The Heart of Matter
Professor Hooman Kamel
The keynote lecture of the session was given by Professor Hooman Kamel and delved into the intricate relationship between atrial cardiopathy and atrial fibrillation (AF) in the context of stroke patients. Atrial cardiopathy, characterized by structural and functional abnormalities in the atria, has emerged as a significant player, coexisting with or more often preceding AF.
Regarding AF, new data is available from NOAH-AFNET and ARTESIA – two trials that randomised patients with device-detected short episodes of subclinical AF to oral anticoagulation vs placebo or Aspirin. In the meta-analysis of those trials, there was a benefit in the reduction of (disabling) stroke at the cost of a slightly increased risk of major bleeding. The question remains whether those findings can be extrapolated to stroke survivors since only about 10% had prior stroke and most patients in the trial had a previous cardiac condition requiring the implantation of a pacemaker or implantable cardioverter/defibrillator and only a very tiny minority was diagnosed based on implantable cardiac monitors.
With regards to atrial cardiopathy, Professor Kamel explored details of his ARCADIA trial, that overall did not show benefit of oral anticoagulation for patients with atrial cardiopathy. In further analyses, there was also no benefit in patients with a more severe phenotype of atrial cardiopathy based on the biomarkers used (P-terminal force V1, BNP, and left atrial dilatation).
A vivid discussion followed this enlightening lecture. Raised question included whether biomarkers of more severe atriopathy, a combination of atrial myopathy and a thrombogenic condition or older populations might still benefit from oral anticoagulation. Another alternative would be to test the COMPASS regimen (low dose Rivaroxaban + Aspirin) since there is a significant burden of non-stenosing atherosclerosis in people with cryptogenic ischaemic stroke.
Further related trials in the pipeline include the ongoing FIND-AF2 trial, that hopefully clarifies whether prolonged ECG monitoring is able to prevent recurrent events. Another option might include mechanical occlusion of the left atrium as tested in LAAOS-4, CHAMPION-AF or the ELAPSE trial. Additionally, trials testing factor XIa inhibition are ongoing (LIBREXIA-AF, LILAC-TIMI 76), although recently OCEANIC-AF was stopped early for lack of efficacy of the oral factor XIa inhibitor Asundexian.
In conclusion, this keynote session and discussion provided a comprehensive overview of the complex relationship between atrial cardiopathy, AF, and ischaemic stroke. The integration of clinical, imaging, and biomarker insights paved the way for a deeper understanding of these interrelated cardiovascular conditions, offering promising avenues for future research and improved patient care.
Professor Mira Katan
Professor Mira Katan made a strong argument for the potential of biomarkers to find tailored therapeutic management strategies in stroke patients. Biomarkers are available providing etiological clues, but also bearing prognostic significance for recurrence risk stratification. One such option is currently tested in the ongoing MOSES trial, that tests the hypothesis that patients with ischaemic stroke, in sinus rhythm, with an elevated mid-regional pro-atrial natriuretic peptide (MR-proANP) – a biomarker strongly associated with severe atrial cardiopathy at the chosen cut-off – benefit from oral anticoagulation as compared to antiplatelet therapy. Given the complexity and multitude of available biomarkers, artificial intelligence models might be helpful to disentangle.
Dr. Märit Jensen
Dr. Jensen gave a fantastic talk on the concept of early rhythm control for AF. In the EAST-AFNET 4 trial, a strategy of early rhythm control was able to reduce the composite outcome in a cardiology-based AF population. However, a significant proportion of AF is diagnosed after stroke by neurologists. This raises the question, whether those patients should be referred for rhythm control, especially since a subgroup analysis of EAST-AFNET 4 trial led by Dr. Jensen and Professor Götz Thomalla and Professor Paulus Kirchhof showed that the benefit of rhythm control was even more pronounced in the subgroup of patients with prior stroke. The stroke-specific EAST-STROKE trial is in the planning and could provide reliable evidence for this exciting new approach and novel hope for stroke patients with AF.
Associate Professor Signild Åsberg
The last talk of the session looked back at the history of anticoagulation for patients with AF and ischaemic stroke. In recent decades, the transition from Vitamin-K-antagonists to DOACs took place and led to better adherence to anticoagulation given the favorable safety profile. The latest advances include the TIMING trial and ELAN trial that showed that earlier start of DOAC therapy in patients with ischemic stroke and AF is safe and most likely beneficial. The ongoing large OPTIMAS and START trials and a planned individual patient data meta-analysis will hopefully provide definitive evidence of the effectiveness and safety of early initiation of oral anticoagulation for AF after ischaemic stroke both overall and in sub-groups.
A lively discussion started after the talks proving the relevance, timeliness and quality of the topics and speakers. This session was a great start and shed light on exciting developments for the interdisciplinary care of patients with stroke and cardiac disease.