Thomas Meinel, MD
European Stroke Organisation Conference
September 1–3, 2021
Stroke prevention — especially in patients with atrial fibrillation — is a team effort of cardiologists and vascular neurologists. Vice-versa, work-up of cardiac disease and cardioaortic sources of embolism is a joint effort of stroke physicians and cardiologists. Several novel diagnostic options, medical therapies and devices are available in the cardiovascular field. Hence, this joint session of the ESO and ESC was a logical consequence of intensified collaboration of these two big societies.
The first speaker was Marta Rubiera from Spain, who elaborated on the diagnostic options to identify structural cardioaortic sources of embolism in stroke patients. Presenting the expected diagnostic findings and weighing nicely the pros and cons of each modality, she guided the audience to choose the correct test according to the patient and the stroke characteristics. Cardiac MRI and cardiac CT represent novel diagnostic options in selected patients, but echocardiography remains the working horse of stroke work-up. However, the lack of randomized diagnostic studies with clinical outcomes and the uncertainty of what to do with minor sources of embolism remain a major drawback of this daily task during stroke unit rounds. Joint efforts of cardiology and neurology are necessary to overcome this evidence gap.
Next up was Renate Schnabel and her talk on detection of atrial fibrillation after ischemic stroke. She emphasized that the longer the monitoring duration, the higher the chances of detection of atrial fibrillation, even in patients with clear other etiology of the ischemic event such as large-artery atherosclerosis or small-vessel disease. Since use of cardiac monitors is limited by healthcare resources, her talk and the Q&A nicely covered alternatives such as use of smartwatches and predictors for paroxysmal atrial fibrillation that can be used to select patients for monitoring. Nevertheless, the minimal burden of atrial fibrillation in patients with and without prior stroke necessary to benefit from anticoagulation is still an open question.
Hooman Kamel made the argument that detection of atrial fibrillation might even not be necessary to provoke ischemic stroke, explaining the concept of atrial cardiopathy. Factors such as endothelial dysfunction, atrial enlargement, fibrosis, electrical remodeling and premature contractions might cause thrombosis within the left atrium and hence cardioembolic stroke even without atrial fibrillation. Several ongoing studies are investigating whether anticoagulation in patients with surrogate markers of atrial cardiopathy can protect these patients against recurrent stroke as compared to standard therapy.
Urs Fischer covered the topic of when to start anticoagulation in atrial fibrillation–related ischemic stroke. Using case scenarios, he gave useful advice on how to use imaging (infarct size, hemorrhagic transformation) to define the optimal timepoint of anticoagulation start. His multicenter international trial on this topic is ongoing, and it is still possible for centers to join the trial and contribute patients.
Another success story of the collaboration of cardiologists and vascular neurologists is the topic of persistent foramen ovale (PFO), where finally the benefit of interventional closure could be shown in young stroke patients without many other risk factors. Jan Kovac pointed out, for which patients’ closure is indicated, and which adverse effects have to be considered to correctly inform the patient. Further research regarding the optimal type and duration of antithrombotic therapy and significance of residual shunting is needed.
The last speaker was Jan Scheitz, who gave a talk on the complex interplay of cardiovascular risk factors, troponin elevation and incident dementia. In his excellent overview, he clearly showed the association of cardiovascular risk factors (especially in midlife), stroke and dementia. Several pathways, including microembolisms, autonomic dysfunction, and strategic infarction, contribute to brain frailty and result in dementia. Troponin levels seem to be a strong surrogate to assess the cardiovascular risk in borderline patients. The prevention not only of stroke, but also of vascular dementia, is a huge task for cardiologists and stroke physicians, and the main weapons are control of hypertension, diabetes, smoking cessation and use of anticoagulation wherever indicated.
Prevention of stroke was identified as the highest priority of the Stroke Association. A close collaboration in clinical routine between vascular neurologists and cardiologists is necessary to apply the latest knowledge to every patient. Interdisciplinary research is needed to clarify the potential benefits of novel diagnostic and therapeutic strategies. The collaboration between ESO and ESC connects physicians and researchers of both societies, hence leveraging mutual expertise and commitment.