Cardioneurology: The Multidisciplinary Team Is the Best Approach

Melissa Walton-Shirley


August 31, 2016

It was my distinct pleasure Tuesday to witness some of the best presentations I've ever attended at any European Society of Cardiology meeting.[1] The multidisciplinary team (MDT) approach was on grand display at the 11 am session. Several tough cardioneurovascular cases were discussed rapid fire and in such glorious detail that I was instantly envious. According to the World Heart Federation, 15 million people around the globe suffer a stroke annually, six million die, and another five million are left disabled. We're spending gazillions of dollars on boutique viral research, rightly needed, but we are straining at the Zika virus and swallowing the poor hemianopic camel. Why don't third-party payers and government agencies insist upon more training and more assimilation of every integral part of the cardioneurovascular team? If they were smart, they would sponsor the education of more practitioners of both prevention and therapy, but that's another story for another day.

As a cardiologist who practiced in a facility where we could never keep a neurologist for any length of time, acute stroke therapy sometimes fell upon us. My mind flashed back to the case of a retired nurse who presented many years ago aphasic and just barely within the window for lytic therapy. She was on warfarin for chronic afib and we strongly suspected she was subtherapeutic. When her blood was drawn, someone put it into a dumbwaiter in the wall of the emergency department and forgot it. When I kept calling for the result and realized we could not get it back in time, I called my office to ask someone to bring over our point-of-care testing kit urgently. The INR returned in the normal range, and the patient was lysed and began to speak within just a few minutes. I breathed a sigh of relief until her symptoms started to wax and wane again. I then had to make arrangements to transfer her to a tertiary center. I admit I was left unnerved by the fact this patient's ability to speak was placed firmly in my hands. After she was safely transported, I went into the bathroom and looked in the mirror. I recalled the 1988 US vice presidential debate when Senator Lloyd Bentsen said to Senator Dan Quayle, "Senator, you're no Jack Kennedy." I quipped to myself, "Melissa, you're no neurologist." That particular day I was all she had, and I was barely adequate. I could have sure used an MDT then.

Today's presentation comprised neurology, interventional cardiology, and electrophysiology. We also enjoyed an impromptu hematology commentary when an audience member pointed out that her specialty was missing from the mix. There were case reports, questions from the attendees, and quizzes. The culmination was a clear-cut plan for optimal care based on both data and experience. The entire world should strive to use this approach instead of the complete absence of some portions of the team or our feeble attempts at utilization of teleneurology.

One case that was particularly interesting involved a 34-year-old male with no known risk factors who developed a sudden onset of a motor deficit. The MRI revealed two distinct areas of stroke. His LDL was 129 mg/dL (3.4 mmol/L), the fasting blood sugar normal with no known inflammatory syndromes. MR angiography was also normal. The ECG revealed sinus rhythm and a right intraventricular conduction delay (RIVCD). No atrial arrhythmias were found in 72 hours of monitoring. The resting echo demonstrated normal wall motion and LVEF but the bubble study on the transesophageal echocardiography (TEE) as well as the transthoracic echocardiography (TTE) demonstrated brisk shunting. It was presumed to be a large patent foramen ovale (PFO) as >20 bubbles zoomed from the right to the left atrial cavity. He was treated with aspirin and a statin.

The following question was then put to the audience:

Is the stroke due to:

  • The PFO.

  • Probably not related to the PFO.

  • Related to the PFO and it should be closed.

  • Just deliver aspirin therapy.

  • I don't know.

Among the audience members, 43% voted to close the PFO, but was that the right course?

After the vote, varying potential mechanisms of the stroke were discussed, including paradoxical embolism from the venous circulation, direct embolization from the PFO tunnel or from the atrial septal aneurysm present on echo. The ROPE score calculator was used to assess whether the PFO was incidental or causal.[2] The patient received 1 point each for having no history of hypertension, diabetes, or prior transient ischemic attack (TIA). He received an additional point for being a nonsmoker. He was also given a point for the presence of a cortical infarct on imaging. He got 5 points for being in the age bracket from 30 to 39 years of age. This brought his total to 9 (high ROPE score is >6) that suggests a very high probability that his strokes were PFO related.

The next discussion involved whether or not to actually close the PFO.

The interventionalist said it was a good option, with a low rate of complication for this procedure. Another panelist pointed out the need to present all the options and consider the patient's preference. Another physician said that since there were two areas of stroke involvement he would favor closure. Another noted that PFO closure is really meant for those who failed medical therapy. This patient had not been on any therapy when he was admitted and had experienced no further symptomatology since placed on aspirin and statin. The final decision was to proceed with closure due to multiple stroke sites.

The outcome?

There were no recurrent strokes or TIA and no complications at 6 months. The interventionalist noted that "it took only 30 minutes" to perform the closure. One audience member lamented that since the newer American guidelines advise against PFO closure, "It brings us many difficulties in choosing the right therapy." Then the hematologist, Dr Julia Czuprynska (King's Thrombosis Centre, London, UK), asked, "How hard did you look for anticardiolipins and lupus anticoagulants? Did you confer with a hematologist?"

A member of the panel answered that they sent off their standard thrombophilia panel, which was normal, and they do have a hematologist available for consultation. They seemed genuinely enthusiastic for the input and pointed out that 14% of cryptogenic-stroke patients will be diagnosed with a hypercoagulable state. Dr Czuprynska then added, "It's important not to miss antiphospholipid syndrome in cryptogenic stroke workup." This includes two separate screening tests for the presence of the lupus anticoagulant as well as testing for anticardiolipins and beta 2 glycoprotein 1 antibodies. There is a risk of false-positive results when screening for the lupus anticoagulant in the presence of anticoagulants, but if the patient is already established on warfarin, a lupus anticoagulant screen can be performed using the Taipan venom time:ecarin clotting time ratio. Antibody testing is not affected by the presence of anticoagulants. Seems hematology is another integral part of this team.

Additional great caveats during other case presentations included the eloquence of the assessment of left atrial function by the electrophysiologist using such terminology as a "dirty P wave," noting its biphasic or flat configuration. He utilized echo findings including left atrial velocity, volume, and size to get a sense of "left atrial damage," a phrase I'd never heard before but understood well the implication. The interventionalist was measured and confident. All contributors played an important and equally respected role in the decision-making process.

The mastery of the data and the common goal of patient well-being, combined with a sense of camaraderie, all spell the best chance for an optimal outcome. Teamwork is required to put up our best fight against stroke and heart disease. At that session I witnessed the best few rounds of that fight that any hospital system could offer. Every stroke patient deserves an MDT approach.

I wish to thank the teams from Hospitals Louis Pradel and Wertheimer, Lyon, which included Drs Laura Mechtouff, Gilles Rioufol, Cyrille Bergerot, Philippe Chevalier, Martine Barthelet, and Mathieu Schaaf, as well as chairpersons Dr Sergio Berti (Fondazione Toscana Gabriele Monasterio—Ospedale del Cuore G Pasquinucci, Massa, Italy) and Dr Helene Thibault (Hôpital Cardio-Vasculaire et Pneumologique Louis Pradel, Bron, France) for their excellent contributions to medicine and education.


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