Stroke Patients Need Cardiologists

Wolfram Doehner MD, PhD

Disclosures

Eur Heart J. 2020;41(27):2514-2516. 

In This Article

Abstract and Introduction

Introduction

We Cardiologists Need a Better Understanding of Stroke

Although we appreciate stroke as a life-threatening disease, many of us have little understanding of stroke beyond the consideration as a cardiovascular endpoint.

Stroke is not only the second most important cause of death in our society, it is also the leading cause for disability in adult life. The strong link between multiple cardiovascular pathologies and ischaemic strokes (85% of all strokes) or haemorrhagic strokes (15%) is clearly established (Figure 1). Around half of ischaemic strokes may be directly caused by heart disease and cardiovascular risk factors may be involved in most other strokes. In fact, stroke may often be the initial event to indicate an underlying cardiovascular disease. Clearly, cardiologists should be aware of pathophysiological and clinical aspects of stroke, and cardiologic expertise needs to be included regularly in all phases of stroke care, from prevention to acute diagnostics and treatment to long-term care (Figure 2).

Figure 1.

Cardiologists' contribution to stroke according to stroke aetiology (by Toast classification).

Figure 2.

Cardiologists' contribution to stroke care according to stroke phases.

The ESC addressed this clear need for a better understanding of stroke among the cardiology community with the foundation of the ESC Council on Stroke in 2016. As of today, over 2000 clinicians, scientists, nurses, and other medical professionals enrolled for the free membership in the Council on Stroke (https://www.escardio.org/Councils/Council-on-Stroke). The unique characteristic of this council is its strict interdisciplinary concept throughout, from the Board composition to the working agenda of the council. It brings together clinicians and scientist from all specialties that are involved in stroke care including partner societies such as ESC, ESO, ESVS, EANS, ESMINT, EAN, and others.

The 3rd Annual Conference 'ESC Heart and Stroke': An Ambitious Interdisciplinary Concept

The interdisciplinary concept is particularly visible at the annual conference of the Council that was held this year in Barcelona (23–25 January 2020). Participants from 63 countries attended this conference and engaged with a faculty as multidisciplinary as the audience. A wide range of aspects of the stroke–heart interaction were targeted in the 2-day programme. Debates confronted the cardiologist's perspective with the neurologist's view, offered neuroradiologist concepts and presented newest evidence from stroke interventional pioneering work. Workshops provided mechanistic insights of risk factors and discussed tricky or challenging cases in the light of modern therapy and guidelines.

Highlights From the Conference ESC Heart and Stroke 20

One topic of particular interest is the ESUS concept (embolic stroke of unknown source) that fuelled the discussion with recent data from two major clinical trials (REPSECT ESUS and NAVIGATE ESUS). The unexpected neutral results from both trials confirmed once more that better understanding of the cardiovascular pathophysiology of stroke and careful individual diagnostic workup of cardiovascular risk patterns is needed to assign optimum stroke treatment.

Professor Hans-Christoph Diener, one of the fathers of the ESUS concept and a founding member of the Council on Stroke, presented in his keynote lecture a fascinating outline of the history of the ESUS concept. He also offered illustrative background knowledge on the unexpected trial results and analysed consequences and potential future direction to overcome the limitations of the current ESUS concept. Discussions of advanced anticoagulation strategies and the increasing complexity of combination therapies in specific cardiovascular patient groups provided clinically useful information that was well perceived by the audience.

Clearly, a systematic diagnostic workup of stroke aetiology and risk factors is and remains the key principle for optimal and individualized therapy. Improving strategies for arrhythmia detection, a major cause of cardioembolic strokes, is therefore a permanent hot topic. The president of the EHRA, Professor Hein Heidbuchel, engaged in a compelling pro and contra debate on the long-term search of atrial fibrillation using implantable loop recorders and further technological innovations.

Another new and pressing topic in the field was discussed, namely the emerging evidence of acute interventional thrombectomy as the most promising causal therapy of ischaemic stroke. While the dramatic benefit of percutaneous thrombectomy is beyond doubt, optimum techniques, imaging, surrounding therapy, and more were discussed and the perspective from cardiologists, neurologists, interventionalists, neuroradiologists, and intensive care unit specialists were put forward to an eagerly listening audience and triggered vivid discussions. One challenge of this demanding and complex interventional treatment rests with its implementation into emergency care networks and health care systems.

The stroke management in complex cardiovascular patients was addressed in dedicated sessions. Elderly patients, those with heart failure, with cancer or with further complex comorbidities clearly represent high-risk patients for stroke. Examples for complex and challenging clinical situations were discussed in interactive workshops by an experienced faculty presenting real clinical cases and including personal experience and guideline perspective to the lively discussions.

The role of cardiologists in the acute phase of stroke was another focus in the conference programme. Not only the immediate diagnostic workup to identify underlying causes for the stroke but in particular the firm involvement of the cardiologist at the stroke unit was discussed. Clearly, the need for cardiologist expertise in early treatment decisions and management of complications became apparent. A particular challenge and a fascinating current research focus is the feedback myocardial injury secondary to a stroke that includes electrical instability, calcium imbalance, mechanical coupling problems, myocardial necrosis, plaque instability, and severe imbalance of vegetative vascular pressure control. Emerging evidence led to the term Stroke-Heart Syndrome and research is ongoing on the mechanisms of this myocardial injury feedback that may in some cases trigger full myocardial infarction.

In organized poster sessions, all poster presenters were asked to meet with chairmen from the faculty in condensed poster presentations and discussions. The feedback of this intense academic dialogue was excellent particularly from the younger attendees (Figure 3). Among all posters, three poster prizes were voted on by an independent jury (Figure 4).

  • Abstract and Introduction
  • Summary

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