Download Structural Heart Defects and Stroke Structural Heart Defects and

11/12/2014
Stroke Update Symposium
Nov. 14, 2014
Structural Heart
Defects and Stroke
George V. Moukarbel, MD
Assistant Professor of Medicine
Interventional Cardiology
Director, Heart Failure & LVAD Program
Associate Director, Cardiovascular Fellowship Program
The University of Toledo Medical Center
Objectives:
• Review structural heart defects that are
associated with stroke and the therapy
to prevent stroke events
• Discuss the cardiac evaluation of
patients presenting with stroke
• Outline the treatment of stroke patients
who have underlying structural cardiac
lesions
Disclosures
• I have no disclosures
relevant to this presentation
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11/12/2014
Patent
foramen
ovale
Structural
Heart
Disease
Spectrum
Atrial septal
defect
Ventricular
septal defect
Paravalvular
leak
Hypertrophic
cardiomyopathy
Valvular heart
disease
Left atrial
appendage
Vascular
fistulae
sinus of
valsalva
aneurysm
Left
ventricular
aneurysm
Patent
ductus
arteriosus
Heart Disease and Strokes:
Leading Killers in the United States
Cause 1 of every 3 deaths
More than 1 of 3 (83 million) U.S. adults currently
lives with one or more types of cardiovascular
disease.
Over 2 million heart attacks and strokes each year
• $444 B in health care costs and lost productivity
• Greatest contributor to racial disparities in life
expectancy
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Roger VL, et al. Circulation 2012;125:e2-e220
Heidenriech PA, et al. Circulation 2011;123:933–4
Stroke Subtypes
Ischemic
80%
Hemorrhagic
20%
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Stroke
Ischemic
Hemorrhagic
Small vessel
Lg. vessel
Embolic
Causes of Ischemic Stroke in
Young Adults
Eur Neurol 2007;57:212–218
CARDIOEMBOLIC SOURCES
LV thrombus
Valvular heart
disease
Prosthetic
valves
Acute MI
10%
10%
5%
15%
Other less
common sources
(PFO, ASA,
aortic debris, etc.)
10%
50%
Nonvalvular
Atrial Fibrillation
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Definition of Cardioembolic
Stroke
• Embolism of material forming on or
crossing through the atrial or
ventricular wall or heart valves
• Particles/debris embolize to the
arterial circulation of a brain region
• Embolus is: Thrombus, fat, air,
cancer cells, clumps of bacteria,
etc…
Clinical Characteristics of
Cardioembolic Stroke
• Sudden in onset, with maximum
neurologic deficit at once
• Decreased consciousness at
onset
• Embolism to other brain regions
• Embolism to other organs
• Palpitations at onset
Clinical Characteristics of
Cardioembolic Stroke
• Generally worse prognosis than
thrombotic strokes as the area
infarcted is usually larger due to
large emboli
• Emboli from the heart most often
lodge in the MCA, PCA, and
infrequently ACA
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Cardiac Workup of the Patient
with Stroke: What to Look For
•
•
•
•
•
•
Cardiac arrhythmias
Cardiac murmurs
Signs of Heart Failure
Recent MI
Concomitant diseases ( eg.
endocarditis)
Signs of systemic embolism
Physical Exam
• Neurologic Exam
• Cardiac Exam
• Vascular Exam (Carotid Bruits,
•
•
Peripheral Pulses)
Dermatologic
• Splinter hemorrhages and needle
tracks (endocarditis)
• Xanthoma (hyperlipidemia)
Ophthalmologic
Cardiovascular Diagnostic
Testing for Patients With Stroke
•
•
•
•
•
•
Carotid ultrasonography
Transthoracic echocardiography
Transesophageal echocardiography
Electrocardiogram
Prolonged ECG monitoring with Holter
or event loop recorder (external or
implantable)
Blood studies (Thrombophilia panel)
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Embolic Risk of Various Cardiac Lesions
High Risk
Medium Risk
Low/Unclear Risk
Atrial
fibrillation/flutter
LV hypokinesia /
aneurysm
Patent foramen
ovale
Recent anterior MI
Bioprostetic valve
Mechanical valve
LV systolic
dysfunction
Atrial septal
aneurysm
Rheumatic mitral
stenosis
Thrombus / tumor
(myxoma)
? Myxomatous
MVP
Spontaneous
echo contrast
SSS
Endocarditis
Additional (Minor risk) sources
• Calcific Aortic Valve or Bicuspid
Aortic Valve
• Mitral Annular Calcification
• Fibroelastomas (benign tumors on
valves)
• Lambl’s excrescences (filliform
•
•
outgrowths from free borders of
valves)
LV regional wall motion abnormality
Aortic arch atheromatous plaques
Treatment
• Primary prophylaxis depends on
•
the particular risk factor but centers
primarily around anti-coagulation,
especially in the high-risk group
(except for endocarditis and
myxoma)
Primary prophylaxis for medium or
low risk factors is less clear as
benefit of anti-coagulation is not
yet proven
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Stroke Is the Most Common and
Devastating Complication of AF
• All-cause stroke rate with
AF is 5% per year
• AF - independent risk factor
for stroke
• ~5-fold increase in stroke risk
• ~15% of all strokes caused by
AF
• Stroke risk increases with
age
• Stroke risk persists
asymptomatic AF
Fuster V, et al. Circulation. 2006;114:e257-e354.
Wolf PA, et al. Stroke. 1991;22:983-988.
Page RL, et al. Circulation. 2003;107:1141-1145.
Hart RG, et al. J Am Coll Cardiol. 2000;35:183-187.
90% of Clots Reside in the
Appendage
Stroke Risk in AF: CHADS2 Score
Risk Factor
Points
C
Congestive HF
1
H
Hypertension
1
A
Age ≥ 75
1
D
Diabetes
1
S2
Prior Stroke/TIA
2
Gage BF, et al. JAMA. 2001;285:2864-2870.
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Risk of Stroke Without Warfarin in
National Registry of Atrial Fibrillation
(NRAF) by CHADS2 Score
50
40
10
5
*Crude stroke
rate per 100
patient-years
0
0
1
2
3
4
CHADS2 Score
5
6
Gage BF, et al. JAMA. 2001;285:2864-2870.
Clot Prevention: Management
Options
Medical Management:
Anticoagulant
Surgical Excision
(Appendectomy)
Transcatheter Device Closure
Warfarin vs Placebo in
Stroke Prevention in AF
AFASAK-1
SPAF
BAATAF
CAFA
SPINAF
EAFT
ALL Trials
100%
50%
Favors Warfarin
Warfarin reduces incidence
of stroke by ~64%
0%
-50%
-100%
Favors Placebo/
Control
Hart R, et al. Ann Intern Med. 2007;146:857-867.
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Aspirin vs Placebo in
Stroke Prevention in AF
AFASAK-1
SPAF I
EAFT
ESPS-II
LASAF, daily
LASAF, alternate day
UK-TIA, 300 mg daily
UK-TIA, 1200 mg daily
JAST
Aspirin Trials
SAFT
ESPS II, Dipyridamole
ESPS II, Combination
All Trials
100%
50%
0%
Favors Antiplatelet
Antiplatelet therapy reduces
incidence of stroke by ~22%
-50%
-100%
Favors Placebo/
Control
Hart R, et al. Ann Intern Med. 2007;146:857-867.
Warfarin vs Antiplatelet Therapy in
Stroke Prevention in AF
AFASAK I
AFASAK II
Chinese ATAFS
EAFT
PATAF
SPAF II, ≤ 75 yrs
SPAF II, >75 yrs
Aspirin trials
Warfarin reduces incidence
of stroke by ~39%
SIFA
ACTIVE-W
NASPEAF
All Trials
100%
50%
0%
Favors Warfarin
-50%
-100%
Favors Antiplatelet
Hart R, et al. Ann Intern Med. 2007;146:857-867.
Antithrombotic Therapy – A CHADS2
Risk Score-based Approach
0
• None*
• Aspirin
1
≥2
• OA*
• DAPT
• OA*
• DAPT
CHA2DS2-VASc
OA: oral anticoagulation
DAPT: dual antiplatelet therapy
(ASA/Clopidogrel)
* Preferred strategy
Additional risk factors:
Female gender
Age 65 to 74 y
Vascular disease
ACCP 2012 Guidelines
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Newer Therapies
Factor Xa Inhibitors and Direct Thrombin Inhibitors
Tissue Factor/VIIa
IX
X
IXa
VIIIa
Rivaroxaban
Apixaban
Edoxaban
(DU-176b)
Va
Xa
II
IIa
Fibrinogen
Dabigatran
Fibrin
Harenberg J. Semin Thromb Hemost. 2009;35:574-586.
Novel Oral Anticoagulants in Atrial
Fibrillation: A Meta-analysis of Large,
Randomized, Controlled Trials vs
Warfarin
Trials included in analysis:
SPORTIF III, SPORTIF IV, RE-LY, ROCKET AF, ARISTOTLE
Dogliotti et al. Clin. Cardiol. 2013
Non-Pharmacologic Approaches
• Surgery
• Percutaneous left atrial exclusion
Amplatzer
Watchman
Lariat
Class IIb, level of evidence B
2014 AHA/ASA Stroke Guidelines
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When to start
anticoagulation
in patients with
stroke in the
setting of AF?
Within 14 days for most
patients.
Delay beyond 14 days in
patients with high risk of
hemorrhagic conversion
2014 AHA/ASA Stroke Guidelines
Mechanism of stroke with
PFO
• Paradoxical embolism
• Valsalva inducing activities?
• Occult DVT?
• ASA and thrombus?
• Large PFO?
• Atrial arrythmias?
Mas et al. 2001
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WARCEF: HF with EF≤ 35%,
no AF; 2305 patients
• Significant reduction in the occurrence of
ischemic stroke among patients on warfarin.
• This benefit was tempered by an increased risk of
major hemorrhage in the warfarin group
NEJM 2012
Mitral stenosis: 1ary prevention
Associated condition
Treatment
Prior embolic event
Anticoagulation
Class of Rec.
I, B
Left atrial thrombus
Anticoagulation
I, B
LA ≥55 mm
Anticoagulation
IIb, B
Large atrium, Spontaneous Anticoagulation
echocontrast
IIb, C
AHA/ASA Guidelines for the primary
prevention of stroke. Stroke 2014
Valve replacement: 1ary prevention
Associated
condition
Aortic, mechanical,
no risk factors
Treatment
Warfarin (2-3), aspirin
Class of
Rec.
I, B
Aortic, mechanical,
risk factors
Warfarin (2.5-3.5), aspirin
I, B
Mitral, mechanical
Warfarin (2.5-3.5), aspirin
I, B
Aortic, bioprosthetic Aspirin
Warfarin (2-3) for 3 months
Mitral, bioprosthetic Aspirin
Warfarin (2-3) for 3 months
IIa, B
IIa, C
IIa, B
IIa, C
AHA/ASA Guidelines for the primary
prevention of stroke. Stroke 2014
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Other conditions: 1ary prevention
Condition
Treatment
Class of
Rec.
Myxoma
Surgery
I, C
Heart failure, no AF, no prior
embolic event
Anticoagulant/
antiplatelet
IIa, B
Fibroelastoma, symptomatic
Surgery
I, B
Fibroelastoma, asymptomatic, Surgery
>1 cm , mobile
LV thrombus post MI
Anticoagulation
IIa, B
IIa, C
IIa, C
LV aneurysm post MI
Anticoagulation
IIb, C
PFO, no prior stroke
Antithrombotic/ III, C
catheter therapy
AHA/ASA Guidelines for the primary
prevention of stroke. Stroke 2014
Other conditions: 2ary prevention
Condition
Treatment
Class of
Rec.
Heart failure, LA or LV
thrombus
Anticoagulation
I, C
Heart failure, LVAD
LV thrombus post MI
Anticoagulation
Anticoagulation
IIa, C
IIa, C
LV aneurysm post MI
Anticoagulation
IIb, C
Aortic Arch Atheroma
Antiplatelets
I, A
Statins
I, B
Anticoagulation
IIb, C
Surgery
III, C
AHA/ASA Guidelines for the secondary
prevention of stroke. Stroke 2014
PFO: 2ary prevention
Condition
Treatment
Class of
Rec.
If no indication for OAC
DVT
Antiplatelet
Anticoagulation
I, B
I, A
DVT, Anticoagulation C/I
IVC filter
IIa, C
No DVT
Closure
III, A
DVT
Closure
IIb, C
AHA/ASA Guidelines for the secondary
prevention of stroke. Stroke 2014
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Conclusions
• Multiple structural heart defects are
associated with embolic stroke
• The diagnosis relies on detection of
•
•
potential emboligenic sources in the
absence of another etiology of equal or
greater plausibility
Imaging, including TEE is important
Treatment (medical/catheter
based/surgical) depends on the risk
associated with the condition and
requires a multidisciplinary approach
[email protected]
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