Speakers - American Heart Associationwcm/@hcm/@gwtg/... · ©2015, American Heart Association 1 Lee...
Transcript of Speakers - American Heart Associationwcm/@hcm/@gwtg/... · ©2015, American Heart Association 1 Lee...
©2015, American Heart Association 1
Lee Schwamm, MD, FAHA
Executive Vice Chairman of Neurology, Massachusetts General Hospital
Director, Stroke Service and Medical Director, MGH TeleHealth, Massachusetts General Hospital
Director, Partners TeleStroke Center, Massachusetts General Hospital
Chair, Get With The Guidelines-Stroke Committee
Eric Edward Smith, MD, MPH, FRCPC, FAHA
Associate Professor, Dept of Clinical Neurosciences,
Radiology and Community Health Sciences
Member, Hotchkiss Brain Institute
Cumming School of Medicine, University of Calgary
Medical Director, Cognitive Neurosciences Clinic
Stroke Neurologist, Calgary Stroke Program
Speakers
©2015, American Heart Association 2
Cryptogenic Stroke Incidence in the U.S.
©2015, American Heart Association 3
“Reports that say that something hasn't happened are always
interesting to me, because as we know, there are known knowns;
there are things we know we know.
We also know there are known unknowns; that is to say we know
there are some things we do not know.
But there are also unknown unknowns – the ones we don't know we
don't know. And if one looks throughout the history of our country and
other free countries, it is the latter category that tend to be the difficult
ones”
Sec of Defense Donald Rumsfeld Briefing the Press on
Cryptogenic Stroke
4Defense.gov News Transcript: DoD News Briefing – Secretary Rumsfeld United States
Department of Defense (defense.gov)
What is a Cryptogenic Stroke?
AHA Heart and Stroke Statistics
Cardioembolic (20%)Lacunar (25%)(small vessel disease)
Ischemic Stroke (85%) Hemorrhagic Stroke (15%)
Subarachnoid Hemorrhage (30%)
Cryptogenic (30%)
Atherothrombotic CerebrovascularDisease (20%)
Intracerebral Hemorrhage (70%)
Cerebrovascular Disease: Stroke Subtypes
?
Large Artery Atherosclerosis*
Cardioembolism* (high and medium risk sources)
Small Vessel Occlusion*
Stroke of Other Determined Etiology*
Stroke of Undetermined Etiology
2 or more causes identified
Negative Evaluation
Incomplete Evaluation
Stroke Classification Systems: TOAST
7
*possible or probable depending on ancillary testsAmerenco et al. Cerebrovac Dis 2009
Atherothrombosis
Tandem Arterial Pathology
Cardiac Embolism
Lacune
Unusual Cause
Infarction of Undetermined Cause
Stroke Classification Systems: NINDS Stroke Databank
8Amerenco et al. Cerebrovac Dis 2009
Total Anterior Circulation (TAC)
Partial Anterior Circulation (PAC)
Lacunar (LAC)
Posterior Circulation (POC)
Stroke Type is amended as a final letter
I for infarct
S for syndrome prior to imaging or if indeterminate
Stroke Classification Systems:
Oxford Community Stroke Project (OCSP)
9Bamford et al. Lancet 1991; 337:1521
Stroke Classification Systems: Causative Classification of Stroke
10E.M. Arsava et al. Neurology 2010;75:1277-1284
Definition of Cryptogenic Stroke
©2013, American Heart Association 11
Stroke Diagnosis: Can I Buy a Vowel?
12
STROKE TYPE
CC
NLA I E CD M
C R O GY NL A E RG TA Y
Stroke Diagnosis: Can I Buy a Vowel?
In a Patient with AF and Prior Lacunes, is this a
Cryptogenic Stroke?
13
An illustration of coronal cross section of the brain
showing a small cavity termed a “lacune” within the
subcortical white matter and in the territory of
perforating arteries. (A) acute DWI SVI, (B) chronic
lacune on DWI MRI
Ay. Stroke. 1998; 29: 1393-1397
Is Stroke in a Young Patient with a PFO Cryptogenic?
D.J. Beacock, j.euje.2005.03.010 171-174
Round up the usual suspects
Call in the Crime Scene Investigators (CSI)
Two approaches
AHA Stroke Guidelines for Secondary Prevention
Kernan. Stroke 2014
Extracranial Vascular Imaging
It is important to evaluate the extracranial vasculature after the onset of acute cerebral
ischemia (stroke or TIA) to aid in the determination of the mechanism of the stroke and thus
potentially to prevent a recurrence
Antiplatelet Therapy
Oral administration of aspirin (initial dose is 325 mg) within 24 to 48 hours after stroke onset is
recommended for treatment of most patients.
Anticoagulation Therapy
Anticoagulation is recommended for high risk cardioembolic sources
Young patients with cryptogenic TIA or stroke and PFO should be evaluated for lower
extremity or pelvic venous thrombosis, which would be an indication for anticoagulation
PFO
For patients with a cryptogenic ischemic stroke or TIA and a PFO without evidence for DVT,
available data do not support a benefit for PFO closure (Class III; Level of Evidence A).
• Telemetry
• Holter monitoring
• MCOT
• ICM/PCM
Monitoring and Detection Strategies
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Approximately 10% of patients with acute ischemic stroke or TIA will have new AF detected
during their hospital admission
In stroke or TIA patients with an indication for a pacemaker, interrogation of the device identified
a 28% incidence of occult AF during 1 year
A similar rate of occult AF has been reported among high-risk, non-stroke patients with
implantable cardiac rhythm devices
Occult AF detected during pacemaker interrogation in stroke-free patients or mixed populations
is associated with increased risk for stroke
Detection of Occult AF
Prospective studies (n=31) reporting proportion of new AF diagnosed using ECG-monitoring for >12 hr
in patients with recent stroke or TIA were analyzed
Longer duration of monitoring was associated with an increased detection of AF when examining
monitoring time as a continuous variable (p<0.001 for meta-regression analysis) or as ≤ 72 hours vs. ≥
7 days vs. 3 months (5.1% vs. 15% vs. 29%)
Significant heterogeneity within studies was detected for both groups (≤72 hr: I2 = 91%; ≥7 d: I2 = 75%)
When assessing the odds of AF detection in the 3 randomized controlled trial, there was a 7.26
increased odds of AF detection with long-term monitoring (95% CI [3.99-12.83]; p<0.001)
Detecting AF after IS or TIA:
Systematic Review and Meta-Analysis
Dussault. Circ Arrhythm Electrophysiol. 2015 Jan 31.
Estimated rate of detection in ICM arm was 30.0% vs 3.0% in control arm
Sanna T ; NEJM 2014;370;2478
30% v 3%
Crystal AF: Detection Rates: 36 months
Predictors of AF in the Cryptogenic Stroke Population
Hazard Ratio
0.01 0.1 1 10 100
PFO (present)
Congestive Heart Failure
Hypertension
Diabetes
PR Interval (per 10ms)
CHADS2 Score
Modified Rankin Score
Index Event (stroke)
BMI (per kg/m^3)
Race (white)
Gender (male)
Age (>65 years)
AF More LikelyAF Less Likely
p<0.01
p<0.0001
p<0.01
Univariate Predictors of Atrial Fibrillation
p<0.05
Variable HR (95% CI) p-valueAge (per 10 years) 1.91 (1.31, 2.80) 0.0009PR interval (per 10 ms)
On PR-lengthening medication 1.17 (1.02, 1.35) 0.02Off PR-lengthening medication 1.58 (1.32, 1.90) <0.0001
Assar M, Passman R:; ESC 2014
New Statements and Guidelines and Their
Relevance for Stroke Performance Measurement
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©2013, American Heart Association 24
New 2015 Scientific Statement
Two prior warnings/relative contraindications where treated is now recommended
based on pooled RCT evidence in subgroups:
Old age.
Severe stroke.
Many clinical scenarios where tPA is reasonable or “may be considered”.
Implication: clinical judgement required, also reasonable to NOT give tPA based on physician judgement of risk:benefit
ratio (which should be documented).
Major New Recommendations in 2015 Statement
Exclusion and Relative Exclusion Criteria
©2013, American Heart Association 27
4/4/2016 ©2013, American Heart Association 28
Statin Prescribed at Discharge
©2013, American Heart Association 29
New ‘Reporting’ measure: Statin Prescribed at Discharge
Includes removal of two exclusion criteria:
(a) No documented prior cholesterol reducing therapy and
(b) LDL <100
A documented reason for not prescribing a statin at discharge continues to be
an exclusion for the measure population.
Patient Management Tool Updates
©2013, American Heart Association 30
Stroke Etiology
©2013, American Heart Association 31
Stroke Diagnostic Tests and Interventions – Discharge Tab
©2013, American Heart Association 32
Configurable Measure Report: Ischemic Stroke Etiology
©2013, American Heart Association 33
23%
34%
21%
6%
16%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Large-arteryatherosclerosis(e.g., carotid orbasilar artery
stenosis)
Cardioembolism(e.g., atrial
fibrillation/flutter,prosthetic heartvalve, recent MI)
Small-vesselocclusion (e.g.,
Subcortical or brainstem lacunar
infarction <1.5 cm)
Stroke of otherdetermined
etiology (e.g.,dissection,
vasculopathy,hypercoagulable or
hematologicdisorders
Cryptogenic Stroke(Stroke of
undeterminedetiology)
•Of the first 3947
cases, 68% in
2015-2016
had no stroke
etiology
documented
•Among 2680
entered, 16%
were
cryptogenic
Documented exclusions or relative exclusions for not initiating
IV thrombolytic
©2013, American Heart Association 34
Previous contraindications and warnings moved to Historic Tab
©2013, American Heart Association 35
Thank you for attending this review of the Get With the
Guidelines-Stroke® PMT Update
and for
your participation in the
Get With the Guidelines program
For PMT questions and assistance please contact the
GWTG Helpdesk at
888-526-6700
[email protected]©2013, American Heart Association 36