How many decades before your hospital puts a protocol in place for this? Maybe in time for your children and grandchildren? OR, if we had survivor led associations it would be spread across the world in one month.
Stroke patients need cardiologists
European Heart Journal, Volume 41, Issue 27, 14 July 2020, Pages 2514–2516, https://doi.org/10.1093/eurheartj/ehaa395
Published:
14 July 2020
Report from the ESC Heart & Stroke Conference 2020, by Wolfram Doehner, Chair of the ESC Council on Stroke
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).
Summary
The overarching objective of the conference is
to bridge the gap between medical specialties and to join efforts to
provide comprehensive stroke care to the often elderly and multimorbid
patients. The strict interdisciplinary concept of the conference is a unique feature in the conference curriculum of the ESC.
The conference received excellent marks in the post-event survey from
all parties involved, attendants, faculty, and supporting industry.
Driven by the encouraging feedback the planning for the coming conference, ESC Heart and Stroke ‘21, has already started, to continue this successful format in the coming years.
More information on the Council on Stroke can be found at: https://www.escardio.org/Councils/Council-on-Stroke.
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