Speakers - American Heart Associationwcm/@hcm/@gwtg/... · ©2015, American Heart Association 1 Lee Schwamm, MD, FAHA Executive Vice Chairman of Neurology, Massachusetts General Hospital

©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


Cryptogenic Stroke Incidence in the U.S.


“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


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

http://www.cardiachealth.org/cardiac-healthcare-providers/surgical-anatomy/defects-with-a-left-to-right-shunt/asd




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

4/4/2016 ©2013, American Heart Association 18

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



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



Statin Prescribed at Discharge


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


Stroke Etiology


Stroke Diagnostic Tests and Interventions – Discharge Tab


Configurable Measure Report: Ischemic Stroke Etiology


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


Previous contraindications and warnings moved to Historic Tab


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

Documents

Speakers - American Heart Associationwcm/@hcm/@gwtg/... · ©2015, American Heart Association 1 Lee Schwamm, MD, FAHA Executive Vice Chairman of Neurology, Massachusetts General Hospital