The management of stroke patients often requires multidisciplinary collaboration. Stroke and cardiovascular disease share many common risk factors, and the two often coexist, and cardiologists can provide many professional recommendations in the management of stroke patients. Recently, the European Society of Cardiology (ESC) released a clinical document on optimizing the management of stroke-related heart disease, proposing ABC strategies: A. Appropriate antithrombotic therapy; B. Better functional and psychological status; C. Cardiovascular risk factors and Optimal management of comorbidities.
The 2022 ESC position paper states that 20%-30% of strokes are recurrent and that an integrated management approach can help improve patient management, thereby Reduce the incidence of cardiovascular events. In addition, integrated management of stroke and cardiovascular disease should be advanced.
A: Appropriate Antithrombotic Therapy< /span>
For post-stroke patients, if they have atrial fibrillation, A refers to the use of oral anticoagulants, and alternative drugs include non-vitamin K oral anticoagulants coagulants (NOACs) or vitamin K antagonists (VKAs such as warfarin). For patients with atrial fibrillation on warfarin, the time INR in the therapeutic range (TTR) is recommended to be ≥70%. For patients with implanted mechanical heart valves, the anticoagulant drug should be warfarin.
Appropriate use of antiplatelet drugs is indicated in patients with atherosclerotic vascular disease and without atrial fibrillation or mechanical valves.
If the patient has both atrial fibrillation and vascular disease (including coronary artery, carotid artery, and peripheral artery), antithrombotic drugs should be selected reasonably. In patients with atrial fibrillation with stable vascular disease, single-agent anticoagulation is sufficient. For AF patients with acute coronary syndrome (ACS), a better balance of bleeding and ischemic risks is required. Carotid endarterectomy is usually considered for patients with atrial fibrillation complicated by asymptomatic high-grade carotid stenosis; carotid stenting is an option for those who are not suitable for surgery, and short-term combined antithrombotic therapy is required after surgery.
In patients with stable atherosclerotic vascular disease without atrial fibrillation and an increased risk of ischemic events, low-dose rivaroxaban combined with Aspirin is a treatment option.
In the secondary prevention of non-cardiac stroke, guidelines-recommended antiplatelet drugs include aspirin, clopidogrel, or ticagrelor.
B: Better functioning and mental state
For all stroke patients, whether it is ischemic or hemorrhagic, regardless of whether hyperacute intervention is given or not, attention should be paid to reducing Brain injury, prevention of complications, and early initiation of rehabilitation to improve patient outcomes.
The goal of overall post-stroke management is to improve function and mental status and requires a multidisciplinary approach. Awareness-raising and a multidisciplinary approach are also needed for post-stroke depression and post-stroke dementia.
C: Optimal Management of Cardiovascular Risk Factors and Comorbidities< /strong>
Stroke patients often have multiple cardiovascular risk factors and comorbidities, including atrial fibrillation, atherosclerotic vascular disease, Hypertension, heart failure, dyslipidemia, etc. The goal of optimal management is to reduce the patient’s cardiovascular risk burden and reduce the risk of recurrent stroke or other major adverse cardiovascular events.
1. Lifestyle interventions
In terms of diet, the Mediterranean diet is recommended. In addition, a low-salt diet was associated with a reduced risk of stroke. For overweight and obese patients, weight loss and intensive lifestyle interventions are recommended.
Exercise and regular physical activity can reduce stroke risk and positively influence stroke risk factors through weight loss, lower blood pressure, and cholesterol. When possible, post-stroke patients should participate in 40 minutes of moderate-intensity aerobic exercise 3-4 times per week.
In addition, stroke patients should also quit smoking.
2. Screening for atrial fibrillation
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17%-36% of ischemic strokes are caused by atrial fibrillation. In as many as one-quarter of patients with AF, the first presentation is an ischemic stroke or TIA. AF-related stroke is associated with a higher rate of death or disability than other causes. Therefore, for unexplained ischemic stroke, the presence of atrial fibrillation should be actively sought.
The detection rate of atrial fibrillation depends not only on patient characteristics, time since stroke, stroke type, and definition of atrial fibrillation, but also on monitoring Duration and quality. Atrial fibrillation may be found in more post-stroke patients if we “look more closely, look longer, look more complex (e.g. with more sophisticated equipment)…”
For post-stroke patients with undiagnosed atrial fibrillation, short-term 24-h continuous ECG monitoring is recommended to screen for arrhythmias, followed by long-term (≥72 h) ECG monitoring. The 2018 Canadian Stroke Best Practice Recommendations advocate for ≥2 weeks of ECG monitoring in patients with ESUS.
For patients with a history of stroke and a high likelihood of atrial fibrillation, implantable implants may be considered after 7-14 days of noninvasive monitoring. Heart monitor for 30 days of continuous monitoring.
3. Hypertension, diabetes and dyslipidemia management< /p>
Controlling blood pressure helps prevent stroke recurrence. Sudden and significant reductions in blood pressure during the acute phase of ischemic or hemorrhagic stroke may worsen the patient’s condition. After the acute phase, strict blood pressure control can prevent recurrent stroke and other cardiovascular events. The blood pressure target is <130/80 mmHg in diabetic patients and <140/90 mmHg in non-diabetic patients. For patients with cerebral small vessel disease, a blood pressure target of <130/80 mmHg is reasonable.
All stroke patients with undiagnosed diabetes should be screened for diabetes. Strict glycemic control after acute stroke is not only unhelpful but also potentially harmful and may lead to hypoglycemiaSugar and early neurological deterioration. Therefore, the range of glycemic control in the acute phase of stroke is generally 70–180 mg/dL. The risk of cardiovascular complications in diabetic patients after stroke is very high, and the target HbA1c <7% should be strictly controlled.
In terms of blood lipid management, lowering LDL-C is the main goal, and the target LDL-C is 1.4 mmol/L (55 mg/dL), and decreased by at least 50% from baseline. Early and long-term statin use reduces the risk of recurrent stroke. For patients with baseline LDL-C levels well above target, ezetimibe can be started immediately. For patients whose triglyceride levels remain elevated despite statin therapy, triglyceride-lowering therapy reduces residual risk and improves patient survival.
For patients with carotid dissection, patent foramen ovale, endocarditis, and atrial myxoma leading to ischemic stroke or TIA, Lipid-lowering therapy should be based on individualized 10-year cardiovascular risk.
4. Heart Thrombosis
Atrial fibrillation, atrial flutter, left ventricle/left atrium/left atrial appendage thrombosis, prosthetic heart valve, mitral stenosis, atrial myxoma, Intracardiac masses or valve vegetations, etc.
Left ventricular mural thrombus accounts for 10% of cardioembolic strokes and is most common in patients with prior extensive anterior wall infarction with phasic dyskinesia patient. Transthoracic echocardiography (TTE) is the standard imaging technique for detecting left ventricular thrombus in patients with acute ischemic stroke, and ultrasound contrast agents significantly improve the diagnostic accuracy of TTE. Recent studies have shown that cardiac magnetic resonance (CMR) is superior to TTE in detecting LV thrombus in patients with a history of myocardial infarction and left ventricular dysfunction (LVEF < 50%).
In patients with detected LV thrombus, anticoagulation is indicated and other risk factors are managed. The anticoagulant drug is usually warfarin.
Bibliography: Gregory Y. H. Lip, Deirdre A. Lane, Radosław Lenarczyk, et al. Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke. Eur Heart J. 2022 May 13.