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Structural Heart Defects and Stroke
Structural Heart Defects and Stroke
George V. Moukarbel, MDAssistant Professor of MedicineInterventional CardiologyDirector, Heart Failure & LVAD ProgramAssociate Director, Cardiovascular Fellowship ProgramThe University of Toledo Medical Center
George V. Moukarbel, MDAssistant Professor of MedicineInterventional CardiologyDirector, Heart Failure & LVAD ProgramAssociate Director, Cardiovascular Fellowship ProgramThe University of Toledo Medical Center
Stroke Update Symposium Nov. 14, 2014
Objectives: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
• 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
DisclosuresDisclosures
• I have no disclosures relevant to this presentation
• I have no disclosures relevant to this presentation
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Structural Heart
Disease Spectrum
Structural Heart
Disease Spectrum
Patent foramen
ovale
Atrial septal defect
Ventricular septal defect
Hypertrophic cardiomyopathy
Left atrial appendage
Left ventricular aneurysm
Patent ductus
arteriosus
sinus of valsalva
aneurysm
Vascular fistulae
Valvular heart disease
Paravalvular leak
Heart Disease and Strokes:Leading Killers in the United States Heart Disease and Strokes:Leading Killers in the United States
Cause 1 of every 3 deathsMore 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
Cause 1 of every 3 deathsMore 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
Roger VL, et al. Circulation 2012;125:e2-e220Heidenriech PA, et al. Circulation 2011;123:933–47
Stroke SubtypesStroke Subtypes
Ischemic 80%
Hemorrhagic 20%
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Stroke
IschemicHemorrhagic
Lg. vesselSmall vessel Embolic
Eur Neurol 2007;57:212–218
Causes of Ischemic Stroke in Young AdultsCauses of Ischemic Stroke in Young Adults
50%50%15%15%
10%10%
5%5%
10%10% 10%10%
CARDIOEMBOLIC SOURCESCARDIOEMBOLIC SOURCES
NonvalvularAtrial Fibrillation
NonvalvularAtrial Fibrillation
Acute MIAcute MI
LV thrombusLV thrombusValvular heart
diseaseValvular heart
disease
Prostheticvalves
Prostheticvalves
Other lesscommon sources
(PFO, ASA,aortic debris, etc.)
Other lesscommon sources
(PFO, ASA,aortic debris, etc.)
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Definition of CardioembolicStrokeDefinition of CardioembolicStroke
• 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…
• 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 StrokeClinical 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
• 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
• 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
• 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
Clinical Characteristics of Cardioembolic StrokeClinical Characteristics of Cardioembolic Stroke
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Cardiac Workup of the Patient with Stroke: What to Look ForCardiac 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
• Cardiac arrhythmias• Cardiac murmurs• Signs of Heart Failure• Recent MI• Concomitant diseases ( eg.
endocarditis)• Signs of systemic embolism
• Neurologic Exam• Cardiac Exam• Vascular Exam (Carotid Bruits,
Peripheral Pulses)• Dermatologic
• Splinter hemorrhages and needle tracks (endocarditis)
• Xanthoma (hyperlipidemia)• Ophthalmologic
• Neurologic Exam• Cardiac Exam• Vascular Exam (Carotid Bruits,
Peripheral Pulses)• Dermatologic
• Splinter hemorrhages and needle tracks (endocarditis)
• Xanthoma (hyperlipidemia)• Ophthalmologic
Physical ExamPhysical Exam
Cardiovascular Diagnostic Testing for Patients With StrokeCardiovascular 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)
• 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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High Risk Medium Risk Low/Unclear Risk
LV hypokinesia / aneurysm
Bioprostetic valve
LV systolic dysfunction
? Myxomatous MVP
Patent foramen ovale
Atrial septal aneurysm
Spontaneous echo contrast
SSS
Embolic Risk of Various Cardiac Lesions
Atrial fibrillation/flutter
Recent anterior MI
Mechanical valve
Rheumatic mitralstenosis
Thrombus / tumor (myxoma)
Endocarditis
Additional (Minor risk) sourcesAdditional (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
• 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
TreatmentTreatment• 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
• 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 AFStroke 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
• 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 Appendage90% of Clots Reside in the Appendage
Stroke Risk in AF: CHADS2 ScoreStroke 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 inNational Registry of Atrial Fibrillation (NRAF) by CHADS2 Score
Risk of Stroke Without Warfarin inNational Registry of Atrial Fibrillation (NRAF) by CHADS2 Score
0 1 2 3 4 5 60
5
10
40
50
CHADS2 Score
Gage BF, et al. JAMA. 2001;285:2864-2870.
*Crude stroke rate per 100 patient-years
Medical Management: Anticoagulant
Surgical Excision (Appendectomy)
Transcatheter Device Closure
Clot Prevention: Management Options
Warfarin vs Placebo inStroke Prevention in AF
100% 50% 0% -50% -100%
AFASAK-1
SPAF
BAATAF
CAFA
SPINAF
EAFT
ALL Trials
Favors Warfarin Favors Placebo/Control
Hart R, et al. Ann Intern Med. 2007;146:857-867.
Warfarin reduces incidence of stroke by ~64%
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Aspirin vs Placebo inStroke Prevention in AF
Favors Placebo/Control
Antiplatelet therapy reduces incidence of stroke by ~22%
All Trials
100% 50% 0% -50% -100%
AFASAK-1 SPAF IEAFTESPS-II
LASAF, daily
UK-TIA, 300 mg daily
Favors Antiplatelet
LASAF, alternate day
UK-TIA, 1200 mg daily
JAST
Aspirin Trials SAFTESPS II, Dipyridamole
ESPS II, Combination
Hart R, et al. Ann Intern Med. 2007;146:857-867.
Warfarin vs Antiplatelet Therapy inStroke Prevention in AF
100% 50% 0% -50% -100%
Favors Warfarin Favors Antiplatelet
AFASAK I AFASAK II
Chinese ATAFSEAFTPATAF
SPAF II, ≤ 75 yrs
SPAF II, >75 yrs
Aspirin trials
SIFAACTIVE-W
NASPEAF
All Trials
Warfarin reduces incidence of stroke by ~39%
Hart R, et al. Ann Intern Med. 2007;146:857-867.
Antithrombotic Therapy – A CHADS2Risk Score-based Approach
Antithrombotic Therapy – A CHADS2Risk Score-based Approach
0
• None*• Aspirin
1
• OA*• DAPT
≥2
• OA*• DAPT
OA: oral anticoagulationDAPT: dual antiplatelet therapy (ASA/Clopidogrel)* Preferred strategy
ACCP 2012 Guidelines
Additional risk factors:Female genderAge 65 to 74 yVascular disease
CHA2DS2-VASc
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Newer TherapiesFactor Xa Inhibitors and Direct Thrombin Inhibitors
Newer TherapiesFactor Xa Inhibitors and Direct Thrombin Inhibitors
Harenberg J. Semin Thromb Hemost. 2009;35:574-586.
Tissue Factor/VIIa
IX
IXa
X
Xa
VIIIa
Va
II IIa
Fibrinogen Fibrin
RivaroxabanApixabanEdoxaban(DU-176b)
Dabigatran
Dogliotti et al. Clin. Cardiol. 2013
Novel Oral Anticoagulants in AtrialFibrillation: A Meta-analysis of Large,Randomized, Controlled Trials vs Warfarin
Novel Oral Anticoagulants in AtrialFibrillation: A Meta-analysis of Large,Randomized, Controlled Trials vs Warfarin
Trials included in analysis: SPORTIF III, SPORTIF IV, RE-LY, ROCKET AF, ARISTOTLE
Non-Pharmacologic ApproachesNon-Pharmacologic Approaches
• Surgery• Percutaneous left atrial exclusion• Surgery• Percutaneous left atrial exclusion
Lariat
AmplatzerWatchman
Class IIb, level of evidence B2014 AHA/ASA Stroke Guidelines
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When to start anticoagulation in patients with
stroke in the setting of AF?
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 PFOMechanism of stroke with PFO
• Paradoxical embolism• Valsalva inducing activities?• Occult DVT?• ASA and thrombus? • Large PFO?• Atrial arrythmias?
• 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 patientsWARCEF: HF with EF≤ 35%, no AF; 2305 patients
NEJM 2012
• 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
Mitral stenosis: 1ary preventionMitral stenosis: 1ary prevention
Associated condition Treatment Class of Rec.
Prior embolic event Anticoagulation I, B
Left atrial thrombus Anticoagulation I, B
LA ≥55 mm Anticoagulation IIb, B
Large atrium, Spontaneousechocontrast
Anticoagulation IIb, C
AHA/ASA Guidelines for the primary prevention of stroke. Stroke 2014
Valve replacement: 1ary preventionValve replacement: 1ary prevention
Associated condition
Treatment Class of Rec.
Aortic, mechanical, no risk factors
Warfarin (2-3), aspirin 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 AspirinWarfarin (2-3) for 3 months
IIa, BIIa, C
Mitral, bioprosthetic AspirinWarfarin (2-3) for 3 months
IIa, BIIa, C
AHA/ASA Guidelines for the primary prevention of stroke. Stroke 2014
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Other conditions: 1ary preventionOther conditions: 1ary preventionCondition 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,>1 cm , mobile
Surgery IIa, BIIa, C
LV thrombus post MI Anticoagulation IIa, C
LV aneurysm post MI Anticoagulation IIb, C
PFO, no prior stroke Antithrombotic/catheter therapy
III, C
AHA/ASA Guidelines for the primary prevention of stroke. Stroke 2014
Other conditions: 2ary preventionOther conditions: 2ary prevention
Condition Treatment Class of Rec.
Heart failure, LA or LV thrombus
Anticoagulation I, C
Heart failure, LVAD Anticoagulation IIa, C
LV thrombus post MI Anticoagulation 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 preventionPFO: 2ary prevention
Condition Treatment Class of Rec.
If no indication for OAC Antiplatelet I, B
DVT Anticoagulation 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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• 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
• 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
ConclusionsConclusions
[email protected]@utoledo.edu