Πρόληψη και θεραπεία του αγγειακού. εγκεφαλικού επεισοδίου από τη σκοπιά του. Καρδιολόγου

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1 Πρόληψη και θεραπεία του αγγειακού εγκεφαλικού επεισοδίου από τη σκοπιά του Καρδιολόγου Κωνσταντίνος Π. Τσιούφης Αν. Καθηγητής Καρδιολογίας ΕΚΠΑ Πρόεδρος Ελληνικής Καρδιολογικής Εταιρείας

2 Δήλωση σύγκρουσης συμφερόντων Καμία σύγκρουση συμφερόντων για τη συγκεκριμένη ομιλία Εχω λάβει υποστήριξη συμμετοχής σε συνέδρια ή ερευνητική υποστήριξη ή τιμητική αμοιβή ομιλίας από Medtronic, St. Jude Medical, Bayer, Novartis, Astra-Zeneca, Boehringer In, Pfizer, Chiesi, Pharmanel, Sanofi, Vianex, Win- Medica, Elpen, Menarini

3 Stroke classification based on etiology

4 Αγγειακό εγκεφαλικό επεισόδιο και ο Καρδιολόγος 1. Διάγνωση θεραπεία Πρωτογενής ή / και δευτερογενής πρόληψη υπέρτασης κολπικής μαρμαρυγής ασυμπτωματικής/συμπτωματικής καρωτιδικής στένωσης θρόμβου κορυφής αρ κοιλίας μετά από έμφραγμα 2. Διερεύνηση κρυπτογενούς ΑΕΕ 3. Επιπλοκή κατά τις ενδαγγειακές διαγνωστικές-θεραπευτικές επεμβάσεις 4. Σύγκλειση ωτίου αριστερού αρ κόλπου 5. Σύγκλειση ανοικτού ωοειδούς τρήματος 6. Θρομβόλυση-Ενδαγγειακή θεραπεία του ΑΕΕ

5 Silent Cerebral Damage in Hypertension Cardiovascular risk factors Silent cerebral damage Clinical outcomes HTN Microaneurysms Atherosclerosis Remodeling WML Lacunae Microbleeds Hemorrhagic stroke Ischemic stroke Early cognitive impairment Dementia Sierra, Coca et al. Cardiol Clin Pract 2012;4:1-12

6 Risk Reduction (%) for 10 mm Hg fall in SBP 613,815 patients 20 % risk reduction Irrespective of baseline BP or pre-existing conditions Major CVD CHD Stroke CCF Mortality Ettehad D et al, Lancet. 2016,387:

7 Target SBP

8 Relation between efficacy and safety according to various targets: a network meta-analysis Stroke MI Death Bangalore et al, Am J Med, 2017

9 ACC/AHA guidelines 2017 Use of BP-lowering medications is recommended in patients with an average BP > 130/80 mm Hg for secondary prevention of recurrent CVD events in patients with clinical CVD and for primary prevention in adults with an estimated 10- year risk of CVD greater than or equal to 10%

10 2018 Annual Meeting NEW ESC/ESH HTN guidelines June 2018 Target BP close to 130/85 mmhg for most people with hypertension? Barcelona

11 34 ESH Affiliated Societies

12 187 ESH Centres of Excellence

13 Blood Pressure Control in ESH Excellence Centers Blopresh study Research Project of the European Society of Hypertension To determine 1. average BP values in different ESH Excellent Centers, countries and European regions (attended and unattended BP) 2. Prevalence of uncontrolled hypertensive patients and analyze the most important factors/predictors for treatment failure in ESH Excellence Centers. 3. Preparation of strategies aiming to increase hypertension control globally but with specificities for particular countries/regions Timeframe: December 2017-December 2019

14 Drugs to be preferred in specific conditions

15 Summary results of the direct comparisons of each class vs all other classes of BP-lowering drugs on seven major outcomes Stroke CHD HF St + CHD St + CHD + HF CV Death All-cause Death Each class vs all other D BB CA ACEI ARB RASB Thomopoulos, Parati, Zanchetti, J Hypertens 2015; 33:

16 Αγγειακό εγκεφαλικό επεισόδιο και ο Καρδιολόγος 1. Διάγνωση θεραπεία Πρωτογενής ή / και δευτερογενής πρόληψη υπέρτασης κολπικής μαρμαρυγής ασυμπτωματικής/συμπτωματικής καρωτιδικής στένωσης θρόμβου κορυφής αρ κοιλίας μετά από έμφραγμα 2. Διερεύνηση κρυπτογενούς ΑΕΕ 3. Επιπλοκή κατά τις ενδαγγειακές διαγνωστικές-θεραπευτικές επεμβάσεις 4. Σύγκλειση ωτίου αριστερού αρ κόλπου 5. Σύγκλειση ανοικτού ωοειδούς τρήματος 6. Θρομβόλυση-Ενδαγγειακή θεραπεία του ΑΕΕ

17 Patients with AF have about fivefold increased risk of ischaemic stroke versus Patients with no AF Framingham Heart Study (n=5070) Risk ratio=4.8; p<0.001 Without AF 5 increased risk of ischaemic stroke With AF Wolf et al, 1991

18 Novel markers of increased stroke risk in AF Nature Reviews Cardiology 2016;13:549-5

19 X-fold increase in AUC vs. normal renal function Different Renal Clearance Mild Moderate Severe Rivaroxaban Apixaban Dabigatran NOTE: Graphs based on data in respective SmPCs. No head to head comparison. Data for edoxaban are currently not available. 1. Rivaroxaban SmPC; 2. Apixaban SmPC; 3. Dabigatran SmPC; 4. Stangier J et al. Clin Pharmacokinet. 2010;49(4):

20 Έναρξη ή επανέναρξη αντιπηκτικής αγωγής σε ασθενή με ΜΒΚΜ μετά από οξύ ισχαιμικό Α.Ε.Ε ή ΤΙΑ TIA or ischaemic stroke Exclude ICB by CT or MRI TIA Mild stroke (NIHSS<8) Moderate stroke (NIHSS 8 16) Severe stroke (NIHSS>16) After 1 day After 3 days Exclude haemorrhagic transformation by CT or MRI at day 6 Exclude haemorrhagic transformation by CT or MRI at day 12 Start after 6 days Start after 12 days *This flowchart is based on expert consensus from the EHRA Practical Guide and not prospective clinical data. 1 CT: computerised tomography; EHRA: European Heart Rhythm Association; ICB: intracerebral bleeding; MRI: magnetic resonance imaging; NIHSS: National Institutes of Health Stroke Score; NVAF: non-valvular atrial fibrillation; TIA: transient ischaemic attack. Reproduced from Heidbüchel et al Heidbüchel et al. Europace 2015;17:

21 Cryptogenic Stroke is a Diagnosis of Exclusion Atherosclerotic Small arterial occlusion Cardioembolic Other causes Cryptogenic Atherosclerotic* Arteroembolic* Aortoembolic Branch occlusive disease Small arterial occlusion Cardioembolic Paroxysmal atrial fibrillation Paradoxical embolism Other causes Cancer-related coagulopathy Cryptogenic Bang OY et al. Stroke. 2014;45:

22 Conventional Monitoring Strategies hours of monitoring External loop recorder Saves all cardiac rhythm data Up to 30 days of monitoring Event-triggered loop recorder Saves events only Up to 30 days of monitoring External loop recorder Saves all cardiac rhythm data 62% patient compliance % patient compliance Vasamreddy CR et al. J Cardiovasc Electrophysiol. 2006;17: ; 2. Gladstone DJ et al. N Engl J Med. 2014;370: ; 3. Rosenberg MA et al. Pacing Clin Electrophysiol. 2013;36: ; 4. Kamel H et al. Stroke. 2013;44: Shinbane JS et al. Heart Rhythm Society th Annual Scientific Sessions, Volume 10, Issue 5S, 2013.

23 About 20% ischaemic Strokes are caused by carotid stenosis

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26 Carotid artery disease our experience Carotid sinus hypersensitivity in patients undergoing coronary arteriography: relation with the severity of carotid atherosclerosis and the extent of coronary artery disease. Kallikazaros I, Stratos C, Tsioufis C, et al. J Cardiovasc Electrophysiol Exaggerated carotid sinus massage responses are related to severe coronary artery disease in patients being evaluated for chest pain. Tsioufis C, Kallikazaros I, et al. Clin Cardiol Closed relation between carotid and ascending aortic atherosclerosis in cardiac patients. Kallikazaros IE, Tsioufis CP, et al. Circulation Carotid artery disease as a marker for the presence of severe coronary artery disease in patients evaluated for chest pain. Kallikazaros I, Tsioufis C, et al. Stroke. 1999

27 Carotid artery disease: Treatment options

28 Emergence of medical Mx Introduction of antiplatelets, Intensive lipid-lowering regimen & Aggressive control of risk factors The incidence rate of ipsilateral stroke was 1,68% (CI, 1.34% to 2.11%) per year of follow-up. Very similar to that observed in ACT I and CREST after successful CAS or CEA factors

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32 Θρόμβος αριστερής κοιλίας μετά ΕΜ For mural thrombi, once diagnosed, oral anticoagulant therapy should be considered for up to 6 months, guided by repeated echocardiography and with consideration of bleeding risk and need for concomitant antiplatelet therapy. However, prospective randomized data on the best anticoagulation regimen, duration, and strategy of combination with antiplatelet agents are lacking. The clinical experience with direct-acting oral anticoagulants in this setting is limited.

33 PFO Syndromes: Isolated or Combined Migraine Stroke Hypoxemia

34 Cryptogenic Stroke and PFO Higher incidence of PFO in pts with cryptogenic stroke than those with a known cause of stroke Patients with neurological event and large PFO and atrial septal aneurysm (ASA) had higher incidence of recurrent neurological events than those without PFO and ASA

35 PFO Occluder in Clinical Trial STARFlex (NMT Med) Amplatzer PFO occlude (Abbott Vascular) Helex Septal Occluder (GoGore) Septal Occluder (Gore)

36 October 18, 2016: FDA approves first PFO device The AMPLAZTER PFO device is indicated for percutaneous transcatheter closure of a patent foramen ovale (PFO) to reduce the risk of recurrent ischemic stroke in patients, Predominantly between the ages of 18 and 60 years, Who have had a cryptogenic stroke due to presumed paradoxical embolism, As determined by a neurologist and cardiologist Following an evaluation to exclude known causes of ischemic stroke

37 Summary (All PFO trials) Oral anticoagulants do not significantly reduce the risk of stroke recurrence in comparison to antiplatelet agents. However is trend in favor of oral anticoagulants.

38 Divers and PFO Routine screening for PFO is not recommended Screening for PFO is suggested in high risk divers History of DCI, Migraine and aura, history of stroke If PFO is detected Assess size of shunt Limit depth and number of dives, and avoid straining PFO closure may be indicated in divers with large PFO and those who would like to return to normal diving UK Sports Diving Medical Committee (UKSDMC

39 Conclusions PFO is a normal variant, however in some circumstances right to left shunting across the defect can lead to certain clinical syndromes Assessment of magnitude shunt across a PFO is important for clinical decision making. In carefully selected patients, transcatheter closure of PFO is safe and effective for treatment or reduction of recurrences of these clinical syndromes.

40 LAA the patient s fingerprint

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42 Embolic brain injury: pathway

43 NEW BRAIN LESIONS FOLLOWING CV PROCEDURES

44 Mechanical thrombectomy in acute ischemic stroke: Consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN Mechanical thrombectomy, in addition to intravenous thrombolysis within 4.5 h when eligible, is recommended to treat acute stroke patients with large artery occlusions in the anterior circulation up to 6 h after symptom onset (Grade A, Level 1a, KSU Grade A). new Mechanical thrombectomy should not prevent the initiation of intravenous thrombolysis where this is indicated, and intravenous thrombolysis should not delay mechanical thrombectomy (Grade A, Level 1a, KSU Grade A). changed. Mechanical thrombectomy should be performed as soon as possible after its indication (Grade A, Level 1a, KSU Grade A)..

45 Session for stroke Παρασκευή 20/10/2017 Τερψιχόρη Β

46 Η ΕΚΕ ΣΤΗ ΝΕΑ ΕΠΟΧΗ E ΠΡΟΣΑΡΜΟΓΗ ΣΤΙΣ ΨΗΦΙΑΚΕΣ ΑΠΑΙΤΗΣΕΙΣ S ΣΥΜΜΕΤΟΧΗ ΣΤΙΣ ΑΠΟΦΑΣΕΙΣ ΤΗΣ ΠΟΛΙΤΕΙΑΣ B ΔΙΕΥΡΥΝΣΗ ΤΟΥ ΓΝΩΣΤΙΚΟΥ ΠΕΔΙΟΥ ΤΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ Αγγειακά Εγκεφαλικά Επεισόδια Περιφερικά Αγγεία