The Brain & Heart Connection Ryna K. Then, MD Director of Stroke Program Assistant Professor of Neurology Cooper Medical School of Rowan Medical School (CMSRU) Cooper Neurological Institute (CNI) Cooper University Health Care MT2020+ US Physician Liaison
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The Brain & Heart Connection
Ryna K. Then, MDDirector of Stroke ProgramAssistant Professor of Neurology Cooper Medical School of Rowan Medical School (CMSRU)Cooper Neurological Institute (CNI)Cooper University Health CareMT2020+ US Physician Liaison
Disclosures
• No relevant disclosures
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Learning Objectives
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• Determine how the heart and brain are connectedo Cardioembolic strokes
• Learn about relationship between cardiac markers and stroke• Discuss common stroke risk factors related to cardioembolism
• 20-30% of ischemic strokes are caused by cardiac disease• Cardioembolic stroke generally carries a worse prognosis with respect to disability, mortality, and
both early and long-term recurrence of stroke compared to other etiologies• There is clinical and experimental evidence suggests a causal relationship between brain damage and
heart dysfunction• The Framingham study reported that stroke incidence more than doubled in the presence of
coronary heart disease, more than tripled with hypertension, increased 4-fold with cardiac failure, and increased 5-fold with atrial fibrillation
Ischaemic stroke in young adults: risk factors and long-term consequences. Maaijwee, N. A. M. M. et al. Nat. Rev. Neurol. 10, 315–325 (2014)
Zhili Chen, Poornima Venkat, Don Seyfried, Michael Chopp, Tao Yan, Jieli Chen. Brain–Heart Interaction. Cardiac Complications After Stroke. Circulation Research. 2017;121:451–468
Hayang Yang1,2, Martina Nassif1, Paul Khairy3, Joris R. de Groot, Yvo B.W.E.M. Roos4, Robbert J. de Winter1, Barbara J.M. Mulder1,2, and Berto J. Bouma1 . Cardiac diagnostic work-up of ischaemic stroke. European Heart Journal (2018) 39, 1851–1860
Overlap among stroke etiologies
5Hooman Kamel, Jeff S. Healey. Cardioembolic Stroke. Circ Res. 2017;120:514-526
How do you know a stroke is cardioembolic?
• Sudden onset of neurological deficits that are maximal at onset
• Cardiac embolism often lodges in distal arteries supplying the cerebral cortex
Oh Young Bang, MD, PhD, Bruce Ovbiagele, MD; Jong S. Kim, MD, PhD. Evaluation of Cryptogenic Stroke With Advanced Diagnostic Techniques. Stroke. 2014;45:1186-1194
Cardioembolic Stroke
7Hayang Yang, Martina Nassif, Paul Khairy, Joris R. de Groot, Yvo B.W.E.M. Roos, Robbert J. de Winter, Barbara J.M. Mulder, and Berto J. Bouma . Cardiac diagnostic work-up of ischaemic stroke. European Heart Journal (2018) 39, 1851–1860
Updated Model of Cardioembolic Stroke
8Hooman Kamel, MD; Peter M. Okin, MD; Mitchell S.V. Elkind, MD, MS; Costantino Iadecola, MD Atrial Fibrillation and Mechanisms of Stroke Time for a New Model. Stroke. 2016;47:895-900
The Brain & Heart Connection
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Zhili Chen, Poornima Venkat, Don Seyfried, Michael Chopp, Tao Yan, Jieli Chen. Brain–Heart Interaction. Cardiac Complications After Stroke. Circulation Research. 2017;121:451–468
The Brain & Heart Connection
10Zhili Chen, Poornima Venkat, Don Seyfried, Michael Chopp, Tao Yan, Jieli Chen. Brain–Heart Interaction. Cardiac Complications After Stroke. Circulation Research. 2017;121:451–468
• Cardiac dysfunction manifested during the acute phase after brain injury usually resolves over the following several weeks alongside improvement of neurological function
12Rongjun Zou, Wanting Shi, Jun Tao, Hongmu Li, Xifeng Lin, Songran Yang, and Ping Hua. Review Article. Neurocardiology: Cardiovascular Changes and Specific Brain Region Infarcts. BioMed Research International. Volume 2017, Article ID 5646348.
The Brain & Heart Connection
Clinical Case
• 72 years old Woman with history of CAD on ASA and Plavix, HTN, DM, HLD, bilateral pontine strokes presents with right arm and leg weakness
• Outside the window for IVT or MER• Initial labs were unrevealing except for mildly elevated
troponins• TTE was normal
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Clinical Case
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What are the clues?
15Oh Young Bang, MD, PhD, Bruce Ovbiagele, MD; Jong S. Kim, MD, PhD. Evaluation of Cryptogenic Stroke With Advanced Diagnostic Techniques. Stroke. 2014;45:1186-1194
Troponin Elevation
• What are the mechanisms and pathophysiology behind an elevated troponin in the setting of acute stroke?
• Does it affect prognosis and mortality?
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• Elevated troponin level after acute stroke is common
• Associated with ECG changes suggestive of myocardial ischemia
• Increases risk of death
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Troponin Elevation
• 5 to 10%• Troponin T more specific biomarker• Most recent reviews showed 1 in 5 patients
have elevated troponins • Some studies stated that troponin elevation is
an independent predictor of death
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Troponin Elevation
• Implantable cardiac monitor placed• Discharge to inpatient rehabilitation
• Afib found at 83 days post index event• Patient started on DOAC
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Back to our clinical case…
Atrial Fibrillation
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• 33 million people worldwide• Subclinical Afib leading mechanism of ESUS • Recent guidelines make a moderate recommendation for post
discharge heart-rhythm monitoring• It remains unclear whether anticoagulation is superior to
antiplatelet therapy for secondary prevention of stroke in patients with subclinical AF detected after ESUS
Mechanism of Stroke in Afib
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Atrial Fibrillation (Afib)
23Youcheng Wang, Yongsheng Qian, Daniel Smerin, Shujuan Zhang, Qingyan Zhao, Xiaoxing Xiong. Newly Detected Atrial Fibrillation after Acute Stroke: A Narrative Review of Causes and Implications. AF and Stroke: Review Article. Cardiology . DOI: 10.1159/000502971
Occult Atrial Fibrillation
• ¼ of all AIS ; > ½ of cardioembolic origin• 8% receives new diagnosis on first ECG• Loop recorder, 2-4 weeks cardiac telemetry, PPM and ICD with
ability to detect Afib• CRYSTAL AF 9% 6 months, 12% at 1 year, and 30% at 3 years
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Heart Monitoring
25Carlos Cantu´-Brito, MD, PhD, Gisele Sampaio Silva, MD, MPH, PhD,w and Sebastia´n F. Ameriso, MD Embolic Stroke of Undetermined Source in Latin America. A Review. The Neurologist Volume 22, Number 5, September 2017
Treatment of Atrial Fibrillation
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Reversal agents for non-vitamin K antagonist oral anticoagulants. NATURE REVIEWS | CARDIOLOGY. 2018
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Hooman Kamel, Jeff S. Healey. Cardioembolic Stroke. Circ Res. 2017;120:514-526.
Atrial Cardiopathy
• First introduced 1972 • 1997 associated Afib• 2017-Introduced as Atrial cardiomyopathy (EHRA,
A/PHRA, AHA, ACC)• “ Any complex of structural, architectural, contractile
or electrophysiological changes affecting the atria with potential to produce clinical relevant manifestations”
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• May cause cardiac thromboembolism• LA volume measurement (34 ml/m2)
o Volume adjusted for body surface area
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Atrial Cardiopathy
How do we measure atrial cardiopathy?
• P wave terminal force in lead V1 of EKG • Paroxysmal supraventricular tachycardia• Biomarkers
o NT-proBNP (Amino-terminal pro-B type natriuretic)
o HS cTNT (high sensitive troponins)
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Stroke Mechanism of Atrial Atriopathy
• Left atrial enlargemento Promotes stasis, endothelial dysfunction and
Hooman Kamel, MD1,3; Alexander E. Merkler, MD1; Costantino Iadecola, MD1; et al Ajay Gupta, MD1,2; Babak B. Navi, MD1 . Tailoring the Approach to Embolic Stroke of Undetermined Source: A Review. JAMA Neurol. 2019;76(7):855-861
Hooman Kamel, MD1,3; Alexander E. Merkler, MD1; Costantino Iadecola, MD1; et al Ajay Gupta, MD1,2; Babak B. Navi, MD1 . Tailoring the Approach to Embolic Stroke of Undetermined Source: A Review. JAMA Neurol. 2019;76(7):855-861
• Normal connection between the right and left atria• The communication closes in the majority of people over a period of time
after birth• However, if the septum primum fails to fuse with the septum secundum,
the PFO remains patent allowing interatrial blood flow• 25% of the adult population; 70 % has atrial septum aneurysm• A Bayesian attributable risk analysis of pooled data from 12 studies
suggested that PFO is probably causally related to the stroke in approximately half of the cryptogenic patient
• Young age• Valsalva maneuver at the onset of stroke• Extended immobility• Concomitant venous thrombosis in the leg/pelvis• Coexisting venous hypercoagulable state• Coexisting atrial septal aneurysm• History of migraine with aura• Cortical location and multiplicity• Large size of cerebral infarcts
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Andrew Farb, M.D., Nicole G. Ibrahim, Ph.D., and Bram D. Zuckerman, M.D. Patent Foramen Ovale after Cryptogenic Stroke — Assessingthe Evidence for Closure. N Engl J Med. 2017 Sep 14;377(11):1006-1009
BaoshanQiu,M.D.,YingCai, M.D., DilongWang, M.D., JingLin,M.D.,and XuhuaFan, M.D. Closure versus Medical Therapy for Patent Foramen Ovale in Patients with Cryptogenic Stroke: An Updated Meta-Analysis of Randomized Controlled Trials. Journal of Stroke and Cerebrovascular Diseases, Vol.27,No.12(December),2018:pp3463 3472
Overview
45Hooman Kamel, MD1,3; Alexander E. Merkler, MD1; Costantino Iadecola, MD1; et al Ajay Gupta, MD1,2; Babak B. Navi, MD1 . Tailoring the Approach to Embolic Stroke of Undetermined Source: A Review. JAMA Neurol. 2019;76(7):855-861