george ntaios department of internal medicine university ... · update: prevention after stroke...
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Update: Prevention after Stroke
George Ntaios
Department of Internal Medicine
University of Thessaly, Larissa, Greece
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Disclosures
Speaker fees/Advisory Boards/Research supportAmgen; Bayer; BMS/Pfizer; Boehringer-Ingelheim; Elpen; European Union; Galenica; Sanofi; Winmedica
Disclosures
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Disclosures
Atrial fibrillation- Aspirin for AF patients?- NOAC or VKA?- SAME-TTR to select oral anticoagulant?- When to restart OAC after ischemic stroke?- Is there a role for left atrial appendage occlusion?- Carotid filter for stroke prevention?Heart failure with sinus rhythm- Is there a role for OAC?Atherosclerotic stroke- low-dose rivaroxaban & aspirin- LDL targetsMinor strokes- Dual antiplatelet treatment: for how long?PFO- Closure or medical treatment?- OAC or aspirin in non-closed PFOs?ESUS- ESUS vs. cryptogenic- NAVIGATE ESUS and RE-SPECT ESUS results- Potential explanation and implications for future research
Agenda
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DisclosuresAspirin for AF patients? -ESC Guidelines 2010
Kirchhoff, et al. Eur Heart Journal 2016
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Disclosures
Kirchhoff, et al. Eur Heart Journal 2016Connolly, et al. NEJM 2011 Huisman, et al. JACC 2017
Aspirin for AF patients? –AVERROES & ESC Guidelines 2016
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Ntaios, Michel et al. Int J Stroke 2017
NOAC vs. VKA?
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Disclosures
Kirchhoff, et al. Eur Heart Journal 2016
NOAC vs. VKA? – ESC Guidelines 2016
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Lip, et al. Nature Reviews 2018
SAME-TT2R2 for OAC selection
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Start anticoagulants - how soon (or late)?
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TIAMild stroke(NIHSS<8)
Moderate stroke(NIHSS 8–16)
Severe stroke(NIHSS>16)
After 1 day After 3 days
Start after 6 days
Start after 12 days
Exclude haemorrhagic
transformation by CT or MRI at day 6
Exclude haemorrhagic
transformation by CT or MRI at day
12
Ischaemic stroke or TIA
Kirchhoff, et al. Eur Heart Journal 2016
Start anticoagulants - how soon (or late)? / 1-3-6-12
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Left atrial appendage occlusion
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Holmes, et al. JACC 2015
Left atrial appendage occlusion vs. OAC
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Disclosures
Kirchhoff, et al. Eur Heart Journal 2016
Left atrial appendage occlusion – ESC Guidelines 2016
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DisclosuresCarotid filter for stroke prevention
Reddy, et al. JACC 2019
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Disclosures
Atrial fibrillation- Aspirin for AF patients?- NOAC or VKA?- SAME-TTR to select oral anticoagulant?- When to restart OAC after ischemic stroke?- Is there a role for left atrial appendage occlusion?- Carotid filter for stroke prevention?Heart failure with sinus rhythm- Is there a role for OAC?
Agenda
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DisclosuresHeart failure with sinus rhythm: a prothrombotic condition
N Engl J Med 1997; 336:251-7
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Disclosures
Ntaios, et al. Int J Stroke 2019
0.60 (0.46-0.78)
1.92 (1.51-2.45)
Heart failure with sinus rhythm: is there a role for OAC?
Green: stroke reductionRed: hemorrhage risk
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Disclosures
Atrial fibrillation- Aspirin for AF patients?- NOAC or VKA?- SAME-TTR to select oral anticoagulant?- When to restart OAC after ischemic stroke?- Is there a role for left atrial appendage occlusion?- Carotid filter for stroke prevention?Heart failure with sinus rhythm- Is there a role for OAC?Atherosclerotic stroke- low-dose rivaroxaban & aspirin- LDL targets
Agenda
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DisclosuresAtherosclerotic strokes: COMPASS
Eikelboom, et al. NEJM 2017
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DisclosuresAtherosclerotic strokes: LDL targets
ESC/EAS Guidelines, Eur Heart Journal 2019
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DisclosuresAlgorithm for LDL management
ESC/EAS Guidelines, Eur Heart Journal 2019
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Disclosures
Atrial fibrillation- Aspirin for AF patients?- NOAC or VKA?- SAME-TTR to select oral anticoagulant?- When to restart OAC after ischemic stroke?- Is there a role for left atrial appendage occlusion?- Carotid filter for stroke prevention?Heart failure with sinus rhythm- Is there a role for OAC?Atherosclerotic stroke- low-dose rivaroxaban & aspirin- LDL targetsMinor strokes- Dual antiplatelet treatment: for how long?
Agenda
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Disclosures
Pan et al., JAMA Neurology 2019
Dual antiplatelet in the early phase of minor stroke
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DisclosuresDual antiplatelet in the early phase of minor stroke
Pan et al., JAMA Neurology 2019
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Disclosures
Atrial fibrillation- Aspirin for AF patients?- NOAC or VKA?- SAME-TTR to select oral anticoagulant?- When to restart OAC after ischemic stroke?- Is there a role for left atrial appendage occlusion?- Carotid filter for stroke prevention?Heart failure with sinus rhythm- Is there a role for OAC?Atherosclerotic stroke- low-dose rivaroxaban & aspirin- LDL targetsMinor strokes- Dual antiplatelet treatment: for how long?PFO- Closure or medical treatment?- OAC or aspirin in non-closed PFOs?
Agenda
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DisclosuresPFO closure
Ntaios, Michel et al. Stroke 2018
Green: stroke reduction all patients
Red: stroke reduction high risk PFOs
Orange: stroke reduction low risk PFOs
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DisclosuresOAC vs aspirin for non-closed PFO
Sagris, Ntaios et al. Stroke 2019
Green: stroke reductionRed: hemorrhage risk
0.68 [0.32–1.48]
1.61 [0.69-3.73]
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Disclosures
Atrial fibrillation- Aspirin for AF patients?- NOAC or VKA?- SAME-TTR to select oral anticoagulant?- When to restart OAC after ischemic stroke?- Is there a role for left atrial appendage occlusion?- Carotid filter for stroke prevention?Heart failure with sinus rhythm- Is there a role for OAC?Atherosclerotic stroke- low-dose rivaroxaban & aspirin- LDL targetsMinor strokes- Dual antiplatelet treatment: for how long?PFO- Closure or medical treatment?- OAC or aspirin in non-closed PFOs?ESUS- ESUS vs. cryptogenic- NAVIGATE ESUS and RE-SPECT ESUS results- Potential explanation and implications for future research
Agenda
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Cryptogenic
Not investigated Multiple causes Really cryptogenic
ESUS vs. cryptogenic
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Hart, Ntaios, et al. Stroke 2015
ESUS are frequent
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0
ESUS
0
0.1
0.2
0.3
0.4
Risk
of s
trok
e re
curr
ence
(%)
12 24 36 48 60Months
CardioembolicLarge-artery atherosclerotic
Undetermined other than ESUSLacunar
Miscellaneous
Ntaios, Michel et al. Stroke 2015
ESUS: high recurrence rate
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Hart, et al. Lancet Neurol. 2014
ESUS: Potential embolic sources
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Hart, Ntaios, et al. Stroke 2017
ESUS: 90% are treated with antiplatelets
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New AF after stroke without cause (CRYSTAL – AF)
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Hart, et al. NEJM 2018
NAVIGATE ESUS
Stroke reduction
Hemorrhage risk
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Diener, et al. NEJM 2018
HR 0.84; 95% CI: 0.68-1.03
RE-SPECT ESUS
HR 1.19; 95% CI: 0.85-1.66
Stroke reduction
Hemorrhage risk
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AVERROES
Connolly, et al. NEJM 2011
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ESUS: red & white thrombi
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Ntaios, Michel, et al. JAHA 2019
ESUS: Overlap of potential embolic sources
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Eikelboom, et al. NEJM 2017
ESUS + Aspirin
White-thrombi
PES
Red-thrombi
PES
+ NOAC
ESUS: Implications for future research
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Disclosures
Atrial fibrillation- Aspirin for AF patients? NO- NOAC or VKA? NOACs- SAME-TTR to select oral anticoagulant? Maybe, but not sure if improves outcomes- When to restart OAC after ischemic stroke? 1-3-6-12- Is there a role for left atrial appendage occlusion? If OAC is contraindicated, perhaps- Carotid filter for stroke prevention? Too prematureHeart failure with sinus rhythm- Is there a role for OAC? NoAtherosclerotic stroke- low-dose rivaroxaban & aspirin Significant net clinical benefit- LDL targets <55mg/dl (1.42mmol/l)Minor strokes- Dual antiplatelet treatment: for how long? ~3 weeksPFO- Closure or medical treatment? Closure for <60years, especially if higher risk PFOs- OAC or aspirin in non-closed PFOs? AspirinESUS- ESUS vs. cryptogenic ESUS- NAVIGATE ESUS and RE-SPECT ESUS results Negative- Potential explanation and implications for future research overlap of red & white thrombi
Take-home messages