Cardiovascular care of patients with stroke and high risk of stroke: The need for interdisciplinary action: A consensus report from the European Society of Cardiology Cardiovascular Round Table

Glucagon-like peptide-1 receptor agonists and stroke: A systematic review and meta-analysis of cardiovascular outcome trials

BACKGROUND

In patients surviving stroke, approximately 15% and 60% exhibit concurrent diabetes mellitus and overweight/obesity, respectively, necessitating heightened secondary prevention efforts. Despite glucagon-like peptide-1 receptor agonists (GLP-1 RAs) demonstrating improved outcomes for those with diabetes mellitus or obesity, their underutilization persists among eligible individuals. This systematic review and meta-analysis investigated the impact of GLP-1 RAs on stroke risk. The findings aim to optimize the implementation of this therapeutic strategy in patients surviving stroke with diabetes mellitus or obesity.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we systematically reviewed MEDLINE and Scopus until 15 November 2023. Eligible studies included randomized cardiovascular outcome trials (CVOTs) with individuals, with or without type 2 diabetes, randomized to either GLP-1 RA or placebo. The outcomes were total strokes, non-fatal strokes, and fatal strokes. Analyses were conducted using RevMan 5.4.1.

RESULTS

Among 1369 screened studies, 11 were eligible, encompassing 82,140 participants (34.6% women) with a cumulative follow-up of 247,596 person-years. In the GLP-1 RAs group, the stroke rate was significantly lower compared to placebo (RR: 0.85, 95% CI: 0.77-0.93; NNT: 200), showing no heterogeneity or interaction with administration frequency (daily vs weekly). In addition, the GLP-1 RAs group exhibited a significantly lower rate of non-fatal strokes compared to placebo (RR: 0.87, 95% CI: 0.79-0.95; NNT: 250), with no heterogeneity or interaction based on administration frequency, route (oral vs subcutaneous), or diabetes presence.

CONCLUSION

In this meta-analysis of 11 CVOTs with 82,140 participants, GLP-1 RAs demonstrated a 16% relative reduction in stroke risk compared to placebo. This finding may increase implementation of GLP-1 RAs by stroke specialists in individuals with stroke and comorbid diabetes mellitus or obesity.

DATA ACCESS STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis

Heart failure (HF) is a major disease in our society that often presents with multiple comorbidities with mutual interaction and aggravation. The comorbidity of HF and stroke is a high risk condition that requires particular attention to ensure early detection of complications, efficient diagnostic workup, close monitoring, and consequent treatment of the patient. The bi-directional interaction between the heart and the brain is inherent in the pathophysiology of HF where HF may be causal for acute cerebral injury, and - in turn - acute cerebral injury may induce or aggravate HF via imbalanced neural and neurovegetative control of cardiovascular regulation. The present document represents the consensus view of the ESC Council on Stroke, the Heart Failure Association and the ESC Working Group on Thrombosis to summarize current insights on pathophysiological interactions of the heart and the brain in the comorbidity of HF and stroke. Principal aspects of diagnostic workup, pathophysiological mechanisms, complications, clinical management in acute conditions and in long-term care of patients with the comorbidity are presented and state-of-the-art clinical management and current evidence from clinical trials is discussed. Beside the physicians perspective, also the patients values and preferences are taken into account. Interdisciplinary cooperation of cardiologists, stroke specialists, other specialists and primary care physicians is pivotal to ensure optimal treatment in acute events and in continued long-term treatment of these patients. Key consensus statements are presented in a concise overview on mechanistic insights, diagnostic workup, prevention and treatment to inform clinical acute and continued care of patients with the comorbidity of HF and stroke.

Stroke survivors', caregivers' and nurse coaches' perspectives on health coaching program towards hospital-to-home transition care: A qualitative descriptive process evaluation

AIMS AND OBJECTIVES

To explore the perspectives of stroke survivors, caregivers and nurse coaches on a health coaching program during hospital-to-home transitional care.

BACKGROUND

Stroke is a major public health problem that seriously affects the health and safety of people in China. Nurse-led health coaching is a promising support option in enabling smooth hospital-to-home transition for stroke survivors and family caregivers. A qualitative study is valuable for gaining insight into their perspectives on using this program.

DESIGN

An exploratory, descriptive qualitative process evaluation was conducted parallel with a former randomised controlled trial. Data were obtained from 26 stroke survivors, 33 caregivers and four nurse coaches with semi-structured interviews. The inductive reflexive thematic analysis approach was used for data analysis. The COREQ checklist was followed in reporting this study.

RESULTS

Seven themes were generated from the data: (1) the applicability of individualised health coaching sessions, (2) driving self-efficacy to establish self-care skills, (3) the key role of nurse coaches, (4) coordination among healthcare teams during the transition, (5) adequate community and social support, (6) insufficient rehabilitative services after discharge and (7) perceived extra workload for nurse coaches.

CONCLUSIONS

The study captured perspectives on a nurse-led health coaching program towards hospital-to-home transition care from stroke survivors, caregivers and nurse coaches. Individualised health coaching sessions and driving self-efficacy were perceived as facilitators for empowering the self-care skills of stroke survivors and caregivers. The key role of nurse coaches in coordinating healthcare teams and adequate community and social support were detected as the power frame of the program's implementation. However, health system obstacles, such as insufficient rehabilitative services and the high workload of nurses, still need to be addressed to ensure the sustainability of health coaching intervention in transitional care.

RELEVANCE TO CLINICAL PRACTICE

The study suggested the feasibility of implementing nurse-led health coaching to smooth post-stroke hospital-to-home transitional care. The findings also highlighted the importance of qualitative process evaluation when implementing evidence-based interventions in health care.

TRIAL REGISTRATION

The trial was registered with the Australia New Zealand Clinical Trials Registry (ID: ACTRN12619000321145).

[Thromboembolic diseases from a cardiological point of view]

Thromboembolic disease is associated with a high mortality. It can be divided into two groups: embolism from a venous and embolism from an arterial side. This article gives an overview on thromboembolic disease (with a focus on pulmonary embolism and ischemic stroke) from a cardiologist's perspective.The therapeutic options for acute pulmonary embolism range from anticoagulation to fibrinolysis to interventional recanalization and surgery. The deciding factor for choice of therapy is the risk of early death. Besides clinical parameters, laboratory markers like cardiac troponin and right ventricular function on echocardiography or CTPA (computed tomography pulmonary angiography) are used to determine the early mortality risk. In hemodynamically instable patients, immediate thrombolysis is required, whereas patients with intermediate and low risk can be treated with anticoagulation. Interventional recanalization is currently being studied in patients at risk for development of CTEPH (chronic thromboembolic pulmonary hypertension) or an intermediate risk of early mortality.In ischemic stroke, early interdisciplinary workup involving a cardiologist is paramount. Post stroke screening should include monitoring for arrythmias (especially atrial fibrillation) and transthoracic echocardiography as well as sonography of extra- and intracranial arteries. If no embolic source can be detected (embolic stroke of undetermined source), transesophageal echo can be helpful to detect intracardiac shunts like patent foramen ovale (PFO) or intracardiac tumors. Post stroke care includes secondary prevention measures like risk factor modification and lipid lowering therapy as well as anticoagulation. In high risk for paradoxical embolization, interventional PFO closure can be performed. Interventional closure of the left atrial appendage (LAA) can be discussed in patients with both high thromboembolic and bleeding risk.

Development and psychometric testing of the intention to engage in children's healthy weight (iCHeW) guideline scale for dental staff

STATEMENT OF PROBLEM

In the evaluation of interdisciplinary interventions for childhood overweight and obesity, behavioural determinants can provide valuable insight into the reasons behind lack of adherence, or ineffectiveness of the intervention. Therefore, it is vital to assess the behavioural determinants of staff when evaluating the implementation of such interdisciplinary interventions. This study aimed to develop and psychometrically evaluate the intention to engage in Children's Healthy Weight guideline (iCHeW) scale, which assesses the behavioural determinants influencing dental staff's intention to conduct children's growth assessments.

METHODS

Initial items were generated based on review of the literature and the dimensions of the integrative model of behavioural prediction (IM). To test this scale, a cross-sectional survey design was undertaken consisting of three phases: (i) face validity; (ii) content validity; and (iii) psychometric evaluation of the iCHeW scale with a national sample of 125 dental staff.

RESULTS

The 35 items generated for the iCHeW scale were revised following feedback from a reference group. These 35 items were then appraised by an expert panel, yielding 27 items for psychometric testing. Using exploratory factor analysis, a five-factor solution was extracted, which corresponded to the IM domains, with the deletion of two items. Overall, Cronbach's alpha of the iCHeW scale was 0.95, with the following values for each subscale: (i) attitudes, 0.93; (ii) behavioural constraints, 0.83; (iii) perceived norms, 0.93; (iv) self-efficacy, 0.94; and (v) behavioural intention, 0.95.

CONCLUSIONS

The iCHeW scale is valid and reliable for assessing dental staff's intention to provide routine growth assessments to children and demonstrates potential for use with non-dental staff.

Management of Oral Anticoagulation and Antiplatelet Therapy in Post-Myocardial Infarction Patients with Acute Ischemic Stroke with and without Atrial Fibrillation

The association between atrial fibrillation (AF), acute coronary syndrome (ACS), and stroke is a complex scenario in which the assessment of both thrombotic and hemorrhagic risk is necessary for scheduling an individually tailored therapeutic plan. Recent clinical trials investigating new antithrombotic drugs and dual and triple pathways in high-risk cardiovascular patients have revealed a new therapeutic scenario. In this paper, we review the burden of ischemic stroke (IS) in patients post-myocardial infarction with and without atrial fibrillation and the possible therapeutic strategies from a stroke point of view.

Differences in Cardiac Etiologies for Ischemic Stroke in Young and Middle-Aged Patients: A Single-Center Experience in Taiwan

Background: The cardiac etiology of acute ischemic stroke (AIS) plays an important role in young adults; therefore, complete cardiac workups and subsequent prevention methods are important for treating young AIS patients. However, the definition of a young age for AIS patients could be below 45 years old, while in some previous studies, it has been below 55 years old. It remains unclear whether cardiac workups are equally important for AIS patients in the young (the age of 20–45 years old) and middle-aged (46–55 years old) categories. Materials and methods: This prospective study included 103 patients admitted due to a first AIS attack younger than 55 years old during the period from 1 October 2018 to 31 December 2020. All the patients received cardiologist consultations and cardiac workups accordingly. The characteristics of patients, cardiac workups, clinical findings, and management were analyzed. Results: AIS patients in the 46–55-year-old group had a higher prevalence of hypertension (61.4% vs. 39.0%), diabetes mellitus (27.3% vs. 15.3%), a previous history of coronary artery disease (9.1% vs. 1.7%), and atrial fibrillation (9.1% vs. 1.7%) compared to the 20–45-year-old group. After cardiologist consultations, a higher prevalence of newly diagnosed coronary artery disease (6.8% vs. 1.7%) and congestive heart failure (11.4% vs. 1.7%) was noted. Both groups disclosed similar percentages of patent foramen ovale (PFO) (27.3% vs. 22.0%) and valvular disease. These results led to subsequent changes in treatment in both groups. The 20–45-year-old group had higher percentages of receiving PFO occluders (11.9%) compared to the 46–55-year-old group (6.8%). Conclusion: Cardiologist consultations with thorough cardiac workups for AIS patients can reveal many cardiac findings in both young and middle-aged patients. This leads to a subsequent change in treatment, including medical and surgical aspects, which are important as secondary prevention for AIS.

The Heart Brain Team and Patient-Centered Management of Ischemic Stroke

The multifaceted connections between the heart and the brain have been extensively studied at the anatomy, pathophysiology, and clinical levels. Studies have suggested a vital role for both cardiologists and neurologists in the management of various cardiovascular and neurological disorders. However, a true heart-brain team-based approach remained confined to large, specialized centers. In this paper, we review the various intersection areas of cardiology and neurology with regard to ischemic stroke. We focus our discussion on the challenges and opportunity for a heart-team approach to stroke in the context of atrial fibrillation, carotid disease, and patent foramen ovale, and in the setting of strokes complicating transcatheter endovascular interventions.

OUP accepted manuscript

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:

A: Appropriate Antithrombotic therapy.

B: Better functional and psychological status.

C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).

Prevalence and determinants of systolic and diastolic cardiac dysfunction and heart failure in acute ischemic stroke patients: The SICFAIL study

AIMS

Ischaemic stroke (IS) might induce alterations of cardiac function. Prospective data on frequency of cardiac dysfunction and heart failure (HF) after IS are lacking. We assessed prevalence and determinants of diastolic dysfunction (DD), systolic dysfunction (SD), and HF in patients with acute IS.

METHODS AND RESULTS

The Stroke-Induced Cardiac FAILure in mice and men (SICFAIL) study is a prospective, hospital-based cohort study. Patients with IS underwent a comprehensive assessment of cardiac function in the acute phase (median 4 days after IS) including clinical examination, standardized transthoracic echocardiography by expert sonographers, and determination of blood-based biomarkers. Information on demographics, lifestyle, risk factors, symptoms suggestive of HF, and medical history was collected by a standardized personal interview. Applying current guidelines, cardiac dysfunction was classified based on echocardiographic criteria into SD (left ventricular ejection fraction < 52% in men or <54% in women) and DD (≥3 signs of DD in patients without SD). Clinically overt HF was classified into HF with reduced, mid-range, or preserved ejection fraction. Between January 2014 and February 2017, 696 IS patients were enrolled. Of them, patients with sufficient echocardiographic data on SD were included in the analyses {n = 644 patients [median age 71 years (interquartile range 60-78), 61.5% male]}. In these patients, full assessment of DD was feasible in 549 patients without SD (94%). Prevalence of cardiac dysfunction and HF was as follows: SD 9.6% [95% confidence interval (CI) 7.6-12.2%]; DD in patients without SD 23.3% (95% CI 20.0-27.0%); and clinically overt HF 5.4% (95% CI 3.9-7.5%) with subcategories of HF with preserved ejection fraction 4.35%, HF with mid-range ejection fraction 0.31%, and HF with reduced ejection fraction 0.78%. In multivariable analysis, SD and fulfilment of HF criteria were associated with history of coronary heart disease [SD: odds ratio (OR) 3.87, 95% CI 1.93-7.75, P = 0.0001; HF: OR 2.29, 95% CI 1.04-5.05, P = 0.0406] and high-sensitive troponin T at baseline (SD: OR 1.78, 95% CI 1.31-2.42, P = 0.0003; HF: OR 1.66, 95% CI 1.17-2.33, P = 0.004); DD was associated with older age (OR 1.08, 95% CI 1.05-1.11, P < 0.0001) and treated hypertension vs. no hypertension (OR 2.84, 95% CI 1.23-6.54, P = 0.0405).

CONCLUSIONS

A substantial proportion of the study population exhibited subclinical and clinical cardiac dysfunction. SICFAIL provides reliable data on prevalence and determinants of SD, DD, and clinically overt HF in patients with acute IS according to current guidelines, enabling further clarification of its aetiological and prognostic role.

The role of cardiologists on the stroke unit

Cardiologists need a better understanding of stroke and of cardiac implications in modern stroke management. Stroke is a leading disease in terms of mortality and disability in our society. Up to half of ischaemic strokes are directly related to cardiac and large artery diseases and cardiovascular risk factors are involved in most other strokes. Moreover, in an acute stroke direct central brain signals and a consecutive autonomic/vegetative imbalance may account for severe and life-threatening cardiovascular complications. The strong cerebro-cardiac link in acute stroke has recently been addressed as the stroke-heart syndrome that requires careful cardiovascular monitoring and immediate therapeutic measures. The regular involvement of cardiologic expertise in daily work on a stroke unit is therefore of high importance and a cornerstone of up-to-date comprehensive stroke care concepts. The main targets of the cardiologists' contribution to acute stroke care can be categorized in three main areas (i) diagnostics workup of stroke aetiology, (ii) treatment and prevention of complications, and (iii) secondary prevention and sub-acute workup of cardiovascular comorbidity. All three aspects are by themselves highly relevant to support optimal acute management and to improve the short-term and long-term outcomes of patients. In this article, an overview is provided on these main targets of cardiologists' contribution to acute stroke management.

The Impact of the Associated Pathology in Acute Coronary Events

Acute coronary events (ACE) are one of the main concerns for both clinical medicine and prophylaxis. The study aims to follow the frequency of the pathology associated with ACE and to establish its association with the occurrence of ACE. The study included 865 adult participants between the ages of 19-86. Subjects completed a complex questionnaire that included questions about health status. The study was conducted by applying the subjects to an anonymous questionnaire, in three family medicine practices between November 2018 to May 2019 and targeted healthy people. The frequencies of the following types of associated pathologies were evaluated: high blood pressure (HBP), hypercholesterolemia, stroke, diabetes, depression, stress. In hypertensive patients the prevalence of ACE was 6,99% (N=11) and in those not diagnosed with HBP of only 0,29% (N=2). The risk of ACE was 20 times higher than in those without HBP (RR=20,93; p<0.001). The prevalence of ACE was high among subjects with high cholesterol levels (21,43%) compared with those with normal values (3,03%; N=22), the risk of ACE being 7 times higher (RR=7,06; p<0.001). The prevalence of diabetes was more than four times higher in subjects with ACE (17,3%; N=9) compared with those without ACE (3,9%; N=32). Among those affected by diabetes, the prevalence of ACE was 21,95% (9/41), and risk of ACE in people with diabetes was four times higher (RR=4,21; p<0.001). Although cardiovascular disease is the most common pathology in the contemporary world, a number of comorbidities arise as ACE generators (hypertension, hypercholesterolemia, diabetes), along with psycho-emotional disorders such as depression, anxiety or stress, which outline, ensures, contributes or accelerates the progression to ACE.