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*Only for medical professionals to read and refer to the latest points of the OCC conference! The 15th Oriental Cardiology Conference (OCC 2021) will be held on May 27-30, 2021 in Shanghai through a combination of online and offline.
The big names gather to talk about the frontiers and hotspots of the cardiovascular field
.
An epidemiological survey of stroke in China shows that the prevalence rate of stroke is 1114.
8 per 100,000 person-years, the incidence rate is 246.
8 per 100,000 person-years, and the mortality rate is 114.
8 per 100,000 person-years
.
Cardiac stroke accounts for 14% to 30% of all ischemic strokes; cryptogenic stroke (presumably caused by cardiogenic embolism) accounts for 25% of ischemic strokes
.
The causes of cardiogenic stroke are divided into atrial fibrillation (atrial fibrillation), heart failure, acute coronary syndrome, patent foramen ovale, aortic arch atherosclerosis, rheumatic heart disease, artificial heart valve, and infective endocarditis , Dilated cardiomyopathy and ten types of cardiac myxoma
.
Among them, strokes related to atrial fibrillation (with or without other cardiovascular diseases) accounted for 79% of all cardiogenic strokes, and the incidence of adult patent foramen ovale was 20%~25%
.
So, how to prevent cardiogenic stroke according to different causes? Professor Zhao Xianxian from Changhai Hospital Affiliated to Naval Military Medical University shared on the prevention of cardiogenic stroke at the Oriental Cardiology Conference (OCC 2021)
.
Figure 1 Professor Zhao Xianxian's speech at the meeting.
The basics of cardiogenic stroke Cardiogenic stroke refers to a clinical syndrome in which cardiogenic embolism from the heart and aortic arch passes through the circulation to cause cerebral artery embolization and cause corresponding brain dysfunction
.
The mechanisms include slow blood flow leading to thrombosis and fall off in the heart cavity, fall off of attachments on the surface of abnormal valves, and abnormal embolism
.
Prevention and treatment of cardiogenic stroke related to atrial fibrillation.
Stroke and systemic embolism caused by atrial fibrillation can often be life-threatening and seriously affect the quality of life of patients
.
The prevention of atrial fibrillation-related stroke is an important part of the prevention of cardiogenic stroke
.
Research evidence proves that standardized anticoagulant therapy in patients with atrial fibrillation who are at high risk of thromboembolic events can significantly improve the prognosis of patients
.
Figure 2 Selection of anticoagulant drugs for the prevention of embolic events caused by atrial fibrillation Warfarin is an effective drug for the prevention and treatment of atrial fibrillation stroke.
It is widely used in anticoagulation for valvular atrial fibrillation (VAF) and non-valvular atrial fibrillation (NVAF) Treatment reduces ischemic stroke by 70% and all-cause mortality by 16%
.
But it also has many shortcomings, including narrow treatment window, bleeding risk, poor compliance, and susceptibility to interference, so its anticoagulant status is gradually being replaced by new anticoagulant drugs
.
New oral anticoagulant drugs (NOACs) overcome the shortcomings of warfarin, are simple to use, and do not require routine monitoring of coagulation indicators
.
A randomized controlled study (RCT) showed that compared with warfarin, NOACs can effectively reduce the risk of stroke and thromboembolism.
More importantly, compared with warfarin, NOACs can effectively reduce the risk of major bleeding
.
Figure 3 NOACs VS.
Warfarin Professor Zhao Xianxian especially emphasized the antithrombotic options for atrial fibrillation combined with percutaneous coronary intervention (PCI)
.
The WOEST study shows that warfarin combined with clopidogrel for anticoagulation in patients with atrial fibrillation combined with PCI can effectively reduce the incidence of ischemic cardiovascular events, but significantly increase the incidence of bleeding events
.
The PIONEER-AF study showed that clopidogrel combined with rivaroxaban for anticoagulation in patients with atrial fibrillation combined with PCI did not increase the incidence of ischemic events and significantly reduced the incidence of hemorrhagic events
.
The subsequent RE-Dual study and the AUGUSTUS study both proved that NOACs significantly improved safety without increasing the occurrence of ischemic events
.
Therefore, Professor Zhao Xianxian pointed out that the current anticoagulation for atrial fibrillation + PCI is mainly done by "subtraction"
.
The latest European guidelines recommend that patients with low bleeding risk can choose triple antithrombotic therapy, and patients with high bleeding risk are advised to use only NOAC combined with antiplatelet drugs
.
Figure 4 In addition to new anticoagulant drugs for interventional treatment of patients with atrial fibrillation combined with PCI, another popular treatment method in recent years is left atrial appendage closure (LACC) to prevent cardiogenic stroke
.
Figure 5 Types of left atrial appendage occluder The left atrial appendage is the main source of atrial fibrillation thromboembolism.
In theory, sealing the left atrial appendage is an effective way to prevent embolic complications in patients with atrial fibrillation
.
There are currently two randomized controlled studies comparing the effectiveness and safety of the WATCHMAN device and warfarin in preventing thromboembolic events in patients with atrial fibrillation.
The results show that hemorrhagic stroke, cardiovascular death, all-cause death, and postoperative bleeding events WATCHMAN Outperforms warfarin
.
2019 EHRA/EAPC recommendation, patients who are suitable for oral anticoagulation drugs are recommended to take oral anticoagulation drugs directly
.
In the case of patients who do not want to take oral anticoagulants or patients with high bleeding risk, left atrial appendage occlusion can be selected
.
In the 2019AHA/ACC/HRS guidelines and China's 2018 atrial fibrillation: current understanding and treatment recommendations, left atrial appendage occlusion is classified as category IIb and IIa recommendations, respectively
.
Figure 6 Recommendations of domestic and foreign guidelines for left atrial appendage occlusion.
Prevention and treatment of PFO-related cardiogenic stroke.
The foramen ovale is used as a physiological channel to allow blood to flow from the right atrium (RA) to the left atrium (LA) to maintain the blood circulation of the fetus.
.
After birth, the baby's breathing is established, the pulmonary circulation pressure drops, the left atrial pressure is greater than the right atrial pressure, the foramen ovale is first functionally closed, and most of them are closed anatomically at 5-7 months of birth
.
If children older than 3 years old still have potential interatrial passages, it is called patent foramen ovale (PFO)
.
Studies have shown that the incidence of adult PFO is about 25%
.
PFO may cause paradoxical embolism, migraine and decompression sickness, and is also an independent cause of cryptogenic stroke
.
PFO-related stroke prevention can choose drugs or interventional therapy
.
The latest research shows that PFO occlusion (PFOC) is associated with a lower incidence of ischemic events.
1/5 of patients stopped antithrombotic therapy during the follow-up period, and the withdrawal did not lead to an increase in the incidence of ischemic events.
PFOC has gradually become the new standard for the treatment of patients with PFO combined with unexplained stroke
.
Figure 7 Types of PFO occluders Two studies published in the New England Journal of Medicine in the early years showed that PFO occlusion has no difference in the prevention of stroke, transient ischemic attack (TIA), and stroke recurrence compared with drug therapy.
There was no difference in the incidence of adverse events compared to drug treatment
.
The turning point of the evidence occurred in 2017.
The mid- to long-term follow-up results of three PFOC studies published in the New England Journal of Medicine at the same time were all positive
.
In general, PFOC has advantages over drug therapy in the prevention of repeated unexplained strokes
.
Professor Zhao emphasized that the problem is how to choose patients and grasp the indications
.
The current guidelines only recommend PFOC as the second-level prevention of stroke of unknown origin
.
Professor Zhao also mentioned the prevention and treatment of other causes of cardiogenic stroke, such as valvular heart disease, heart failure, and endocarditis
.
Finally, Professor Zhao concluded that cardiogenic stroke has a high incidence and great harm, and early diagnosis and risk assessment are the basis; reasonable antithrombotic therapy is the cornerstone, and device therapy is a beneficial supplement or even a necessary preventive method
.
From May 27th to 30th, 2021, the 15th Oriental Cardiology Conference (OCC 2021) will be held online and offline simultaneously
.
The latest information of the conference is available in one hand! The "Forefront of OCC 2021 Conference" zone is here!
The big names gather to talk about the frontiers and hotspots of the cardiovascular field
.
An epidemiological survey of stroke in China shows that the prevalence rate of stroke is 1114.
8 per 100,000 person-years, the incidence rate is 246.
8 per 100,000 person-years, and the mortality rate is 114.
8 per 100,000 person-years
.
Cardiac stroke accounts for 14% to 30% of all ischemic strokes; cryptogenic stroke (presumably caused by cardiogenic embolism) accounts for 25% of ischemic strokes
.
The causes of cardiogenic stroke are divided into atrial fibrillation (atrial fibrillation), heart failure, acute coronary syndrome, patent foramen ovale, aortic arch atherosclerosis, rheumatic heart disease, artificial heart valve, and infective endocarditis , Dilated cardiomyopathy and ten types of cardiac myxoma
.
Among them, strokes related to atrial fibrillation (with or without other cardiovascular diseases) accounted for 79% of all cardiogenic strokes, and the incidence of adult patent foramen ovale was 20%~25%
.
So, how to prevent cardiogenic stroke according to different causes? Professor Zhao Xianxian from Changhai Hospital Affiliated to Naval Military Medical University shared on the prevention of cardiogenic stroke at the Oriental Cardiology Conference (OCC 2021)
.
Figure 1 Professor Zhao Xianxian's speech at the meeting.
The basics of cardiogenic stroke Cardiogenic stroke refers to a clinical syndrome in which cardiogenic embolism from the heart and aortic arch passes through the circulation to cause cerebral artery embolization and cause corresponding brain dysfunction
.
The mechanisms include slow blood flow leading to thrombosis and fall off in the heart cavity, fall off of attachments on the surface of abnormal valves, and abnormal embolism
.
Prevention and treatment of cardiogenic stroke related to atrial fibrillation.
Stroke and systemic embolism caused by atrial fibrillation can often be life-threatening and seriously affect the quality of life of patients
.
The prevention of atrial fibrillation-related stroke is an important part of the prevention of cardiogenic stroke
.
Research evidence proves that standardized anticoagulant therapy in patients with atrial fibrillation who are at high risk of thromboembolic events can significantly improve the prognosis of patients
.
Figure 2 Selection of anticoagulant drugs for the prevention of embolic events caused by atrial fibrillation Warfarin is an effective drug for the prevention and treatment of atrial fibrillation stroke.
It is widely used in anticoagulation for valvular atrial fibrillation (VAF) and non-valvular atrial fibrillation (NVAF) Treatment reduces ischemic stroke by 70% and all-cause mortality by 16%
.
But it also has many shortcomings, including narrow treatment window, bleeding risk, poor compliance, and susceptibility to interference, so its anticoagulant status is gradually being replaced by new anticoagulant drugs
.
New oral anticoagulant drugs (NOACs) overcome the shortcomings of warfarin, are simple to use, and do not require routine monitoring of coagulation indicators
.
A randomized controlled study (RCT) showed that compared with warfarin, NOACs can effectively reduce the risk of stroke and thromboembolism.
More importantly, compared with warfarin, NOACs can effectively reduce the risk of major bleeding
.
Figure 3 NOACs VS.
Warfarin Professor Zhao Xianxian especially emphasized the antithrombotic options for atrial fibrillation combined with percutaneous coronary intervention (PCI)
.
The WOEST study shows that warfarin combined with clopidogrel for anticoagulation in patients with atrial fibrillation combined with PCI can effectively reduce the incidence of ischemic cardiovascular events, but significantly increase the incidence of bleeding events
.
The PIONEER-AF study showed that clopidogrel combined with rivaroxaban for anticoagulation in patients with atrial fibrillation combined with PCI did not increase the incidence of ischemic events and significantly reduced the incidence of hemorrhagic events
.
The subsequent RE-Dual study and the AUGUSTUS study both proved that NOACs significantly improved safety without increasing the occurrence of ischemic events
.
Therefore, Professor Zhao Xianxian pointed out that the current anticoagulation for atrial fibrillation + PCI is mainly done by "subtraction"
.
The latest European guidelines recommend that patients with low bleeding risk can choose triple antithrombotic therapy, and patients with high bleeding risk are advised to use only NOAC combined with antiplatelet drugs
.
Figure 4 In addition to new anticoagulant drugs for interventional treatment of patients with atrial fibrillation combined with PCI, another popular treatment method in recent years is left atrial appendage closure (LACC) to prevent cardiogenic stroke
.
Figure 5 Types of left atrial appendage occluder The left atrial appendage is the main source of atrial fibrillation thromboembolism.
In theory, sealing the left atrial appendage is an effective way to prevent embolic complications in patients with atrial fibrillation
.
There are currently two randomized controlled studies comparing the effectiveness and safety of the WATCHMAN device and warfarin in preventing thromboembolic events in patients with atrial fibrillation.
The results show that hemorrhagic stroke, cardiovascular death, all-cause death, and postoperative bleeding events WATCHMAN Outperforms warfarin
.
2019 EHRA/EAPC recommendation, patients who are suitable for oral anticoagulation drugs are recommended to take oral anticoagulation drugs directly
.
In the case of patients who do not want to take oral anticoagulants or patients with high bleeding risk, left atrial appendage occlusion can be selected
.
In the 2019AHA/ACC/HRS guidelines and China's 2018 atrial fibrillation: current understanding and treatment recommendations, left atrial appendage occlusion is classified as category IIb and IIa recommendations, respectively
.
Figure 6 Recommendations of domestic and foreign guidelines for left atrial appendage occlusion.
Prevention and treatment of PFO-related cardiogenic stroke.
The foramen ovale is used as a physiological channel to allow blood to flow from the right atrium (RA) to the left atrium (LA) to maintain the blood circulation of the fetus.
.
After birth, the baby's breathing is established, the pulmonary circulation pressure drops, the left atrial pressure is greater than the right atrial pressure, the foramen ovale is first functionally closed, and most of them are closed anatomically at 5-7 months of birth
.
If children older than 3 years old still have potential interatrial passages, it is called patent foramen ovale (PFO)
.
Studies have shown that the incidence of adult PFO is about 25%
.
PFO may cause paradoxical embolism, migraine and decompression sickness, and is also an independent cause of cryptogenic stroke
.
PFO-related stroke prevention can choose drugs or interventional therapy
.
The latest research shows that PFO occlusion (PFOC) is associated with a lower incidence of ischemic events.
1/5 of patients stopped antithrombotic therapy during the follow-up period, and the withdrawal did not lead to an increase in the incidence of ischemic events.
PFOC has gradually become the new standard for the treatment of patients with PFO combined with unexplained stroke
.
Figure 7 Types of PFO occluders Two studies published in the New England Journal of Medicine in the early years showed that PFO occlusion has no difference in the prevention of stroke, transient ischemic attack (TIA), and stroke recurrence compared with drug therapy.
There was no difference in the incidence of adverse events compared to drug treatment
.
The turning point of the evidence occurred in 2017.
The mid- to long-term follow-up results of three PFOC studies published in the New England Journal of Medicine at the same time were all positive
.
In general, PFOC has advantages over drug therapy in the prevention of repeated unexplained strokes
.
Professor Zhao emphasized that the problem is how to choose patients and grasp the indications
.
The current guidelines only recommend PFOC as the second-level prevention of stroke of unknown origin
.
Professor Zhao also mentioned the prevention and treatment of other causes of cardiogenic stroke, such as valvular heart disease, heart failure, and endocarditis
.
Finally, Professor Zhao concluded that cardiogenic stroke has a high incidence and great harm, and early diagnosis and risk assessment are the basis; reasonable antithrombotic therapy is the cornerstone, and device therapy is a beneficial supplement or even a necessary preventive method
.
From May 27th to 30th, 2021, the 15th Oriental Cardiology Conference (OCC 2021) will be held online and offline simultaneously
.
The latest information of the conference is available in one hand! The "Forefront of OCC 2021 Conference" zone is here!
