Cardiomyocyte Injury Following Acute Ischemic Stroke: Protocol for a Prospective Observational Cohort Study

Abstract

Background: Elevated cardiac troponin, which indicates cardiomyocyte injury, is common after acute ischemic stroke and is associated with poor functional outcome. Myocardial injury is part of a broad spectrum of cardiac complications that may occur after acute ischemic stroke. Previous studies have shown that in most patients, the underlying mechanism of stroke-associated myocardial injury may not be a concomitant acute coronary syndrome. Evidence from animal research and clinical and neuroimaging studies suggest that functional and structural alterations in the central autonomic network leading to stress-mediated neurocardiogenic injury may be a key underlying mechanism (ie, stroke-heart syndrome). However, the exact pathophysiological cascade remains unclear, and the diagnostic and therapeutic implications are unknown.

Objective: The aim of this CORONA-IS (Cardiomyocyte injury following Acute Ischemic Stroke) study is to quantify autonomic dysfunction and to decipher downstream cardiac mechanisms leading to myocardial injury after acute ischemic stroke.

Methods: In this prospective, observational, single-center cohort study, 300 patients with acute ischemic stroke, confirmed via cerebral magnetic resonance imaging (MRI) and presenting within 48 hours of symptom onset, will be recruited during in-hospital stay. On the basis of high-sensitivity cardiac troponin levels and corresponding to the fourth universal definition of myocardial infarction, 3 groups are defined (ie, no myocardial injury [no cardiac troponin elevation], chronic myocardial injury [stable elevation], and acute myocardial injury [dynamic rise/fall pattern]). Each group will include approximately 100 patients. Study patients will receive routine diagnostic care. In addition, they will receive 3 Tesla cardiovascular MRI and transthoracic echocardiography within 5 days of symptom onset to provide myocardial tissue characterization and assess cardiac function, 20-min high-resolution electrocardiogram for analysis of cardiac autonomic function, and extensive biobanking. A follow-up for cardiovascular events will be conducted 3 and 12 months after inclusion.

Results: After a 4-month pilot phase, recruitment began in April 2019. We estimate a recruitment period of approximately 3 years to include 300 patients with a complete cardiovascular MRI protocol.

Conclusions: Stroke-associated myocardial injury is a common and relevant complication. Our study has the potential to provide a better mechanistic understanding of heart and brain interactions in the setting of acute stroke. Thus, it is essential to develop algorithms for recognizing patients at risk and to refine diagnostic and therapeutic procedures.

Trial registration: Clinicaltrials.gov NCT03892226; https://www.clinicaltrials.gov/ct2/show/NCT03892226.

International registered report identifier (irrid): DERR1-10.2196/24186.

Keywords: Takotsubo syndrome; autonomic nervous system; cardiac imaging techniques; ischemic stroke; magnetic resonance imaging; myocardial injury; myocardial ischemia; stroke-heart syndrome; troponin T.

Figure 1

Study procedure of the Cardiomyocyte injury following Acute Ischemic Stroke study. Patients with a confirmed diagnosis of acute ischemic stroke via magnetic resonance imaging within 48 hours of symptom onset are eligible for inclusion. Patients receive a baseline visit, transthoracic echocardiography, 20-min electrocardiogram recording, blood sampling for biobanking, and cognitive testing within the first 2 days after enrolment. 3T cardiovascular magnetic resonance imaging takes place 3-5 days after symptom onset. Telephonic follow-up for cardiovascular events and functional outcomes will be conducted after 3 and 12 months. CMR: cardiovascular magnetic resonance imaging; d: day; ECG: electrocardiogram; MoCA: Motreal-Cognitive-Assessment; PSS: Perceived Stress Scale; TTE: transthoracic echocardiography; y: year.

Figure 2

3T cardiovascular magnetic resonance imaging protocol. Workflow of the cardiovascular magnetic resonance imaging sequences conducted. 2Ch: 2-chamber view; 3Ch: 3-chamber view; 4Ch: 4-chamber view; 3T: 3 Tesla; LGE: late gadolinium enhancement; mv: midventricular; SAX: short axis view; SSPF: steady-state free-precession.

Figure 3

Diagnostic assessment of the Cardiomyocyte injury following Acute Ischemic Stroke study. Illustration of the target points of the multimodal diagnostic workup to provide a thorough phenotyping of patients with stroke-associated myocardial injury. cMRI: cerebral magnetic resonance imaging; ECG: electrocardiogram; MRI: magnetic resonance imaging; TTE: transthoracic echocardiography.