Integrated care for optimizing the management of stroke and associated heart disease: a position paper of the European Society of Cardiology Council on Stroke

Abstract

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).

Keywords: Delivery of care; Heart disease; Integrated care; Patient pathways; Stroke.

Graphical Abstract

Figure 1

Proposed approach to screening for atrial fibrillation in post-stroke patients. AF, atrial fibrillation; CAD, coronary artery disease; PM, pacemaker; ICD, implantable defibrillator-cardioverter; PAC, premature atrial complexes; LA, left atrium; TVR, tricuspid valve regurgitation; MVR, mitral valve regurgitation; NT-proBNP, N-terminal pro-brain natriuretic peptide; BNP, brain natriuretic peptide; HR, hazard ratio; OR, odds ratio; ICM, implantable cardiac monitor; ESUS, embolic stroke of undetermined source. *PR interval (per 10 ms) off PR prolonging drugs; HR 1.58 (95% CI 1.32–1.90) for AF in 12 months; HR 1.41 (95% CI 1.21–1.64) for AF in 36 months PR interval (per 10 ms) on PR prolonging drugs; HR 1.17 (95% CI 1.02–1.35) for AF in 12months; HR 1.15 (95% CI 1.01–1.30) for AF in 36 months. Other ECG markers of atrial myocardiopathy (such as P wave dispersion, P wave index, maximum P-wave duration) could be useful in predicting AF in specific subgroups of patients high-risk for AF. **Age (per 10 years) HR 1.91 (95% CI 1.31–2.80) for AF in 12 months; HR 1.84 (95% CI 1.33–2.52) for AF in 36 months.  ^#PAC >123/24 h; HR 3.94 (95% CI 1.30–11.97) for AF in 12 months; HR 3.41 (95% CI 1.38–8.70) for AF in 36 months—univariate analysis. Greater than or equal to 30 PAC per hour or any episode of runs of ≥20 PACs; HR 2.37 (95% CI 1.07–6.96) for hospital admission for AF within 6.3 years.  ^$LA size >45 mm; HR 3.6 (95% CI 1.6–8.4) for AF within 1 year.  ^@Odds ratio for cardioembolic stroke for highest quartile of BNP in clinical + BNP model OR 4.49 (95% CI 3.26–6.2); for lowest quartile of BNP in clinical + BNP model OR 7.1 (95% CI 4.98–10.12); for highest quartile of NT-proBNP in clinical + NT-proBNP model OR 6.17 (95% CI 4.31–8.84); for lowest quartile of NT-proBNP in clinical + NT-proBNP model OR 3.34 (2.44–4.59).  ^$$C2HEST score [CAD/COPD (1 point each), Hypertension (1 point), Elderly (≥75 years, 2 points), Systolic heart failure (2 points), and Thyroid disease (hyperthyroidism, 1 point)]. The risk of AF increases with increasing score values, being the highest in patients with a C₂HEST score of >3.  ^##Hazard ratios for post-stroke AF based on references.^,,

Figure 2

Proposed management in patient with diabetes mellitus and stroke. Patients with post-stroke hyperglycaemia and hypoglycaemia are at a high risk of cardiovascular complications and blood glucose should be proactively managed. ASCVD, atherosclerotic cardiovascular disease; CAD, coronary artery disease; CKD, chronic kidney disease; DW25, dextrose 25% in water; DW50, dextrose 50% in water; DM, diabetes mellitus; GLP-1RA, glucagon-like peptide-1 receptor antagonist; HF, heart failure; HbA1c, glycated haemoglobin; FPG, fasting plasma glucose; PAD, peripheral artery disease; PPG, postprandial glucose; TBR, time below range, TIR, time in range; SGLT2i, sodium glucose co-transporter-2 inhibitor.

Figure 3

Proposed management of dyslipidaemia in ischaemic stroke. PCSK9-i, proprotein convertase subtilisin/kexin type 9 inhibitor.

Figure 4

The Stroke Continuum. Patient care across the Stroke Continuum: from primordial prevention (maintenance of health) to primary prevention (control of stroke risk factors), acute stroke, secondary prevention and tertiary prevention (minimization of stroke impact). Depending on the stage of the Stroke Continuum in which the stroke patient is encountered, the stroke physician may have different roles and responsibilities. For example: stroke physicians who serve at the acute stroke care setting would preferentially have strong expertise in selecting and implementing interventional procedures, offering best supportive treatment to minimize acute complications, and guiding and evaluating the diagnostic workup to plan the most effective treatments to reduce recurrence risk—typically this would involve specialty physicians of internal medicine, neurology, cardiology, critical care, intensive care and others. stroke physicians who serve at the rehabilitation setting would preferentially have strong expertise in rehabilitation and in the management of chronic complications like dysphagia, malnutrition and related metabolic derangements—typically this would involve specialty physicians of physical medicine and rehabilitation, neurology, internal medicine and others. Stroke physicians who serve at the outpatient clinic and focus mainly on preventing first or recurrent strokes would preferentially have strong expertise in the management of stroke risk factors—typically this would involve specialty physicians of cardiology, neurology, internal medicine, general practitioners and others. Stroke physicians who are engaged with interventional procedures in the hyperacute and acute setting (or else, stroke interventionists) would preferentially have strong expertise in endovascular procedures like interventional neurology, neuroradiology/radiology, neurosurgery, vascular surgery and cardiology. Across the Stroke Continuum, there is a need for multi-disciplinary collaboration and coordination of care, including the complex treatment of cardiovascular conditions with the overarching goal to improve recovery, prevent recurrence, and enhance survival and quality of life for the patient with stroke.