Heart–brain team approach of acute myocardial infarction complicating acute stroke: Evidencing the knowledge gap

Brain-X Pub Date : 2023-08-15 DOI:10.1002/brx2.28
Na Li, Xin Tian, Yongzheng Guo
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The institute in the present study has a structure to provide a heart–brain team approach,<span><sup>3</sup></span> which was defined as cardiac catheterization and antithrombotic therapies, according to the status and severity of an acute stroke and the patient's condition.</p><p>In this issue of the <i>Journal of the American Heart Association</i>, Suzuki et al.<span><sup>4</sup></span> described different clinical characteristics, coronary revascularization and antithrombotic therapies and cardiovascular and major bleeding outcomes of patients with AMI-CAS. These findings were based on a retrospective cohort study using data from the National Cerebral and Cardiovascular Center (Suita, Japan) between 1 January 2007, and 30 September 2020 and included 2393 consecutive patients with AMI. Of these patients, those with takotsubo cardiomyopathy (<i>n</i> = 3) were excluded. The primary outcome was defined as a composite of major adverse cerebral/cardiovascular events (MACCEs), which included cardiac-cause death, nonfatal myocardial infarction, and nonfatal stroke. The authors reported a few attractive findings. Firstly, AMI-CAS was identified in 1.6% (39/2390) of study participants in the current study. The characteristics of AMI-CAS tend to be women (46.2% vs. 26.2%; <i>P</i> = 0.005), chronic kidney disease (71.8% vs. 47.0%; <i>P</i> = 0.002), atrial fibrillation (38.5% vs. 9.8%; <i>P</i> &lt; 0.001) and stroke (33.3% vs. 11.1%; <i>P</i> &lt; 0.001). In 39 patients with AMI-CAS, 37 patients (37/39 = 94.9%) and 2 patients (2/39 = 5.1%) were diagnosed as having an ischemic stroke or hemorrhagic stroke, respectively. 69.2% and 10.3% of them were attributable to cardioembolic and atherosclerotic causes, respectively. AMI occurred within 3 days from the onset of acute stroke in 59.0% of patients with AMI-CAS, and the median duration of AMI from the onset of acute stroke was 2 days (interquartile range, 0–8 days). Secondly, medical procedures were conducted with a diverse frequency between AMI-CAS patients and AMI patients without acute stroke. Primary PCI (43.6% vs. 84.7%; <i>p</i> &lt; 0.001), stent implantation (30.8% vs. 77.9%; <i>p</i> &lt; 0.001) and dual-antithrombotic therapy (38.5% vs. 85.7%) were less frequently received in AMI-CAS, whereas thrombectomy (7.7% vs. 1.4%; <i>p</i> = 0.02) was higher than AMI patients without acute stroke. Additionally, angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker (59.0% vs. 77.8%; <i>p</i> = 0.005) and statin (48.7% vs. 82.3%; <i>p</i> = 0.005) were significantly less used for patients with AMI-CAS. Lastly, MACCEs (95% CI, 1.99–6.05; <i>P</i> &lt; 0.001) and major bleeding events (95% CI, 1.34–8.10; <i>P</i> = 0.009) were more likely to happen in AMI-CAS than the other group during the observational period (median, 2.4 years [interquartile range, 1.1–4.4 years]). AMI-CAS was illustrated as an independent predictor of the occurrence of MACCEs (HR, 1.87 [95% CI, 1.02–3.42]; <i>P</i> = 0.04) and major bleeding events (HR, 2.67 [95% CI, 1.03–6.93]; <i>P</i> = 0.04) using multivariable-adjusted models. The heart–brain team approach is a collaborative platform that facilitates the multidisciplinary decision-making process and patient involvement. It also creates opportunities for education and evaluation of the healthcare provided to patients with AMI-CAS. However, heart–brain team approach was conducted in AMI-CAS patients to reduce the risk of MACCEs, difficulties still exist in coronary revascularization and antithrombotic therapy in patients with AMI-CAS receiving heart–brain intensive care indicated. Similarly, a review<span><sup>5</sup></span> summarized guidelines and consensus statements proposed in the online 2021 Asian-Pacific Heart and Brain Summit, which emphasized the importance of multidisciplinary clinical decision-making of cardiovascular diseases involving neurology, cardiology, and hematology. Future investigations are urgent to elucidate a more refined management of AMI-CAS.</p><p>Data presented by the authors highlighted the significance of the heart–brain team approach in AMI-CAS, which provides a reference for following study directions. As with any observational study, there are several limitations, most of which are pointed out by the authors. 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This underscores the importance of assessing bleeding risks when conducting coronary revascularization and antithrombotic therapy.</p><p>In conclusion, the paper by Suzuki et al. provided evidence of an important knowledge gap, where additional research is eagerly needed to help clinicians make personalized treatment decisions for treatment with the heart–brain team approach in patients with AMI-CAS.</p><p><b>Na Li</b>: Conceptualization; writing—original draft. <b>Xin Tian</b>: Conceptualization, writing—review &amp; editing. <b>Yongzheng Guo</b>: Conceptualization; writing—review &amp; editing.</p><p>The authors declare no conflicts of interest.</p>","PeriodicalId":94303,"journal":{"name":"Brain-X","volume":"1 3","pages":""},"PeriodicalIF":0.0000,"publicationDate":"2023-08-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/brx2.28","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Brain-X","FirstCategoryId":"1085","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1002/brx2.28","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
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Abstract

Acute myocardial infarction (AMI) occurs in 1.6%–2.1% of patients with acute stroke.1 Primary percutaneous coronary intervention (PCI) and antithrombotic therapy, which improve cardiovascular outcomes in patients with AMI, may elevate the risks of hemorrhagic stroke in the acute phase of stroke.2 How to manage the ischemic and bleeding risks in patients with AMI complicating acute stroke (AMI-CAS) is challenging in clinics. Therapeutics for AMI-CAS should be well-balanced by collaborating with cardiologists and neurologists. The institute in the present study has a structure to provide a heart–brain team approach,3 which was defined as cardiac catheterization and antithrombotic therapies, according to the status and severity of an acute stroke and the patient's condition.

In this issue of the Journal of the American Heart Association, Suzuki et al.4 described different clinical characteristics, coronary revascularization and antithrombotic therapies and cardiovascular and major bleeding outcomes of patients with AMI-CAS. These findings were based on a retrospective cohort study using data from the National Cerebral and Cardiovascular Center (Suita, Japan) between 1 January 2007, and 30 September 2020 and included 2393 consecutive patients with AMI. Of these patients, those with takotsubo cardiomyopathy (n = 3) were excluded. The primary outcome was defined as a composite of major adverse cerebral/cardiovascular events (MACCEs), which included cardiac-cause death, nonfatal myocardial infarction, and nonfatal stroke. The authors reported a few attractive findings. Firstly, AMI-CAS was identified in 1.6% (39/2390) of study participants in the current study. The characteristics of AMI-CAS tend to be women (46.2% vs. 26.2%; P = 0.005), chronic kidney disease (71.8% vs. 47.0%; P = 0.002), atrial fibrillation (38.5% vs. 9.8%; P < 0.001) and stroke (33.3% vs. 11.1%; P < 0.001). In 39 patients with AMI-CAS, 37 patients (37/39 = 94.9%) and 2 patients (2/39 = 5.1%) were diagnosed as having an ischemic stroke or hemorrhagic stroke, respectively. 69.2% and 10.3% of them were attributable to cardioembolic and atherosclerotic causes, respectively. AMI occurred within 3 days from the onset of acute stroke in 59.0% of patients with AMI-CAS, and the median duration of AMI from the onset of acute stroke was 2 days (interquartile range, 0–8 days). Secondly, medical procedures were conducted with a diverse frequency between AMI-CAS patients and AMI patients without acute stroke. Primary PCI (43.6% vs. 84.7%; p < 0.001), stent implantation (30.8% vs. 77.9%; p < 0.001) and dual-antithrombotic therapy (38.5% vs. 85.7%) were less frequently received in AMI-CAS, whereas thrombectomy (7.7% vs. 1.4%; p = 0.02) was higher than AMI patients without acute stroke. Additionally, angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker (59.0% vs. 77.8%; p = 0.005) and statin (48.7% vs. 82.3%; p = 0.005) were significantly less used for patients with AMI-CAS. Lastly, MACCEs (95% CI, 1.99–6.05; P < 0.001) and major bleeding events (95% CI, 1.34–8.10; P = 0.009) were more likely to happen in AMI-CAS than the other group during the observational period (median, 2.4 years [interquartile range, 1.1–4.4 years]). AMI-CAS was illustrated as an independent predictor of the occurrence of MACCEs (HR, 1.87 [95% CI, 1.02–3.42]; P = 0.04) and major bleeding events (HR, 2.67 [95% CI, 1.03–6.93]; P = 0.04) using multivariable-adjusted models. The heart–brain team approach is a collaborative platform that facilitates the multidisciplinary decision-making process and patient involvement. It also creates opportunities for education and evaluation of the healthcare provided to patients with AMI-CAS. However, heart–brain team approach was conducted in AMI-CAS patients to reduce the risk of MACCEs, difficulties still exist in coronary revascularization and antithrombotic therapy in patients with AMI-CAS receiving heart–brain intensive care indicated. Similarly, a review5 summarized guidelines and consensus statements proposed in the online 2021 Asian-Pacific Heart and Brain Summit, which emphasized the importance of multidisciplinary clinical decision-making of cardiovascular diseases involving neurology, cardiology, and hematology. Future investigations are urgent to elucidate a more refined management of AMI-CAS.

Data presented by the authors highlighted the significance of the heart–brain team approach in AMI-CAS, which provides a reference for following study directions. As with any observational study, there are several limitations, most of which are pointed out by the authors. First, relatively small numbers of Japanese patients with AMI-CAS were included in this retrospective, single-center, observational study. Because ethnic-related differences exist in the frequency of obstructive and hemorrhagic stroke. Second, cardiovascular and bleeding outcomes in this study were subjected to be affected by variable guidelines for coronary revascularization and antithrombotic and lipid-lowering therapies from 2007 to 2020. Third, the effect of conventional therapy was absent for comparison with the heart–brain team approach in the present study. Finally, selection bias was inevitably exerted in the case of different physicians' experiences in the management and medical therapy. Future research is needed to carry out a multi-center and large-sample study to further clarify the impact of guideline cardiovascular interventions on bleeding risk, to identify the benefits of the heart–brain team approach and to investigate the mechanisms underlying the temporal correlation between stroke and cardiovascular events.

The authors should be encouraged for their contribution to the literature despite the existing limitations. Since they confirmed that a heart–brain team is a promoting approach to managing patients with AMI-CAS. This underscores the importance of assessing bleeding risks when conducting coronary revascularization and antithrombotic therapy.

In conclusion, the paper by Suzuki et al. provided evidence of an important knowledge gap, where additional research is eagerly needed to help clinicians make personalized treatment decisions for treatment with the heart–brain team approach in patients with AMI-CAS.

Na Li: Conceptualization; writing—original draft. Xin Tian: Conceptualization, writing—review & editing. Yongzheng Guo: Conceptualization; writing—review & editing.

The authors declare no conflicts of interest.

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急性心肌梗死并发急性脑卒中的心脑团队方法:认识差距的证据
急性心肌梗死(AMI)发生在1.6%-2.1%的急性中风患者中。1初级经皮冠状动脉介入治疗(PCI)和抗血栓治疗可改善AMI患者的心血管预后,在脑卒中急性期,可能会增加出血性脑卒中的风险。2如何管理AMI并发急性脑卒中(AMI-CAS)患者的缺血性和出血风险在临床上具有挑战性。AMI-CAS的治疗应该通过与心脏病专家和神经科医生合作来很好地平衡。本研究中的研究所根据急性中风的状态和严重程度以及患者的病情,提供了一种心脑团队方法,3该方法被定义为心导管插入术和抗血栓疗法。在本期《美国心脏协会杂志》上,Suzuki等人4描述了AMI-CAS患者的不同临床特征、冠状动脉血运重建和抗血栓治疗以及心血管和大出血结果。这些发现基于一项回顾性队列研究,该研究使用了2007年1月1日至2020年9月30日期间国家脑心血管中心(日本佐田)的数据,包括2393名连续的AMI患者。在这些患者中,排除了患有takotsubo心肌病的患者(n=3)。主要转归被定义为主要不良脑/心血管事件(MACCE)的组合,包括心脏原因死亡、非致命性心肌梗死和非致命性中风。作者报告了一些有吸引力的发现。首先,在当前研究中,1.6%(39/2390)的研究参与者中发现了AMI-CAS。AMI-CAS的特征往往是女性(46.2%对26.2%;P=0.005)、慢性肾脏疾病(71.8%对47.0%;P=0.002)、心房颤动(38.5%对9.8%;P&lt;0.001)和中风(33.3%对11.1%;P&&lt;0.001)。在39名AMI-CAS患者中,37名患者(37/39=94.9%)和2名患者(2/39=5.1%)被诊断为缺血性中风或出血性中风,分别地其中69.2%和10.3%分别归因于心脏栓塞和动脉粥样硬化原因。在59.0%的AMI-CAS患者中,AMI发生在急性卒中发作后3天内,急性卒中发作时AMI的中位持续时间为2天(四分位间距,0-8天)。其次,在AMI-CAS患者和无急性卒中的AMI患者之间进行不同频率的医疗程序。原发性PCI(43.6%对84.7%;p<0.001)、支架植入(30.8%对77.9%;p<0.01)和双重抗血栓治疗(38.5%对85.7%)在AMI-CAS中的接受频率较低,而血栓切除术(7.7%对1.4%;p=0.02)高于无急性卒中的AMI患者。此外,血管紧张素转化酶抑制剂、血管紧张素II受体阻滞剂(59.0%对77.8%;p=0.005)和他汀类药物(48.7%对82.3%;p=005)在AMI-CAS患者中的使用显著减少。最后一点在观察期内(中位数为2.4年[四分位间距,1.1-4.4年]),AMI-CAS发生MACCE(95%CI,1.99-6.05;P&lt;0.001)和大出血事件(95%CI(1.34-8.10;P=0.009)的可能性高于其他组出血事件(HR,2.67[95%CI,1.03-6.93];P=0.04)。心-脑团队方法是一个协作平台,有助于多学科决策过程和患者参与。它还为教育和评估AMI-CAS患者的医疗保健提供了机会。然而,在接受心脑重症监护的AMI-CAS患者中,心脑团队方法被用于降低MACCE的风险,冠状动脉血运重建和抗血栓治疗仍然存在困难。同样,一篇综述5总结了在线2021亚太心脑血管峰会提出的指导方针和共识声明,其中强调了涉及神经病学、心脏病学和血液学的心血管疾病多学科临床决策的重要性。未来的研究迫切需要阐明AMI-CAS的更精细化管理。作者提供的数据强调了心脑团队方法在AMI-CAS中的重要性,这为以下研究方向提供了参考。与任何观察性研究一样,也有一些局限性,其中大多数是作者指出的。首先,在这项回顾性、单中心、观察性研究中,纳入了相对较少的日本AMI-CAS患者。因为阻塞性和出血性中风的发生频率存在种族差异。 其次,从2007年到2020年,本研究中的心血管和出血结果受到冠状动脉血运重建、抗血栓和降脂治疗可变指南的影响。第三,在本研究中,常规治疗的效果与心脑团队方法相比是不存在的。最后,在不同医生的管理和医疗经验的情况下,不可避免地会产生选择偏差。未来的研究需要进行一项多中心和大样本研究,以进一步阐明指导性心血管干预措施对出血风险的影响,确定心脑团队方法的益处,并研究中风和心血管事件之间时间相关性的潜在机制。尽管存在局限性,但应鼓励作者对文献的贡献。由于他们证实了心脑团队是管理AMI-CAS患者的一种促进方法。这强调了在进行冠状动脉血运重建和抗血栓治疗时评估出血风险的重要性。最后,Suzuki等人的论文。提供了一个重要知识差距的证据,迫切需要进一步的研究来帮助临床医生为AMI-CAS患者的心脑团队治疗做出个性化的治疗决策。李:概念化;书写——原始草稿。辛天:概念化,写作——评&amp;编辑。郭永正:概念化;写作——复习;编辑。作者声明没有利益冲突。
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