Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation at low risk of stroke in japan: a retrospective cohort study

AIMS

Contemporary guidelines differ in their recommendations regarding initiating non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) at low risk of stroke. This study aimed to examine the effectiveness and safety of NOACs for low-risk AF in a Japanese cohort.

METHODS AND RESULTS

In this retrospective cohort study based on the JMDC Claims Database extracted between April 2011 and November 2022, we identified 13 291 patients with AF at low risk of stroke. We performed inverse probability of treatment weighting Cox regression analyses to compare the embolization and bleeding risks between the nontreatment and NOAC groups. Net clinical benefit was defined as the annual incidence of ischaemic stroke events prevented by NOACs after subtracting intracranial haemorrhage (ICH) events attributable to NOACs, multiplied by a weighting factor. The incidences of stroke and ICH in the nontreatment group were 0.47 and 0.15 per 100 person-years, respectively. The NOAC group had higher incidences of ICH (hazard ratio [HR]: 1.73, 95% confidence interval [CI]: 0.75-4.00) and stroke (HR: 1.41, 95% CI: 0.84-2.36). The net clinical benefit of NOAC treatment was -0.35% per year (95% CI: -0.99-0.29%).

CONCLUSION

Non-vitamin K antagonist oral anticoagulants treatment may be associated with a slightly high risk of ICH, and it yielded a neutral clinical benefit in the present Japanese population, which provides reassurance concerning the role of ethnicity in NOAC treatment for patients with AF and suggests a need to assess comprehensive weighting of the respective risk factors.

External Validation of COOL-AF Scores in the Asian Pacific Heart Rhythm Society Atrial Fibrillation Registry

Background

The COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with Atrial Fibrillation) risk scores for death, bleeding, and thromboembolic events (TEs) were derived from the COOL-AF cohort from Thailand and require external validation.

Objectives

The authors sought to externally validate the COOL-AF scores in the APHRS (Asia-Pacific Heart Rhythm Society) registry and to compare their performance in the ESC-EHRA (European Society of Cardiology-European Heart Rhythm Association) EORP-AF (EURObservational Research Programme in Atrial Fibrillation) General Long-Term Registry.

Methods

We studied 3,628 APHRS and 8,825 EORP-AF patients. Receiver operating characteristic (ROC) curves and Cox regression analyses were used to test the predictive value of COOL-AF scores and to compared them with the CHA2DS2-VASc and HAS-BLED scores.

Results

Patients in the EORP-AF were older, had a higher prevalence of male sex, and were at higher thromboembolic and hemorrhagic risk than APHRS patients. After 1 year of follow-up in APHRS and EORP-AF, the following events were recorded: 87 (2.4%) and 435 (4.9%) death for any causes, 37 (1.0%) and 111 (1.3%) major bleeding, and 25 (0.7%) and 109 (1.2%) TEs, respectively. In APHRS, the COOL-AF scores showed moderate-to-good predictive value for all-cause mortality (area under the curve [AUC]: 0.77; 95% CI: 0.71-0.83), major bleeding (AUC: 0.68; 95% CI: 0.60-0.76), and TEs (AUC: 0.61; 95% CI: 0.51-0.71), and were similar to the CHA2DS2-VASc and HAS-BLED scores. In EORP-AF, the predictive value of COOL-AF for all-cause mortality (AUC: 0.68; 95% CI: 0.65-0.70) and major bleeding (AUC: 0.61; 95% CI: 0.60-0.62) was modest and lower than in APHRS. In EORP-AF, the COOL-AF score for TE was inferior to the CHA2DS2-VASc score.

Conclusions

The COOL-AF risk scores may be an easy tool to identify Asian patients with AF at risk for death and major bleeding and performs better in Asian than in European patients with AF. (Clinical Survey on the Stroke Prevention in Atrial Fibrillation in Asia [AF-Registry]; NCT04807049).

Optimizing Anticoagulation Management in Atrial Fibrillation: Beyond the Guidelines. How and for Whom?

ABSTRACT

Anticoagulation therapy (AT) is the cornerstone of atrial fibrillation (AF) treatment for thromboembolic event prevention. The AF burden, however, is of predictive relevance and may be used as a foundation for therapeutic decisions in individuals with paroxysmal or persistent AF. Remote rhythm monitoring devices can provide early detection of the arrhythmia, long-term rhythm monitoring, and the development of anticoagulation strategies based on AF recurrence profile and the total burden of the arrhythmia. Although the exact thromboembolic cut-off value for the AF burden has not yet been established, targeted anticoagulation treatments in the new oral anticoagulants era have shown encouraging outcomes. The combined evaluation of AF burden and patient thromboembolic risk reported in some studies supports the concept of tailored anticoagulation management, at least in a subset of patients with low AF burden and intermediate thromboembolic risk, for whom the guidelines recommend that AT should be individualized based on net clinical benefit and patient values and preferences. Although it is still premature to derive firm conclusions or algorithms diverging from the current guidelines, the combination of a patient's AF burden, thromboembolic risk, and bleeding risk can lead in the future to an individualized management of patients with a congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age 65-74 years sex category (female) (CHA 2 DS 2 -VASc) score of 1 (2 for female patients), in whom the guidelines do not strictly recommend long-term AT. In this study, we provide an algorithm regarding the individualized implementation of anticoagulation strategies in AF in different patients' thromboembolic risk profiles, based on the available data on the so far tailored anticoagulation strategies in AF.

Sodium-Glucose Cotransporter-2 Inhibitor Prevents Stroke in Patients With Diabetes and Atrial Fibrillation

Background Atrial fibrillation (AF) is associated with increasing risk of thromboembolic or ischemic stroke. The CHA₂DS₂-VASc score is a well-established predictor of AF stroke. Patients with AF have an increased risk of stroke if they have diabetes. Use of sodium-glucose cotransporter-2 inhibitor (SGLT2i) has been shown to be associated with favorable cardiovascular outcomes in patients with diabetes. It was unknown whether use of SGLT2i decreased stroke risk in patients with AF who have diabetes. Methods and Results A total of 9116 patients with AF and diabetes from the National Taiwan University historical cohort were longitudinally followed up for 5 years (January 2016-December 2020). The risk of stroke related to SGLT2i use was evaluated by Cox model, adjusting CHA₂DS₂-VASc score in the propensity score-matched population with 474 SGLT2i users and 3235 nonusers. Adverse thromboembolic end points during follow-up were defined as ischemic stroke. The mean age was 73.2±10.5 years, and 61% of patients were men. There were no significant differences of baseline characteristics between users and nonusers of SGLT2i, including CHA₂DS₂-VASc score in the propensity score-matched population. The stroke rate was 3.4% (95% CI, 2.8-4.2) patient-years in SGLT2i users and 4.3% (95% CI, 4.0-4.6) in nonusers (P=0.021). SGLT2i users had a 20% reduction of stroke (hazard ratio, 0.80 [95% CI, 0.64-0.99]; P=0.043) after adjustment for the CHA₂DS₂-VASc score. Conclusions Use of SGLT2i was associated with a lower stroke risk in patients with diabetes and AF, and it may be considered to escalate SGLT2i to the first-line treatment in patients with diabetes and AF.

The optimum anticoagulation time after endovascular thrombectomy for atrial fibrillation-related large vessel occlusion stroke: a real-world study

OBJECTIVES

To investigate the relationship between the initiation time of anticoagulation after endovascular treatment (EVT) and the outcomes in atrial fibrillation (AF)-related acute ischemic stroke (AIS) patients.

METHODS

In this prospective registry study, from March 2013 to June 2022, patients with anterior circulation territories AF-related AIS who underwent EVT within 24 h were included. The primary outcome was favorable [modified Rankin Scale (mRS) 0-1) at ninety days and the secondary outcome was hemorrhage events after anticoagulants. Factors affecting the outcomes were pooled into multivariate regression and ROC curve analysis.

RESULTS

Of 234 eligible patients, there were 63 (26.9%) patients achieved a favorable outcome. The symptomatic intracranial hemorrhage (sICH), ICH, and systemic hemorrhage events after anticoagulants occurred in 8 (3.4%), 28 (12.0%), and 39 (16.7%) patients, severally. A longer EVT to anticoagulation time (p = 0.033) was associated with an unfavorable outcome (mRS 3-6). An earlier EVT to anticoagulation time was the independent risk factor of sICH (p = 0.043), ICH (p = 0.005), and systemic hemorrhage (p = 0.005). There was no significant difference in recurrent AIS/ transient ischemic attack (TIA) or mortality among patients who started anticoagulation at ≤ 4 days, ≥ 15 days, or 4 to 15 days. The optimum cut-off for initiating anticoagulants to predict a favorable outcome and hemorrhage events was 4.5 days and 3.5 days after EVT, respectively.

CONCLUSIONS

In AF-related AIS, the time of EVT to anticoagulation is an independent factor of the functional outcome and hemorrhage events after anticoagulation. The optimal initiate time of anticoagulant after EVT is 4.5 days.

CLINICALTRIALREGISTER

NCT03754738.

Validation of CHA2DS2 VASc Score Predictability of Stroke and Systemic Embolization in a Middle Eastern Population with AF: The Jordan Atrial Fibrillation (JoFib) Study

Background and Purpose

CHA2DS2-VASc score is one of the most widely used scoring systems to assess the risk of systemic embolization and stroke in patients suffering from atrial fibrillation (Afib); furthermore, it is important in guiding their treatment. This study aimed to evaluate the predictivity of this score in the Jordanian population, build a deeper understanding of patients' demographic and risk factors, and assess the usefulness of anticoagulation as a preventive measure.

Methods

A total of 2020 patients with Afib registered in the Jordanian Atrial Fibrillation (JoFib) registry were enrolled in this study. All patients were followed up for 1 year to assess their susceptibility to develop cerebrovascular accident (CVA) and systemic embolism (SE). The association between CHA2DS2-VASc score and risk of development of stroke or systemic embolization was analyzed based on bivariate and adjusted multivariate analyses. The ROC curve was used to assess the predictivity of the CHA2DS2-VASc score.

Results

The mean age of the study population was 67.8 years; 45.8% were males, and 81.8% were on anticoagulants. And, 71.8% had a CHA2DS2-VASc score of ≥3. During the follow-up period of 1 year; 69 developed new CVA (mean age, 72.8 years), and 9 developed SE. A total of 276 patients died; 18 patients died (6.5% out of all deceased)% from CVA. A moderate predictive power of the CHA2DS2-VASc score was demonstrated through ROC curve analysis with C statistics of 0.689 CI (0.634 to 0.744) for predicting the development of SE or CVA at 1 year.

Conclusion

CHA2DS2-VASc showed a moderate predictivity of stroke, SE, and all-cause mortality at 1 year. The study suggested disregarding gender differences in deciding to initiate anticoagulant therapy.

Frequency of cardioversions as an additional risk factor for stroke in atrial fibrillation - the FinCV-4 study

BACKGROUND

Patients with atrial fibrillation (AF) are selected for oral anticoagulation based on individual patient characteristics. There is little information on how clinical AF burden associates with the risk of ischaemic stroke or systemic embolism (SSE). The aim of this study was to explore the association of the frequency of cardioversions (CV) as a measure of clinical AF burden on the long-term SSE risk, with a focus on patients at intermediate stroke risk based on CHA₂DS₂-VASc score. For these patients, additional SSE risk stratification by assessing CV frequency may aid in the decision on whether to initiate oral anticoagulation.

METHODS

This retrospective analysis of FinCV Study from years 2003-2010 included 2074 patients who were not using any oral anticoagulation (long term or temporary) after CVs and undergoing a total of 6534 CVs for AF from emergency departments of three hospitals. Two study groups were formed: high CV frequency (mean interval between CVs ≤12 months and low frequency (>12 months).

RESULTS

A total of 107 SSEs occurred during a mean follow-up of 5.4 years. The event rates per 100 patient-years were 1.82 and 0.67 in high versus low CV frequency groups, respectively. After adjustment for CHA₂DS₂-VASc score, CV frequency independently predicted SSE (HR, 2.87 [95% CI, 1.47 to 5.64]; p = .002) at 3 years. Competing risk analysis also identified CV frequency (sHR, 2.70 [95% CI, 1.38-5.31]; p = .004) as an independent predictor for SSE. In patients with CHA₂DS₂-VASc score 1 and low CV frequency, the SSE risk was only 0.08 per 100 patient-years.

CONCLUSIONS

Frequency of CVs for symptomatic AF episodes provides additional information on stroke risk in AF patients with CHA₂DS₂-VASc score 1.Key messagesThis retrospective study offers a unique opportunity to observe the natural course of AF patients with infrequent episodes of clinical arrhythmia when they were not using OAC (before introduction of CHA₂DS₂-VASc score).Stroke or systemic embolism rate was very low (0.08 per 100 patient-years) in patients with one CHA₂DS₂-VASc point who visited the emergency room for cardioversion less than once a year.Frequency of cardioversions can be used for additional risk stratification in patients at intermediate risk of stroke based on CHA₂DS₂-VASc score.

Thromboembolism and bleeding in patients with atrial fibrillation and liver disease - A nationwide register-based cohort study: Thromboembolism and bleeding in liver disease

BACKGROUND

Balancing the risk of thromboembolism and bleeding in patients with liver disease and atrial fibrillation/flutter is particularly challenging.

PURPOSE

To examine the risks of thromboembolism and bleeding with use/non-use of oral anticoagulation (including vitamin K-antagonists and direct oral anticoagulants) in patients with liver disease and AF.

METHODS

Danish nationwide register-based cohort study of anticoagulant naive individuals with liver disease, incident atrial fibrillation/flutter, and a CHA₂DS₂-VASc-score≥1 (men) or ≥2 (women), alive 30 days after atrial fibrillation/flutter diagnosis. Thromboembolism was a composite of ischaemic stroke, transient ischaemic attack, or venous thromboembolism. Bleeding was a composite of gastrointestinal, intracerebral, or urogenital bleeding requiring hospitalisation, or epistaxis requiring emergency department visit or hospital admission. Cause-specific Cox-regression was used to estimate absolute risks and average risk ratios standardised to covariate distributions. Because of significant interactions with anticoagulants, results for thromboembolism were stratified for CHA2DS2-VASc-score, and results for bleeding were stratified for cirrhotic/non-cirrhotic liver disease.

RESULTS

Four hundred and nine of 1,238 patients with liver disease and new atrial fibrillation/flutter initiated anticoagulants. Amongst patients with a CHA2DS2-VASc-score of 1-2 (2-3 for women), five-year thromboembolism incidence rates were low and similar in the anticoagulant (6.5%) versus no anticoagulant (5.5%) groups (average risk ratio 1.19 [95%CI, 0.22-2.16]). In patients with a CHA2DS2-VASc-score>2 (>3 for women), incidence rates were 16% versus 24% (average risk ratio 0.66 [95%CI, 0.45-0.87]). Bleeding risks appeared higher amongst patients with cirrhotic versus non-cirrhotic disease but were not significantly affected by anticoagulant status.

CONCLUSION

Oral anticoagulant initiation in patients with liver disease, incident new atrial fibrillation/flutter, and a high CHA2DS2-VASc-score was associated with a reduced thromboembolism risk. Bleeding risk was not increased with anticoagulation, irrespective of the type of liver disease.

Association Between Ischemic Stroke and Left Atrial Appendage Morphology in Patients With Atrial Fibrillation and Low CHA2DS2-VASc Scores

Background

Patients with atrial fibrillation are at risk for ischemic stroke, even with low CHA2DS2-VASc scores. The left atrial appendage is a known site of thrombus formation in individuals with atrial fibrillation.

Methods

We conducted a prospective study, enrolling patients with nonvalvular atrial fibrillation and CHA2DS2-VASc scores of 0 or 1. Patients were divided into groups based on left atrial appendage morphology (determined by computed tomography): the “chicken wing” group and the non–chicken wing group. We followed patients for more than 1 year to observe the incidence of stroke.

Results

Of 509 patients with a mean (SD) age of 48.9 (11.6) years; 332 (65.2%) were men. The chicken wing group had fewer left atrial appendage lobes, a lower left atrial appendage depth, and a smaller left atrial appendage orifice area (all P < .001). During the follow-up period, 5 of the 133 patients (3.8%) in the chicken wing group and 56 of the 376 patients (14.9%) in the non–chicken wing group experienced ischemic stroke (P < .001). The following findings were significantly associated with the incidence of stroke: left atrial appendage depth (hazard ratio [HR], 1.98; 95% CI, 1.67-3.12; P = .03), left atrial appendage orifice area (HR, 2.16; 95% CI, 1.59–3.13; P < .001), and non–chicken wing left atrial appendage morphology (HR, 1.16; 95% CI, 1.10–1.23; P < .001).

Conclusion

For patients with atrial fibrillation and a low CHA2DS2-VASc score, the non–chicken wing left atrial appendage morphology type is independently associated with ischemic stroke.

Association between lipoprotein(a) and thromboembolism in patients with non-valvular atrial fibrillation: a cross-sectional study

BACKGROUND

Lipoprotein(a) [Lp(a)] is a recognized risk factor for ischemic stroke (IS); however, its role in thromboembolism in patients with non-valvular atrial fibrillation (NVAF) remains controversial. We aimed to assess the association of Lp(a) and IS and systemic embolism (SEE) in NVAF patients.

METHODS

In total, 16,357 patients with NVAF were recruited from the First Affiliated Hospital of Xinjiang Medical University from January 1, 2009, to December 31, 2021, and were divided into groups based on Lp(a) quartiles. Logistic regression models analyzed the association between Lp(a), IS, and SEE. The restriction cubic spline was used to assess the potential nonlinear relationship between Lp(a), IS, and SEE. We conducted subgroup analyses and estimated the multiplicative interaction between the stratified variables and Lp(a) to investigate whether the association between Lp(a) and IS and SEE was affected by age, sex, anticoagulants, and CHA₂DS₂-VASc score.

RESULTS

We identified 1319 IS and 133 SEE events. After correcting for CHA₂DS₂-VASc score and other potential confounders, each 1-standard deviation (SD) increase in log-Lp(a) was related to a 23% increased risk of IS (odds ratios [OR], 1.23; 95% confidence intervals [CI], 1.07-1.41). NVAF patients in the highest Lp(a) quartile were 1.23-fold more likely to have IS than those in the lowest quartile (OR, 1.23; 95% CI, 1.04-1.45). A positive linear relationship between Lp(a) and IS risk was observed (P for nonlinear = 0.341). In the fully adjusted model, subjects had a 1.78-fold increased risk of SEE for each 1-SD increase in log-Lp(a) (OR, 2.78; 95% CI, 1.78-4.36). Subjects in the highest Lp(a) quartile had a 2.38-fold elevated risk of SEE (OR, 3.38; 95% CI, 1.85-6.19) compared with the lowest quartile. Furthermore, Lp(a) had a nonlinear relationship with the risk of SEE (P for nonlinear = 0.005).

CONCLUSIONS

Elevated Lp(a) concentration was significantly associated with IS and SEE, suggesting that Lp(a) may be an emerging biomarker that can help clinicians identify patients at high risk of thromboembolism in this population.

Management of atrial fibrillation: two decades of progress - a scientific statement from the European Cardiac Arrhythmia Society

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. The aim of this review was to evaluate the progress made in the management of AF over the two last decades.

RESULTS

Clinical classification of AF is usually based on the presence of symptoms, the duration of AF episodes and their possible recurrence over time, although incidental diagnosis is not uncommon. The majority of patients with AF have associated cardiovascular diseases and more recently the recognition of modifiable risk factors both cardiovascular and non-cardiovascular which should be considered in its management. Among AF-related complications, stroke and transient ischaemic accidents (TIAs) carry considerable morbidity and mortality risk. The use of implantable devices such as pacemakers and defibrillators, wearable garments and subcutaneous cardiac monitors with recording capabilities has enabled to access the burden of "subclinical AF". The recent introduction of non-vitamin K antagonists has led to improve the prevention of stroke and peripheral embolism. Agents capable of reversing non-vitamin K antagonists have also become available in case of clinically relevant major bleeding. Transcatheter closure of left atrial appendage represents an option for patients unable to take oral anticoagulation. When treating patients with AF, clinicians need to select the most suitable strategy, i.e. control of heart rate and/or restoration and maintenance of sinus rhythm. The studies comparing these two strategies have not shown differences in terms of mortality. If an AF episode is poorly tolerated from a haemodynamic standpoint, electrical cardioversion is indicated. Otherwise, restoration of sinus rhythm can be obtained using intravenous pharmacological cardioversion and oral class I or class III antiarrhythmic is used to prevent recurrences. During the last two decades after its introduction in daily practice, catheter ablation has gained considerable escalation in popularity. Progress has also been made in AF associated with heart failure with reduced or preserved ejection fraction.

CONCLUSIONS

Significant progress has been made within the past 2 decades both in the pharmacological and non-pharmacological managements of this cardiac arrhythmia.

Risk of Cerebrovascular Events in Intracerebral Hemorrhage Survivors With Atrial Fibrillation: A Nationwide Cohort Study

Background:

In patients with intracerebral hemorrhage (ICH) and prevalent atrial fibrillation (AF), the optimal stroke prevention strategy is unclear. We sought to estimate the risk of cerebrovascular events among ICH survivors with AF.

Methods:

We used the Danish Stroke Registry to identify patients with incident ICH and prevalent AF between 2003 and 2018. Key inclusion/exclusion criteria of the PRESTIGE-AF (Prevention of Stroke in Intracerebral hemorrhage Survivors With Atrial Fibrillation) trial were applied. Cumulative incidence of recurrent ICH, cerebrovascular ischemic event, and all-cause death were investigated after one year.

Results:

A total of 1885 patients (median age 80.0 years; 47.6% females) were included in the study. We observed 191 cerebrovascular events and 650 all-cause deaths, and more cerebrovascular ischemic events (N=63) than recurrent ICH events (N=40). Risks of recurrent ICH, cerebrovascular ischemic event, and all-cause death were 1.5%, 3.2%, and 30.3%, respectively, among patients not exposed to OAC during follow-up. The cumulative incidences were 2.8% for recurrent ICH, 3.2% for cerebrovascular ischemic events, and 22.0% for all-cause death among patients initiating/resuming OAC during follow-up.

Conclusions:

We observed a high risk of cerebrovascular ischemic events and a very high risk of all-cause death at one year after the incident ICH. The results of ongoing clinical trials are warranted to determine optimal stroke prevention treatment among ICH survivors with concomitant AF.

Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum

Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.

Computed tomography findings associated with the reduction in left atrial appendage flow velocity in patients with atrial fibrillation

The reduction in flow velocity within the left atrial appendage (LAAFV) is associated with a high risk of thromboembolic events. There has been few reports using sufficient sample size about the relationship between LAAFV reduction and LAA features on cardiac computed tomography (CT), including LAA volume and filling defects, in patients with atrial fibrillation (AF). We evaluated the predictors of reduced flow velocity within the LAA using the findings of cardiac CT in patients with AF. We retrospectively analysed the cardiac CT findings of the LAA of 440 patients who underwent transoesophageal echocardiography prior to pulmonary vein isolation between 12 February, 2013 and 16 December, 2019 at our institution. We investigated the potential predictors of reduced LAAFV and the difference in LAAFV between the different morphological types of the LAA. The reduced flow velocity within the LAA was significantly correlated with higher CHADS₂ scores [P = 0.001; odds ratio (OR), 1.52; 95% confidence interval (CI), 1.18-1.95], early filling defect in the LAA (P = 0.001; OR, 3.36; 95% CI 1.63-6.93), and increased indexed LAA volume (P = 0.036; OR, 1.09; 95% CI 1.01-1.19). The LAA morphological type and AF type were not significant predictors of the LAAFV reduction. Increased LAA volume, early filling defects in the LAA, and higher CHADS₂ scores were independent predictors of LAAFV reduction in patients with AF. Our findings suggest that cardiac CT findings might allow non-invasive estimation of reduced LAAFV. These CT-derived parameters may provide additional information for the risk stratification and management of thromboembolic events in patients with AF.

The Impact of Sex and Gender on Stroke

Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.

Left Atrial Appendage Thrombus in Patients with Nonvalvular Atrial Fibrillation before Catheter Ablation and Cardioversion: Risk Factors beyond the CHA2DS2-VASc Score

Left atrial appendage thrombus (LAAT) is a surrogate of thromboembolic events in patients with nonvalvular atrial fibrillation (NVAF). We aimed to investigate the risk factors for LAAT formation before catheter ablation and cardioversion beside the CHA2DS2-VASc score. In this case-control study, patients with NVAF who underwent transesophageal echocardiography (TEE) were included. Demographic data, laboratory results, and echocardiographic measurements were retrospectively collected. Logistic regression analysis was performed to determine risk factors predicting LAAT. Of the 543 included patients, LAAT was identified in 50 patients (9.2%). Multivariable logistic regression analysis for the entire cohort showed that NT-proBNP (per 500 ng/L increase, OR (95% CI): 1.09 (1.00–1.19), p = 0.038) and LDL-C (per 1 mmol/L increase, OR (95% CI): 1.70 (1.05–2.77), p = 0.032) were independently correlated with the presence of LAAT after the adjustment for CHA2DS2-VASc score and anticoagulant therapy. The subgroup analysis of patients without anticoagulant therapy also yielded similar results. Regarding patients with CHA2DS2-VASc scores ≤ 1, a higher level of LDL-C (per 1 mmol/L increase, OR (95% CI): 6.31 (2.38–16.74), p < 0.001) independently correlated with the presence of LAAT. The present study suggests that beyond CHA2DS2-VASc score, raised NT-proBNP and LDL-C are additional predictors for LAAT in NVAF patients.

OUP accepted manuscript

Aims

There is currently no consensus on whether atrial fibrillation (AF) patients at low risk for stroke (one non-sex-related CHA₂DS₂-VASc point) should be treated with an oral anticoagulant.

Methods and results

We conducted a multi-country cohort study in Sweden, Denmark, Norway, and Scotland. In total, 59 076 patients diagnosed with AF at low stroke risk were included. We assessed the rates of stroke or major bleeding during treatment with a non-vitamin K antagonist oral anticoagulant (NOAC), a vitamin K antagonist (VKA), or no treatment, using inverse probability of treatment weighted (IPTW) Cox regression. In untreated patients, the rate for ischaemic stroke was 0.70 per 100 person-years and the rate for a bleed was also 0.70 per 100 person-years. Comparing NOAC with no treatment, the stroke rate was lower [hazard ratio (HR) 0.72; 95% confidence interval (CI) 0.56–0.94], and the rate for intracranial haemorrhage (ICH) was not increased (HR 0.84; 95% CI 0.54–1.30). Comparing VKA with no treatment, the rate for stroke tended to be lower (HR 0.81; 95% CI 0.59–1.09), and the rate for ICH tended to be higher during VKA treatment (HR 1.37; 95% CI 0.88–2.14). Comparing NOAC with VKA treatment, the rate for stroke was similar (HR 0.92; 95% CI 0.70–1.22), but the rate for ICH was lower during NOAC treatment (HR 0.63; 95% CI 0.42–0.94).

Conclusion

These observational data suggest that NOAC treatment may be associated with a positive net clinical benefit compared with no treatment or VKA treatment in patients at low stroke risk, a question that can be tested through a randomized controlled trial.

Filling defects in the left atrial appendage restricted to the early phase of cardiac computed tomography as a potential risk of left atrial appendage dysfunction

BACKGROUND

Filling defects within the left atrial appendage (LAA) restricted to the early phase of computed tomography (CT) are not highly specific to the presence of thrombosis. The true significance of LAA early filling defects without thrombus remains uncertain. We evaluated the predictors of LAA early filling defects on echocardiography and cardiac CT findings in patients with atrial fibrillation (AF).

METHODS

Cardiac CT findings of 641 patients with AF who underwent transesophageal echocardiography prior to pulmonary vein isolation from 6 January 2013 to 16 December 2019 at our institution were retrospectively analyzed. We investigated potential predictors of LAA early filling defects and computed the receiver operator characteristics, choosing a threshold value at which the likelihood of LAA early filling defects could be predicted.

RESULTS

Early filling defects within the LAA correlated significantly with a history of persistent AF [p = 0.014; odds ratio (OR), 2.36; 95% confidence interval (CI), 1.19-4.66), low left ventricular ejection fraction (p = 0.009; OR, 2.62; 95% CI, 1.28-5.38), diminished LAA flow velocity (p < 0.001; OR, 0.97; 95% CI, 0.96-0.99) below 45.3 cm/s (sensitivity, 63.6%; specificity, 72.4%), and increased indexed LAA volume (p = 0.001; OR, 1.18; 95% CI, 1.07-1.30) ≥7.64 cm3/m2 (sensitivity, 70.5%; specificity, 69.0%).

CONCLUSION

Early filling defects within the LAA on cardiac CT were associated with LAA function including risk factors for thrombus development, which could lead to noninvasive estimation of LAA function and additional information for risk stratification of thromboembolic events in patients with AF.

Does CHA2DS2-VASc score predict mortality in chronic kidney disease?

Chronic kidney disease (CKD) is a leading cause of morbidity and mortality worldwide. Assessment of cardiovascular (CV) and all-cause mortality in CKD patients is of particular importance. CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes, prior stroke, vascular disease, age 65-74 years, and sex) score was originally formulated to predict the annual thromboembolic risk in patients with nonvalvular atrial fibrillation (AF). The calculation of R2CHADS2 and R2CHA2DS2VASc scores awarded an additional 2 points for CrCl < 60 mL/min and GFR < 60 mL/min/1.73 m². Recent studies have investigated whether CHA2DS2-VASc and R2CHADS ± VASC scores could be used to predict CV or all-cause mortality in patients with CKD. CHA2DS2-VASc score was proven to be a significant predictor of CV and all-cause mortality in CKD patients, and a higher CHA2DS2-VASc score was associated with increased mortality. These findings are quite promising, and they may help physicians to identify high-risk groups in this population.

Left atrial strain measured by 4D Auto LAQ echocardiography is significantly correlated with high risk of thromboembolism in patients with non-valvular atrial fibrillation

Background

The 4-dimensional automated left atrial quantification (4D Auto LAQ) tool is a new software for analysis of the structure and function of the left atrium (LA). This study aimed to evaluate the relationship between LA strain (LAS) as measured by 4D Auto LAQ echocardiography and thromboembolism risk in patients with non-valvular atrial fibrillation (NVAF).

Methods

Eight-five patients with NVAF were recruited from the cardiovascular center of our hospital, including 39 patients at high risk and 46 patients at low risk of thromboembolism. The study participants were assessed by routine echocardiography; 4D images were obtained, after which 4D Auto LAQ assessment was performed.

Results

In the thromboembolism high-risk group, the rates of impaired LA reservoir strain, LA contraction strain, LA reservoir circumferential strain, LA conduit circumferential strain, and LA contraction circumferential strain were found to be significantly higher than in the low-risk group. However, there was no significant difference in volume at onset of LA contraction or LA ejection fraction (LAEF) between the 2 groups. LA contraction circumferential strain was found to be an independent high risk factor for thromboembolism [odds ratio (OR): 2.52; P=0.008]. LA contraction circumferential strain >-4.5% was the cut-off for differentiating between participants with high and low risk of thromboembolism, with an area under the curve (AUC) of 0.95 (P<0.0001), a sensitivity of 0.872, and a specificity of 0.978. Sequential analysis revealed that LA contraction circumferential strain had a high diagnostic efficacy for stroke, as well as a specified accuracy in the diagnosis of hypertension and diabetes in patients aged ≥65 years old. However, it was not found to be effective in the diagnosis of heart failure and vascular diseases.

Conclusions

LAS is a useful index for the dynamic evaluation of LA function in patients with non-valvular AF, with higher sensitivity and accuracy than LA volume. LA contraction circumferential strain is an independent high risk factor for thromboembolism, and LA contraction circumferential strain >-4.5% is a valuable cut-off to guide the use of anticoagulant therapy in patients with non-valvular AF.

Optimizing prognosis in atrial fibrillation: A call to action in Portugal

Atrial fibrillation (AF), the most common arrhythmia in the adult population worldwide, represents a significant burden in terms of cardiovascular mortality and morbidity and has repercussions on health economics. Oral anticoagulation (OAC) is key to stroke prevention in AF and, in recent years, results from landmark clinical trials of non-vitamin K oral anticoagulants (NOAC) have triggered a paradigm shift in thrombocardiology. Despite these advances, there is still a significant residual vascular risk associated with silent AF, bleeding, premature sudden death and heart failure. The authors review AF epidemiologic data, the importance of new tools for early AF detection, the current role of catheter ablation for rhythm control in AF, the state-of-the-art in periprocedural OAC, the optimal management of major bleeding, the causes of residual premature death and future strategies for improvements in AF prognosis.

Patient characteristics, adherence, and costs of oral anticoagulation therapy in non-valvular atrial fibrillation using the Dubai Real-World Claims Database

Background:

Non-vitamin K antagonist oral anticoagulants (NOACs) reduce the risk of stroke in patients with non-valvular atrial fibrillation (NVAF) and have better safety profile than vitamin K antagonists (VKAs). However, there is a dearth of quality, real-world, patient data on the use of these drugs to guide healthcare policies in United Arab Emirates (UAE).

Aims and Objectives:

The aim is to address the knowledge gap in demographic and clinical profiles of NVAF patients on NOACs (apixaban, rivaroxaban, and dabigatran) and warfarin in UAE.

Materials and Methods:

This retrospective cohort analysis utilized the Dubai Real-World Claims Database to extract anonymized longitudinal data on NVAF patients with at least one NOAC or warfarin claim between January 2015 and March 2019. Data examined included comorbidities, healthcare resource utilization (HCRU), treatment adherence, and clinical events.

Results:

From 11,086 NVAF patients in the database, 940 patients on oral anticoagulant treatment were selected with mean age of 58.6 ± 14.7 years and 73.7% men. At baseline, the mean CHA₂DS₂-VASc risk score was 2.4, and the mean Deyo–Charlson comorbidity index (CCI) score was 1.6. Most patients (71%) started oral anticoagulation treatment on a standard index dose. High medication possession ratio (MPR) and proportion of days covered (PDC) were observed in 86.8% and 43.1% of the overall cohort. The mean number of HCRU claims and cost during the 180-day follow-up period was 18.5 and 9,747 USD, respectively. Warfarin users accounted for both the highest number of claims and cost, whereas apixaban accounted for the lowest figures. Time to first major bleeding was shorter for warfarin users compared with patients on NOACs. Longer times to first stroke/systemic embolism (SE) were observed for rivaroxaban and warfarin.

Conclusion:

This study provides important comparative insights about comorbidities, adherence, HCRU, and outcome events among NOAC and warfarin users from real-world clinical practice settings.

Ischemic Stroke and Heart Failure: Facts and Numbers. An Update

Heart failure (HF) is a severe clinical syndrome accompanied by a number of comorbidities. Ischemic stroke occurs frequently in patients with HF as a complication of the disease. In the present review, we aimed to summarize the current state of research on the role of cardio–cerebral interactions in the prevalence, etiology, and prognosis of both diseases. The main pathophysiological mechanisms underlying the development of stroke in HF and vice versa are discussed. In addition, we reviewed the results of recent clinical trials investigating the prevalence and prevention of stroke in patients with HF.

Thromboembolic Risk in Nonanticoagulated Patients With Atrial Fibrillation and Valvular Heart Disease

OBJECTIVES

This study sought to describe the risk of thromboembolism in nonanticoagulated atrial fibrillation patients with Evaluated Heartvalves, Rheumatic or Artificial (EHRA) Type 2 valvular heart disease (VHD) <65 or 65 to 74 years of age and with 0 or 1 non-sex comorbidity of the CHA₂DS₂-VASc score.

BACKGROUND

A minor, but important, proportion of patients with atrial fibrillation and VHD beyond moderate-to-severe mitral stenosis and/or a mechanical prosthetic valve, so-called EHRA Type 2 VHD, have 0 or 1 coexisting non-sex comorbidities of the CHA₂DS₂-VASc score, and are therefore not strongly recommended oral anticoagulant therapy according to guidelines. Whether these patients are truly low risk of thromboembolism has not been investigated.

METHODS

This was a cohort study of 55,613 patients identified in nationwide Danish registries from 2000 to 2018, of which 1,907 patients had EHRA Type 2 VHD. Risk of thromboembolism after 1 and 5 years of follow-up were calculated.

RESULTS

At 1 year after atrial fibrillation diagnosis, patients with EHRA Type 2 VHD had a risk of thromboembolism between 1.2% and 1.5%, according to age group (<65 or 65 to 74 years of age), and number of non-sex comorbidities of the CHA₂DS₂-VASc score (0 or 1). Interestingly, in patients with EHRA Type 2 VHD <65 years of age with 0 or 1 comorbidity, the risk was 1.5% (95% confidence interval: 0.7% to 2.8%) and 1.5% (95% confidence interval: 0.6% to 3.4%) at 1 year after the atrial fibrillation diagnosis.

CONCLUSIONS

These observations suggest that in atrial fibrillation patients with EHRA Type 2 VHD, who are not currently recommended oral anticoagulant therapy according to guidelines, the risk of thromboembolism may exceed the level above which oral anticoagulation is considered beneficial.

LDL-C/HDL-C is associated with ischaemic stroke in patients with non-valvular atrial fibrillation: a case-control study

BACKGROUND

This study explored the relationships between the low-/high-density lipoprotein cholesterol ratio (LDL-C/HDL-C) and other clinical indicators and ischaemic stroke (IS) in patients with non-valvular atrial fibrillation (NVAF) in Xinjiang. The findings could provide a theoretical and therapeutic basis for NVAF patients.

METHODS

NVAF patients who were admitted to 10 medical centres across Xinjiang were divided into stroke (798 patients) and control (2671 patients) groups according to the occurrence of first acute IS. Univariate and multivariate logistic regression analysis were used to examine the independent risk factors for IS in NVAF patients. Factor analysis and principal component regression analysis were used to analyse the main factors influencing IS. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminatory ability of LDL-C/HDL-C for predicting the occurrence of IS.

RESULTS

The stroke group had an average age of 71.64 ± 9.96 years and included 305 females (38.22%). The control group had a mean age of 67.30 ± 12.01 years and included 825 females (30.89%). Multivariate logistic regression showed that the risk of IS in the highest LDL-C/HDL-C quartile (≥2.73) was 16.23-fold that of the lowest quartile (< 1.22); IS risk was 2.27-fold higher in obese patients than in normal-weight subjects; IS risk was 3.15-fold higher in smoking patients than in non-smoking patients. The area under the ROC curve of LDL-C/HDL-C was 0.76, the optimal critical value was 2.33, the sensitivity was 63.53%, and the specificity was 76.34%. Principal component regression analysis showed that LDL-C/HDL-C, age, smoking, drinking, LDL-C and hypertension were risk factors for IS in NVAF patients.

CONCLUSIONS

LDL-C/HDL-C > 1.22, smoking, BMI ≥24 kg/m² and CHA₂DS₂-VASc score were independent risk factors for IS in NVAF patients; LDL-C/HDL-C was the main risk factor.

The personalized antithrombotic management of atrial fibrillation with intermediate thromboembolic risk: a case report

Background

So far there has been little evidence on the antithrombotic treatment of patients presenting with atrial fibrillation (AF) and a CHA2DS2-VASc score of 1 in men (2 in women). However, a recently published position paper suggests a personalized approach in weighing individual risk factors and considering additional patient characteristics and biomarkers for the decision for or against antithrombotic treatment in this intermediate-risk AF population.

Case summary

A 63-year-old male patient with a CHA2DS2-VASc score of 1 due to hypertension presents with a first episode of paroxysmal AF. The European Society of Cardiology (ESC) guidelines on the management of AF do not recommend a general antithrombotic therapy in those patients. Therefore, the decision for or against the initiation of oral anticoagulation (OAC) in the presented case is based on recent treatment recommendations of the ESC, that aim to guide clinicals through the question whether to anticoagulate or not.

Discussion

Oral anticoagulation in patients presenting with a CHA2DS2-VASc of 1 remains a challenging approach in clinical practice and physicians need to carefully balance the individual benefit of reducing thromboembolic risk with OAC against the potential harm due to an increase in bleeding risk in this patient population. The ESC provided an easily applicable approach for decision-making in patients with AF and a CHA2DS2-VASc score of 1 via consideration of additional risk factors, scoring tools, and established biomarkers. Of note, if an antithrombotic therapy is offered, non-vitamin K antagonist oral anticoagulants should be preferred over vitamin K antagonists based on the beneficial net clinical benefit.

Can echocardiography improve the prediction of thromboembolic risk in atrial fibrillation? Evidences and perspectives

Atrial fibrillation is the most common arrhythmia and its prevalence is expected to further increase. Patients with atrial fibrillation have an increased risk of stroke (fivefold increased risk), heart failure, and death. In patients with non-valvular atrial fibrillation, the most recent guidelines recommend the use of the CHA₂DS₂-VASc (congestive heart failure, arterial hypertension, age > 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category) scoring system to identify those who may benefit from oral anticoagulant treatment. Guidelines recommend initiation of oral anticoagulation with vitamin K antagonists or direct oral anticoagulants in men with a score ≥ 2 and in women with a score ≥ 3, while oral anticoagulation in individuals with a score of 0 is not recommended. Accordingly, men with CHA₂DS₂VASc score = 1 (and women with CHA₂DS₂VASc = 2) represent a grey zone where guidelines do not provide a definite oral anticoagulant indication. Implementation of risk stratification with transthoracic echocardiography could be extremely useful. Both prospective and observational studies using transthoracic echocardiography prediction of events and studies utilizing transesophageal echocardiographic parameters as surrogate markers of thromboembolic events make sustainable the hypothesis that echocardiography could improve thromboembolism prediction in non-valvular atrial fibrillation. However, because of some controversial results of different studies, determination of the best echocardiographic parameter predicting thromboembolic events in atrial fibrillation remains uncertain. The combination of left atrial enlargement with left atrial function (in particular assessing left atrial strain) appears to be very valuable, but needs to be confirmed in large-scale multi-center trials.

Comparison of Inflammatory Mediators in Patients With Atrial Fibrillation Using Warfarin or Rivaroxaban

Background: Atrial fibrillation (AF) is the most common arrhythmia associated with high risk of venous thromboembolism. Inflammatory mechanisms may be involved in the pathophysiology of AF and in the AF-related thrombogenesis, and patients with AF might benefit from the use of anticoagulants with anti-inflammatory properties. However, the evidence is still scarce, and it points out the need of trials seeking to investigate the levels of inflammatory mediators in patients with AF under different anticoagulant therapies. Therefore, this study was designed to define whether patients with AF treated either with an activated coagulation factor X (FXa) inhibitor (rivaroxaban) or with a vitamin K inhibitor (warfarin) present changes in peripheral levels of inflammatory mediators, mainly cytokines and chemokines. Methods: A total of 127 subjects were included in this study, divided into three groups: patients with non-valvular atrial fibrillation (NVAF) using warfarin (N = 42), patients with NVAF using rivaroxaban (N = 29), and controls (N = 56). Plasma levels of inflammatory mediators were quantified by immunoassays. Results: Patients with AF (both warfarin and rivaroxaban groups) presented increased levels of inflammatory cytokines in comparison with controls. The use of rivaroxaban was associated with decreased levels of inflammatory cytokines in comparison with warfarin. On the other hand, patients with AF using rivaroxaban presented increased levels of the chemokines (MCP-1 in comparison with warfarin users; MIG and IP-10 in comparison with controls). Conclusions: AF is associated with an inflammatory profile that was less pronounced in patients on rivaroxaban in comparison with warfarin users. Further studies are necessary to assess the clinical implications of our results and whether patients with AF would benefit from rivaroxaban anti-inflammatory effects.

Does the CHA2DS2-VASc scale sufficiently predict the risk of left atrial appendage thrombus in patients with diagnosed atrial fibrillation treated with non-vitamin K oral anticoagulants?

The CHA2DS2-VASc scale does not include potential risk factors for left atrial appendage thrombus (LAAT) formation such as a form of atrial fibrillation (AF) and impaired kidney function. The real risk of thromboembolic complications in AF patients is still unclear as well as an optimal anticoagulant treatment in males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.The aim of this study was to compare the predictive value of the CHA2DS2-VASc scale and other scales to estimate the risk of LAAT formation in AF patients treated with non-vitamin K oral anticoagulants (NOACs) and to assess the prevalence of thrombi in patients at intermediate risk of stroke.The observational study included consecutive patients with a diagnosis of non-valvular AF treated with NOACs, admitted to 3 high-reference institutions between 2013 and 2018. All individuals underwent transoesophageal echocardiography before cardioversion or ablation.Out of 1163 enrolled AF patients (62.1% male, mean age 62 years) the LAAT had been detected in 50 individuals (4.3%). Among patients with LAAT, 1 patient (2.0%) was classified as a low-risk category, 9 (18.0%) were at intermediate-risk, and 40 (80.0%) were at high risk of thromboembolic complications according to CHA2DS2-VASc scale. All patients were treated with NOACs: 51.0% rivaroxaban, 47.1% dabigatran, and 1.9% apixaban.Patients at intermediate stroke-risk with detected LAAT had higher R2CHADS2 score (2.1 ± 1.2 vs 1.2 ± 0.8, P = .007), higher CHA2DS2-VASc-RAF score (6.4 ± 4.4 vs 3.7 ± 2.6, P = .027) and more often had an estimated glomerular filtration rate below 56 mL/min/1.73 m (44.4% vs 13.2%, P = .026) compared to patients without LAAT. The receiver operating characteristics revealed that the CHA2DS2-VASc-RAF scale had better predictive ability to distinguish between patients with and without LAAT in the study group than CHA2DS2-VASc (P = .0006), CHADS2 (P = .0006) and R2CHADS2 scale (P = .0140).The CHA2DS2-VASc scale should be supplemented with an assessment of renal function and form of AF to improve stroke risk estimation. The application of additional scales to estimate the risk of LAAT might be especially useful among males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.

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

Comprehensive stroke care is an interdisciplinary challenge. Close collaboration of cardiologists and stroke physicians is critical to ensure optimum utilisation of short- and long-term care and preventive measures in patients with stroke. Risk factor management is an important strategy that requires cardiologic involvement for primary and secondary stroke prevention. Treatment of stroke generally is led by stroke physicians, yet cardiologists need to be integrated care providers in stroke units to address all cardiovascular aspects of acute stroke care, including arrhythmia management, blood pressure control, elevated levels of cardiac troponins, valvular disease/endocarditis, and the general management of cardiovascular comorbidities. Despite substantial progress in stroke research and clinical care has been achieved, relevant gaps in clinical evidence remain and cause uncertainties in best practice for treatment and prevention of stroke. The Cardiovascular Round Table of the European Society of Cardiology together with the European Society of Cardiology Council on Stroke in cooperation with the European Stroke Organisation and partners from related scientific societies, regulatory authorities and industry conveyed a two-day workshop to discuss current and emerging concepts and apparent gaps in stroke care, including risk factor management, acute diagnostics, treatments and complications, and operational/logistic issues for health care systems and integrated networks. Joint initiatives of cardiologists and stroke physicians are needed in research and clinical care to target unresolved interdisciplinary problems and to promote the best possible outcomes for patients with stroke.