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Prevention of Cardioembolic Stroke - Dr Jeremy Chow
- 1. Prevention of CardioembolicStroke in 2025 PRESENTED BY: DR JEREMY CHOW Consultant Cardiologist & Electrophysiologist Director of Electrophysiology Service MBBS, M.Med (Int Med), FAMS FRCP (London), FESC, FHRS, FAsCC Certified Cardiac Device Specialist Website: www.ahvc.com.sg Email: drchow.jeremy@ahvc.com.sg
- 2. AHVC ASM 16August 2025 Where do the clots come from?
- 3. AHVC ASM 16August 2025 So How Can We Prevent Cardioembolic Stroke? 1. Restore AF to Sinus Rhythm Antiarrhythmic vs Ablation to maintain SR 2. Prevent blood clot formation in LAA Anticoagulation vs LAAC 3. PFO Closure in young stroke patients?
- 4. Case – MrVA 35 year old Executive Chef No CV Risk Factor Saw me in 2020 for second opinion. Presented with left sided transient numbness with transient loss of tone. No facial asymmetry MRI confirmed right parietal, occipital and frontal subacute infarcts. MRA normal.
- 5. Case – MrVA Did 72H telemetry monitoring- No AF 24H Holter - No AF First TTE with bubble - negative US carotid – No plaque or stenosis. Transcranial doppler bubble study showed - positive for right to left shunt Auto-immune screen negative
- 7. What are highrisk PFO? ➢ Current evidence indicates that patients with moderate/large PFOs or atrial septal aneurysm (ASA) have a higher risk of stroke recurrence and are more likely to benefit from PFO closure. ➢ The size of the PFO is often quantified by the number of bubbles that cross into the left atrium. A large PFO has been defined as the appearance of more than 20 microbubbles in the left atrium within 3 cardiac cycles after opacification of the right atrium. ➢ An ASA is defined as a septum primum excursion ≥10 mm from the plane of the atrial septum into the right atrium or left atrium and is also considered a high-risk feature.
- 8. Case – MrVA Patient agreed for PFO closure.
- 9. Whose PFO shouldbe close?
- 11. RESPECT REDUCE CLOSE Enrolledpatients 980 664 663 Trial size 980 664 473 Follow-up Median of 5.9 years Median of 3.2 years Device: 5.4 ± 1.9 years Antiplatelet-only: 5.2 ± 2.1 years Atrial Septal Aneurysm 36% 20% 34% Large right-to-left shunt 50% 43% 91% Device used Amplatzer PFO Occluder Helex Septal Occluder or Cardioform Septal Occluder 11 PFO devices used – 51% Amplatzer PFO devices Anticoagulation Permitted Not Permitted Not Permitted Technical success 99.1% 98.8% 99.6% Relative risk reduction in recurrent ischemic stroke 45% (P=0.046) 77% (P=0.002) 97% (P<0.001) Differences in magnitude of risk reduction across trials may be due to patient selection and anticoagulation therapy permitted in each trial All 3 trials published in NEJM in 2017
- 12. How about olderpatients? > 60 yo
- 13. How about olderpatients? > 60 yo
- 14. How about olderpatients? > 60 yo (1) the procedural success rate was high (99.9%) and major procedural-related complications low (<2%), similar to their younger counterparts; (2) the incidence of cerebrovascular ischemic events after a median follow-up of 3 years was lower than expected according to the RoPE score in the older group (<1 and <2 per 100 patient-years for stroke and stroke/TIA, respectively) but higher compared to that observed in younger PFO closure patients; and (3) the rate of new-onset AF after the procedure was 2.66 per 100 patient- years, higher than expected compared to the general population of the same age.
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- 20. AHVC ASM 16August 2025 Most AF patients in Asia receive either inappropriate antithrombotic therapy, or an inadequate level of anticoagulants Proportion on anticoagulants or antiplatelets by region Proportion on anticoagulants Newly-diagnosed AF patients Overall AF patients Anticoagulants are underused and antiplatelets are overused in Asia compared to Europe2 65% 20% 38% 37% 0% 20% 40% 60% 80% 100% Anticoagulants Antiplatelets Europe Asia 10-30% 20% 0% 20% 40% 60% 80% 100% Asia Malaysia Even fewer patients receive anticoagulants1, 3
- 21. AHVC ASM 16August 2025 Even in Singapore according to the GARFIELD Registry Antithrombotic treatment according to CHA2DS2-VASc score, Singapore (N=70)
- 22. AHVC ASM 16August 2025 • Took more than 10 years to plan • Nearly 5k patients recruited from 105 centres in 27 countries • Final follow-up in March 2021 • Mean follow-up – 3.8 years Validating the concept of closing the left atrial appendage to prevent stroke
- 23. Case – MrCKK 60 year old Lawyer CV Risk Factor – Hypertension, Hyperlipidaemia Hx of Chronic AF since 2018 on rate control and anticoagulation Hx of OSA on CPAP Saw me in 2021 for second opinion
- 24. Case – MrCKK He was planned for EPS ablation in July 2021. CTCA done in June showed minor CAD and no LAA clot. His Xarelto was stopped for 1 day and he had TEE prior to EPS. New LAA clot.
- 25. Case – MrCKK He was planned for EPS ablation in July 2021. CTCA done in June showed minor CAD and no LAA clot. His Xarelto was stopped for 1 day and he had TEE prior to EPS. New LAA clot.
- 27. Case – MrCKK After LMWH for 6 weeks, he came back for EPS AF in Dec 2021 and had successful PVI. He was in paroxysmal AF post ablation but his NYHA improved. In April 2022, he had recurrence of persistent AF. He was admitted for cardioversion.
- 28. Case – MrCKK TEE was done before cardioversion which showed no clot in LAA. His Lixiana was uninterrupted.
- 30. Case – MrCKK Cardioversion was successful, he was planned for home the next morning when he suddenly had acute vertigo with incoordination. MRI showed acute right cerebellar stroke. Now what can I do? Stroke despite DOAC
- 35. AHVC ASM 16August 2025 Is LAAC Superior to anticoagulation? 1. Cumulative bleeding risk of DOAC 2. Cost effectiveness of LAAC 3. Mortality benefit ?
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- 37. AHVC ASM 16August 2025 0 10 20 30 40 50 60 0 1 2 3 4 Annual % Bleed Risk Bleeding Risk Compounds Over Patients’ Lifetime HAS-BLED Score Percent Bleeding Risk (%) HAS- BLED Score Annual % Bleed Risk (%) 10-Year Bleeding Risk (%)* 0 0.9 8.6 1 3.4 29.2 2 4.1 34.2 3 5.8 45.0 4 8.9 60.6 5 9.1 61.5 Lip. JACC . 2011; 57(2): 173-180 *Assumes constant risk despite that increasing age and bleeding risk are independent from bleeding risk in previous years Bleeding Risk The HAS-BLED scoring system predicts a patient’s risk of major bleeding while on warfarin.
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- 40. AHVC ASM 16August 2025 PROTECT AF & PREVAIL 5 YEAR Patient level Meta-analysis Compared to the control arm (warfarin), LAAO with the Watchman device reduced: • Haemorrhagic stroke by 80% • Disabling stroke by 55% • All cause mortality by 27% • Major bleeding by 52%
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- 42. Take Home Message…. Highrisk PFO should be closed in young patients < 60 yo. LAAC is superior to DOAC if we want to achieve - less bleeding with similar degree of stroke prevention in the long term. LAAC is the more cost-effective treatment in stroke prevention.