Rationale kardiale Diagnostik nach ischämischem Schlaganfall oder TIA

Eine strukturierte kardiologische Abklärung nach ischämischem Schlaganfall umfasst eine gezielte Anamnese, eine körperliche Untersuchung, ein 12-Kanal-EKG, ein Rhythmus-Monitoring für kumulativ 72 h, regelhaft eine transthorakale Echokardiografie und bei Verdacht auf eine atriale Emboliequelle eine transösophageale Echokardiografie. Eine erweiterte kardiale Abklärung (z. B. mittels MRT/CT, verlängertes Rhythmus-Monitoring) sollte Befund- und Patienten-bezogen erfolgen.

Abstract

Stroke is the most common cause of permanent disability and one of the most common causes of death. Cardio-embolic strokes are associated with a poor prognosis and a high risk of recurrence compared to other stroke etiologies. The most common source of cardiac embolism is atrial fibrillation which must be quickly identified to optimize secondary stroke prevention. A structured evaluation after ischemic stroke includes taking the medical history, a physical examination, 12-lead ECG recording, rhythm monitoring for 72 h, transthoracic echocardiography and transesophageal echocardiography, if an atrial embolic source of stroke is suspected. Extended cardiac work-up (e. g., MRI/CT, prolonged rhythm monitoring) should be performed in selected patients based on diagnostic findings.

Schlüsselwörter

ischämischer Schlaganfall - kardioembolische Genese - TIA - Sekundärprävention

Key words

ischemic stroke - cardio-embolic stroke - TIA - secondary stroke prevention

Publication History

Article published online:
15 June 2021

• Literatur

• 1 Johnson CO, Nguyen M, Roth GA. et al Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019; 18: 439-458 DOI: 10.1016/S1474-4422(19)30034-1.
• 2 Rücker V, Wiedmann S, O’Flaherty M. et al Decline in regional trends in mortality of stroke subtypes in Germany from 1998 to 2015. Stroke 2018; 49: 2577-2583 DOI: 10.1161/STROKEAHA.118.023193.
• 3 Hindricks G, Potpara T, Dagres N. et al 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2020; 42 (05) 373-498 DOI: 10.1093/eurheartj/ehaa612. . doi:10.1093/eurheartj/ehaa612
• 4 Häusler KG, Gröschel K, Köhrmann M. et al Positionspapier zur Detektion von Vorhofflimmern nach ischämischem Schlaganfall. Akt Neurol 2018; 45: 93-106 DOI: 10.1055/s-0043-118476.
• 5 Schnabel RB, Haeusler KG, Healey JS. et al Searching for atrial fibrillation poststroke: a white paper of the AF-SCREEN International Collaboration. Circulation 2019; 140: 1834-1850 DOI: 10.1161/CIRCULATIONAHA.119.040267.
• 6 Camen S, Haeusler K, Schnabel R. Cardiac imaging after ischemic stroke or transient ischemic attack. Cur Neurol Neurosc Rep 2020; 20: 1-12 DOI: 10.1007/s11910-020-01053-3.
• 7 Diener HC, Grau AJ, Baldus S. et al Cryptogenic stroke and patent foramen ovale: S2e guidelines. Nervenarzt 2018; 89: 1143-1153 DOI: 10.1007/s00115-018-0609-y.
• 8 Häusler KG, Neugebauer H. Closure of Patent Foramen Ovale after Ischemic Stroke. Dtsch Med Wochenschr 2019; 144: 1561-1569 DOI: 10.1055/a-0832-5767.
• 9 Saraste A, Barbato E, Capodanno D. et al Imaging in ESC clinical guidelines: chronic coronary syndromes. European Heart Journal – Cardiovascular Imaging 2019; 20: 1187-1197 DOI: 10.1093/ehjci/jez219. %J European Heart Journal – Cardiovascular Imaging
• 10 Cosyns B, Haugaa KH, Gerber BL. et al The year 2018 in the European Heart Journal—Cardiovascular Imaging: Part II. European Heart Journal – Cardiovascular Imaging 2019; 20: 1337-1344 DOI: 10.1093/ehjci/jez218 %J European Heart Journal – Cardiovascular Imaging.
• 11 Ahmed N, Audebert H, Turc G. et al Consensus statements and recommendations from the eso-karolinska stroke update conference, stockholm 11–13 November 2018. Eur Stroke J 2019; 4: 307-317 DOI: 10.1177/2396987319863606.
• 12 Uphaus T, Weber-Krüger M, Grond M. et al Development and validation of a score to detect paroxysmal atrial fibrillation after stroke. Neurology 2019; 92: e115-e124 DOI: 10.1212/WNL.0000000000006727.
• 13 Lip GYH, Nieuwlaat R, Pisters R. et al Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach: The Euro Heart Survey on Atrial Fibrillation. Chest 2010; 137 (02) 263-272
• 14 Li YG, Bisson A, Bodin A. et al C2HEST Score and Prediction of Incident Atrial Fibrillation in Poststroke Patients: A French Nationwide Study. J Am Heart Assoc 2019; 8 (13) e012546
• 15 Kernan WN, Ovbiagele B, Black HR. et al Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45: 2160-2236 DOI: 10.1161/STR.0000000000000024.
• 16 Sposato LA, Cipriano LE, Saposnik G. et al Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2015; 14: 377-387 DOI: 10.1016/S1474-4422(15)70027-X.
• 17 Gröschel S, Lange B, Grond M. et al Automatic Holter electrocardiogram analysis in ischaemic stroke patients to detect paroxysmal atrial fibrillation: ready to replace physicians?. Eur J Neurol 2020; 27 (07) 1272-1278 DOI: 10.1111/ene.14250.
• 18 Freitas-Ferraz AB, Bernier M, Vaillancourt R. et al Safety of transesophageal echocardiography to guide structural cardiac interventions. J Am Coll Cardiol 2020; 75: 3164-3173 DOI: 10.1016/j.jacc.2020.04.069.
• 19 Amarenco P, Davis S, Jones EF. et al Clopidogrel plus aspirin versus warfarin in patients with stroke and aortic arch plaques. Stroke 2014; 45: 1248-1257 DOI: 10.1161/STROKEAHA.113.004251.
• 20 Steffel J, Verhamme P, Potpara TS. et al The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2018; 39: 1330-1393 DOI: 10.1093/europace/euy054.
• 21 Wasser K, Weber-Krueger M, Juerries F. et al The cardiac diagnostic work-up in stroke patients – A subanalysis of the Find-AFRANDOMISED trial. PloS one 2019; 14: e0216530 DOI: 10.1371/journal.pone.0216530.
• 22 Haeusler KG, Jensen C, Scheitz JF. et al Cardiac Magnetic Resonance Imaging in Patients with Acute Ischemic Stroke and Elevated Troponin: A TRoponin ELevation in Acute Ischemic Stroke (TRELAS) Sub-Study. Cerebrovasc Dis Ex 2019; 9: 19-24 . 95e3739f51ef4a1baf4b68a5191c9f50
• 23 Haeusler KG, Kirchhof P, Heuschmann PU. et al Impact of standardized MONitoring for Detection of Atrial Fibrillation in Ischemic Stroke (MonDAFIS): Rationale and design of a prospective randomized multicenter study. Am J Cardiol 2016; 172: 19-25 DOI: 10.1016/j.ahj.2015.10.010.
• 24 Levin LÅ, Husberg M, Sobocinski PD. et al A cost-effectiveness analysis of screening for silent atrial fibrillation after ischaemic stroke. Ep Europace 2015; 17: 207-214 DOI: 10.1093/europace/euu213.
• 25 [Anonym]. BV Med. Risiko Schlaganfall: Implantierbare Ereignis-Rekorder können Herzrhythmusstörungen sicher aufspüren – 2019. Im Internet (Stand: 26.02.2021): https://www.bvmed.de/de/technologien/herz-und-herzgefaesse/risiko-schlaganfall-implantierbare-ereignis-rekorder-koennen-herzrhythmusstoerungen-sicher-aufspueren
• 26 Bosch R, Perings S. Versorgungslücke bei Patienten mit Rhythmusstörungen und Synkope. Der Kardiologe 2019; 13: 24-25
• 27 Schwarzbach C, Eichner F, Pankert A. et al Stroke aftercare: Treatment reality, challenges and future perspectives. Nervenarzt 2020; 91 (06) 477-483 DOI: 10.1007/s00115-020-00909-w.
• 28 Ahmadi M, Laumeier I, Ihl T. et al A support programme for secondary prevention in patients with transient ischaemic attack and minor stroke (INSPiRE-TMS): an open-label, randomised controlled trial. Lancet Neurol 2020; 19: 49-60 DOI: 10.1016/S1474-4422(19)30369-2.
• 29 Eichner FA, Schwarzbach CJ, Keller M. et al Trial design and pilot phase results of a cluster-randomised intervention trial to improve stroke care after hospital discharge–The structured ambulatory post-stroke care program (SANO). Eur Stroke J 2020; DOI: 10.1177/2396987320910596. [Article first published online 2020]
• 30 Piepoli MF, Hoes AW, Agewall S. et al 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016; 37: 2315-2381 DOI: 10.1093/eurheartj/ehw106.
• 31 Haeusler KG, Tütüncü S, Schnabel RB. Detection of Atrial Fibrillation in Cryptogenic Stroke. Curr Neurol Neurosc Rep 2018; 18: 66 DOI: 10.1007/s11910-018-0871-1.
• 32 Kirchhof P, Camm AJ, Goette A. et al Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med 2020; 383: 1305-1316 DOI: 10.1056/NEJMoa2019422.