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Nearly 300 delegates from around the world gathered in Barcelona, Spain, to attend European Society of Cardiology (ESC) Heart & Stroke, the international conference of the ESC Council on Stroke. An engaging programme provided an opportunity for the attending experts of various disciplines – including cardiologists, neurologists, vascular surgeons and interventional neuroradiologists – to discuss a multidisciplinary approach to stroke prevention and treatment.
ESC Heart & Stroke 2020 in Barcelona, Spain
To prevent stroke and ensure full protection of patients with atrial fibrillation (AF), it is important to consider the various factors that can influence patient outcomes, such as co-morbidities (e.g. renal impairment or diabetes), dosing and adherence.
The Bayer-sponsored symposium entitled ‘Optimizing care for patients with AF: Think kidney, protect the brain, it’s the heart of the matter’ focused on the importance of a multidisciplinary approach to improve patient outcomes. Professor Döhner (Berlin, Germany) introduced the symposium by highlighting that 80% of strokes can be avoided1 and by emphasizing that interdisciplinary actions may be needed to improve outcomes in high-risk patients with AF, such as those with co-morbidities. Multiple systems, such as renal function and metabolic function (i.e. diabetes), in addition to the heart should be considered when making treatment decisions.
The management of patients with AF and co-morbidities may be challenging, requiring careful consideration of the most appropriate therapy and dose for each individual. In their combined presentation, Professors Sanmartin (Madrid, Spain) and Coleman (Connecticut, USA) highlighted the need for optimizing care in patients with AF and co-morbid diabetes and renal impairment.
Professor Sanmartin opened the presentation with a case study of a patient with AF and co-morbid type 2 diabetes and chronic kidney disease (CKD) stage 3A. Patients with AF and co-morbid diabetes have an increased risk of not only vascular outcomes, including stroke, myocardial infarction and mortality,2 but also major adverse limb events (MALE).3 Professor Coleman reviewed data from a meta-analysis of randomized controlled trials in patient subgroups with diabetes,4 the diabetic subgroup analysis of ROCKET-AF,5 and results of a real-world US MarketScan database analysis,3 concluding that non-vitamin K antagonist oral anticoagulants (NOACs), including rivaroxaban, have a favourable benefit–risk profile compared with warfarin in patients with AF and diabetes. Furthermore, in the real-world study, rivaroxaban was also associated with a lower risk of MALE in these patients.3
A US MarketScan database analysis demonstrating the beneficial effect of rivaroxaban on the risk of MACE and MALE in patients with AF and diabetes3
The patient discussed in this presentation had renal impairment (CKD stage 3A), which is likely to worsen over time. Professor Coleman highlighted the importance of choosing the right therapy for the right patient and presented real-world evidence showing that NOACs, particularly rivaroxaban, may reduce renal function worsening compared with warfarin.6,7
‘Dependent on how we anticoagulate, we may be able to slow down or attenuate renal decline’
Analysis of a large US administrative database, showing the beneficial effects of NOACs, in particular rivaroxaban and dabigatran, on adverse renal outcomes in patients with AF7
Professor Döhner noted that the risks of stroke and bleeding need to be carefully balanced, especially for patients with end-stage renal disease, who are not currently included on NOAC labelling in most countries.
‘If it’s complicated, don’t shy away. Outweigh the balance of potential benefit and harm.’
Professor Sanmartin summarized the discussion by stressing the importance of providing full protection for patients with AF and co-morbidities, including renal impairment and diabetes. The patient’s limbs and kidneys, in addition to their brain and heart, should be considered when managing these complex patients.
‘Patients are not concerned about their renal function… they are afraid of dialysis and the impact on their quality of life’
The three panelists discussing the need to protect the patient’s kidneys and limbs, in addition to their heart and brain
The importance of considering multiple systems when managing patients with stroke was also the focus of the scientific session ‘Complex stroke patient management’. During this session, the presenters highlighted the increased risk of stroke in complex patients, such as those with cardiovascular disease, cancer, heart failure and those of older age, and discussed appropriate management approaches. It was again highlighted that NOAC therapy should be considered in complex patients with stroke, but that the decision should be based on the individual patient. The importance of individualizing treatment decisions to improve patient outcomes was encapsulated by one of the delegates who reminded the audience that
‘The stroke unit doesn’t treat stroke, it treats the patient’
The symposium in the hotel Barceló Sants in Barcelona