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

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.