Stroke risk with atrial fibrillation
In atrial fibrillation, the atria of the heart beat uncoordinated and very quickly, which leads to reduced blood ejection. As a result, blood can accumulate in the atria, particularly in the left atrial appendage, and form clots (thrombi). These thrombi can break loose and travel through the bloodstream to the brain, where they block blood vessels and cause an ischaemic stroke.
Prevention
The guideline-based therapy for reducing the risk of stroke in AF includes oral anticoagulation. Anticoagulation significantly reduces the risk of stroke, but harbours an increased risk of bleeding, particularly intracranial bleeding. In addition, control of underlying risk factors such as hypertension, diabetes and obesity as well as regular cardiological follow-up are important.
Risk assessment
The CHA2DS2-VASc score is generally used to assess the risk of stroke in atrial fibrillation. This score takes various risk factors into account. Patients with a high CHA2DS-VASc score have an increased risk of stroke, which is why anticoagulation (blood thinning) is recommended. For men, this is recommended at 2 points or more, for women at 3 points or more.
C: Congestive heart failure - 1 poin
H: Hypertension (high blood pressure) - 1 poin
A2: Age ≥ 75 years (age over 75 years) - 2 point
D: Diabetes mellitus - 1 poin
S2: Stroke/TIA (history of stroke or transient ischaemic attack) - 2 point
V: Vascular disease - 1 poin
A: Age 65-74 years (age between 65 and 74) - 1 poin
Sc: Sex category (female) - 1 point
The higher the score, the higher the statistical risk of stroke per year.
PFO closure
In the normal population, around 25 per cent of all people have a persistent foramen ovale (PFO). This means that the two atria of the heart are not closed. This normally happens when breathing begins.
The opening creates a ‘short circuit’ between the right and left atrium, which may allow thrombi from the venous pathway to pass from the right atrium to the left atrium, bypassing the lungs, when the pressure in the right atrium rises, leading to occlusions in the arterial system such as strokes or thromboembolisms.
Various studies show that closing a persistent foramen ovale in patients who have already had a stroke can prevent the occurrence of further cardiac events. Patients under the age of 60 in particular benefit from PFO closure. Different systems can be used for this procedure. PFO closure is now also possible using a suture system that does not leave any foreign material in the body. The basis for carrying out this procedure is a detailed medical history and diagnosis.
The atrial appendage, a small protrusion on the left atrium, is a common area for the formation of blood clots in atrial fibrillation, which can trigger strokes.
For patients for whom blood thinners are not an option, catheter-based closure of the atrial appendage with an occluder is an alternative that reduces the risk of stroke.
LAA closure
The left atrial appendage (LAA) is a bulge in the left atrium. It serves as a blood reservoir and exhibits strong trabecularisation, which leads to blood stasis and increased thrombus formation. In patients with atrial fibrillation, more than 90 percent of thrombi occur in the left atrial appendage as the cause of ischaemic strokes.
In order to reduce the three- to five-fold increased risk of stroke in patients with atrial fibrillation, drug therapy with anticoagulants (blood thinners) is recommended for all patients with a high risk of stroke. However, blood thinning also entails an increased risk of bleeding, especially in patients with an increased risk of bleeding due to other illnesses. The use of blood-thinning medication may also be contraindicated for other indications.
For patients with a high risk of stroke and haemorrhage, closure of the left atrial appendage is an alternative treatment option. This can be performed using an occluder or surgically. All methods of closing the left atrial appendage are available at the DHZC. This method also receives intensive scientific support. State-of-the-art planning methods are used in clinical practice.
Interdisciplinary treatment at the DHZC
The Cardio-Neuro Board
In order to provide patients with optimal and individualised treatment, a cardio-neurological board consisting of specialists from various disciplines was created across the DHZC and Charité campuses. This panel of experts discusses complex patient cases and decides on further treatment. The meetings primarily focus on patients with atrial fibrillation who have already had a stroke and/or also have a patent foramen ovale (PFO), which increases the risk of strokes and cerebral haemorrhages.
The Cardio-Neuro Board discusses patients' diagnostic findings from the perspective of neurology and cardiology. On this basis, our experts determine whether interventional PFO or LAA closure, for example, is necessary for further treatment. This interdisciplinary collaboration ensures that patients receive the best possible treatment based on their individual risk profile and the latest scientific findings.
Patient registrations
Patients can register for an evaluation of treatment options:
- by telephone via the secretariat of the Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, T: +49 30 450 560 758
- by telephone via the secretariat of the Department of Cardiology, Angiology and Intensive Care Medicine at the Benjamin Franklin Campus, T: +49 30 450 513 747
- by e-mail to the functional address brainheartlab@charite.de.
Organising team of the Cardio-Neuro Board
Prof Dr Jan Friedrich Scheitz
Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin
Prof Dr Carsten Skurk
Deutsches Herzzentrum der Charité (DHZC), Department of Cardiology, Angiology and Intensive Care Medicine, Benjamin Franklin Campus
