Teamwork Needed to Reduce Stroke and Its Consequences in Cardiac Surgery: AHA

Good communication and teamwork before, during, and after are keys to minimizing the risk of stroke in patients undergoing cardiac and thoracic aortic surgery, according to a new scientific statement from the American Heart Association (AHA).

“I would be the happiest person on earth if this document is useless because everybody already is doing all these things, but I suspect that this is not the case,” writing committee chair Mario Gaudino, MD (Weill Cornell Medicine, New York, NY), told TCTMD. “Stroke is a really devastating complication. We have a duty to try to do everything we can to reduce the risk of stroke for our patients and that means basically working as a team. There is no ‘I’ in team.”

Gaudino added that the statement is part of an effort by the AHA to streamline the available data and create a resource that is more useful to the everyday physician than lengthier documents of the past.

Stroke Strategies

Published online today in Circulation, the scientific statement reviews the incidence, diagnosis, and treatment of perioperative stroke. Among the recommended intraoperative measures for prevention are neuromonitoring, epiaortic scanning, maintaining a mean arterial pressure of 60-65 mm Hg during CABG, considering left atrial appendage ligation and/or ablation in patients with A-fib at the time of surgery, and use of anticoagulation when intracardiac thrombus is present.

Based on recent data, including several reports from the TRICS group, Gaudino and colleagues also suggest adhering to a recommended transfusion trigger of 7.5 to 8.0 g/dL for cardiac surgery patients, acknowledging that a lower transfusion threshold might be necessary in those at risk of perioperative ischemia.

“Importantly, there have also been a lot of new methods for intraoperative monitoring that allow the anesthesiologist to detect the possibility of a stroke early,” Gaudino noted. “You know, there is a saying that bad news needs to travel fast. It is really true for stroke, because there is a limited window where we can be very, very effective in treating [it].”

Postprocedure clinical evaluations should be considered an important early opportunity to observe stroke symptoms. The document advises a complete neurological examination, “with an emphasis on level of arousal, speech/language function, and motor findings. This type of evaluation, they add, should be performed routinely despite the lingering effects of anesthesia and other psychoactive medications.

Stroke is definitely an outcome that we need to improve as a cardiovascular community. Mario Gaudino

“If there is concern for new neurological deficits suggestive of stroke, a stroke code should be activated to ensure a rapid response team familiar with stroke care can facilitate immediate imaging and initiate urgent medical and endovascular interventions,” the document states.

This is where the multidisciplinary team becomes especially important, Gaudino said, and should consist of stroke neurologists, neurointerventionalists, neurocritical care specialists, and neuroanesthesiologists working alongside the surgical team.

Another important issue in all this is standardization of established protocols within a given hospital system, in order to ensure quick involvement of the acute stroke team and the earliest-possible interventions to minimize neurological injury and improve outcomes. Patients with suspected stroke should undergo a noncontrast CT of the head to rule out intracerebral hemorrhage and characterize signs of early ischemia. In addition, CT angiography should be included in the early imaging if large-vessel occlusion is suspected, and CT perfusion also can be performed to evaluate the cerebral vasculature.

Slowing Down to Improve Outcomes

For patients with a diagnosed stroke, the document recommends transfer to an intensive care setting, optimization of cerebral oxygenation and perfusion, consideration of thrombolysis and thrombectomy, and thorough examination for speech and swallowing problems, screening for depression, stroke rehab, and prophylaxis for deep vein thrombosis.

Finally, recommendations to prevent postoperative stroke include adequate pharmacologic prevention of A-fib. This is important, the document notes, because recent studies have shown that A-fib after cardiac surgery occurs in 27% to 40% of patients. Other considerations for prevention of post-op stroke are anticoagulation within 12 to 48 hours after surgery for those who do develop A-fib and following current recommendations for secondary prevention of CVD events after surgery.

To TCTMD, Gaudino said putting together this new statement is gratifying for clinicians like himself who now see so many new and promising avenues for preventing debilitating strokes that were not available when they first began their careers. Importantly, he said, it is also a call to slow down and take the necessary time to screen patients thoroughly.

“[W]e are all under so much pressure to do the cases and be productive. But we need to stop a second and make sure that we have checked all the boxes,” Guadino said. “Stroke is definitely an outcome that we need to improve as a cardiovascular community.”