ESC Congress 2017 In Review -- Main Edition - 29

ESC Congress 2017

Expert Opinion on Prevention of
Recurrent Stroke
Written by Phil Vinall

As part of the Prevention and Management of Acute
Stroke session on 29 August 2017, Lucas Boersma, MD,
PhD, St. Antonius Hospital, Nieuwegein, The Netherlands,
reviewed data from the general population EWOLUTION
Registry showing that the WATCHMAN left atrial appendage (LAA) closure procedure was associated with
higher success of implant and sealing with less procedural adverse events (AEs) than noted in prior large randomised studies.
EWOLUTION is a prospective, single-arm, multicentre registry of the WATCHMAN LAA closure technology comprising > 1,000 patients (39% with prior major
bleeding or predisposition; 73% contraindicated for oral
anticoagulation [OAC]). The mean CHAD2DS2-VASc score
was 4.5 (± 1.6); 40% of participants had a HAS-BLED
score ≥ 3. The primary analysis included procedural success and safety and the incidence of stroke, bleeding, and
death after 2 years [Boersma LV et al. Eur Heart J. 2016].
The interim data after 1-year show that 91% of patients
were still alive; implant success was 98.5% with a 99%
LAA seal rate. Most patients (83%) were on antiplatelet
therapy; the remainder were on either OAC or no anticoagulation (9%); device thrombus was noted in 3.7% of
patients. The annual rate of ischaemic stroke was 1.1%
(84% RR reduction vs a calculated stroke rate of 7.2%
without the use of anticoagulation for similar CHA2DS2VASc scores); the annual rate of postprocedural major
bleeding was 2.3% (RR reduction of 54% vs expected
rate based on HAS-BLED score) [Boersma LV et al. Heart
Rhythm. 2017]. Procedure- and/or device-related serious
AEs within the first 7 days occurred at a rate of 2.8%,
lower than in prior WATCHMAN trials (Figure 1).
Figure 1. 7-Day Procedure/Device Related SAEs: All WATCHMAN Studies
10.0%

8.7%

% of Patients

8.0%
Kaplan-Meier
SAE rate

6.0%
4.1%

4.0%

4.2%

2.8%

n = 12

n = 26

2.0%
n = 39

n = 23

0.0%
Protect AF

CAP

PREVAIL

EWOLUTION

Composite of vascular complications includes cardiac perforation, pericardial effusion
with tamponade, ischaemic stroke, device embolisation, and other vascular complications

SAE, serious adverse event.
Reprinted from Boersma LV et al, Implant success and safety of left atrial
appendage closure with the WATCHMAN device: peri-procedural outcomes
from the EWOLUTION registry. Eur Heart J. 2016;37(31):2465-2474. doi:10.1093/
eurheartj/ehv730. By permission of Oxford University Press on behalf of the
European Society of Cardiology.

In Review

WATCHMAN stroke prevention appears effective and
safe specifically given that 73% of patients were contraindicated for OACs [Boersma LV et al. Heart Rhythm.
2017]. Improvement in implantation techniques has led
to a reduction in the composite of vascular complications compared with previous studies. Nevertheless,
registries come with several important limitations; to
define the role of LAA occlusion randomised clinical
trial are indispensable.
Blerim Mujaj, MD, MSc, Department of Epidemiology,
Erasmus Medical Center, Rotterdam, The Netherlands,
presented the results of a study that examined the
association between oral antithrombotic treatment and
carotid plaque composition.
The study was based on data for 1,740 patients from
the Rotterdam Study with carotid plaque determined by
MRI. Intraplaque hemorrhage (IPH) was defined as the
presence of a hyperintense region in the atherosclerotic
plaque. Participants were classified as current, past, or
never antithrombotic users. Information on the use of
antithrombotic treatment (vitamin K antagonists [VKA]
and salicylates), including duration of use and dosage,
was obtained from pharmacy records for all participants. The average international normalised ratio (INR
for VKA) and daily defined dose (DDD for antiplatelet
agents) were tracked. The mean age of patients was
72.9 years, and 46% were women.
Current and past use of antithrombotic treatment
was associated with IPH in the carotid artery plaques.
Longer durations of use for VKA (> 3 months) and durations for use of antiplatelet agents (> 30 months) were
significantly associated with IPH. Among oral VKA users,
INR levels > 2.97 were significantly associated with presence of IPH, whereas among the antiplatelet users DDD
levels higher than 1.0 were significantly associated with
presence of IPH (P for trend ≤ .05). No association was
found with other plaque components such as lipid core
or calcification. In conclusion, the use of antithrombotic
treatment relates to a higher frequency of intraplaque
haemorrhage in carotid atherosclerotic plaques.
Hans-Christoph Diener, MD, Department of Neurology
and Stroke Center, University Hospital Essen, Essen,
Germany, discussed the options for antithrombotic therapy
in different subtypes of cerebrovascular ischaemic disease.
Aspirin monotherapy substantially reduces the risk of
early recurrent stroke after transient ischaemic attack
(TIA) and minor stroke if given early (within the first 12
weeks; Figure 2) [Rothwell PM et al. Lancet. 2016]. A single study in Chinese patients showed that the addition of
clopidogrel to aspirin in the first 90 days after a TIA or
mild stroke reduced the risk of recurrent stroke [Wang Y et
al. N Engl J Med. 2013]. This combination is being tested in
Caucasians in the currently recruiting POINT trial. Aspirin
plus ticagrelor was tested in the SOCRATES trial. There was
no significant reduction in the primary composite endpoint

Official Peer-Reviewed Highlights From ESC Congress 2017

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