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Cardiac Magnetic Resonance for the Evaluation of Suspected Cardiac Thrombus: Conventional and Emerging Techniques
Published on: June 11, 2019
Stroke and Recent Myocardial Infarction, Reduced Left Ventricular Ejection Fraction, Left Ventricular Thrombus, and
Ana Catarina Fonseca1,2,3
1Stroke Unit, Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Avenida Professor Egas Moniz, 1640-035, Lisboa, Portugal. acfonseca@medicina.ulisboa.pt.
Purpose Of Review:
To review the evidence regarding stroke and recent myocardial infarction (MI), reduced left ventricular ejection fraction, left ventricular thrombus (LVT), and wall motion abnormalities (WMA).
Recent Findings:
The risk of ischemic stroke associated with acute MI has been greatly reduced with reperfusion treatments that improved myocardium salvage. Acute ischemic stroke is an uncommon complication of diagnostic coronary angiography and percutaneous coronary intervention. For established LVT, anticoagulation is superior to antiplatelet medications to reduce the risk of ischemic stroke. The duration of anticoagulation should be at least 3 to 6 months. Direct oral anticoagulants have been used off-label in this context. In patients with low ejection fraction or WMA, there is no evidence that anticoagulation is superior to antiplatelet treatment in preventing ischemic stroke. In patients with ischemic stroke and recent MI (< 3 months), type of MI (STEMI or NSTEMI), timing, and location should be considered when deciding whether intravenous thrombolysis should be used for stroke treatment. Mechanical thrombectomy should be considered as a therapeutic alternative to intravenous thrombolysis in patients with acute ischemic stroke due to large-vessel occlusion and recent MI. Most guidelines regarding prevention of ischemic stroke in patients with these cardiac causes of stroke are derived from expert opinion. There is a need for high quality evidence to support stroke prevention treatments in these patients.
Insights
For left ventricular thrombus, anticoagulation is recommended over antiplatelet therapy to prevent ischemic stroke. Evidence is lacking for anticoagulation benefits in patients with reduced ejection fraction or wall motion abnormalities.
Area of Science:
- Cardiology
- Neurology
- Vascular Medicine
Background:
- Myocardial infarction (MI) and associated cardiac conditions increase stroke risk.
- Reperfusion therapies have reduced stroke risk post-MI.
- Stroke remains a concern in specific cardiac patient populations.
Purpose of the Study:
- To review evidence on stroke prevention in patients with recent MI, reduced ejection fraction, left ventricular thrombus (LVT), and wall motion abnormalities (WMA).
- To evaluate current treatment strategies and identify evidence gaps.
Main Methods:
- Systematic review of existing literature.
- Analysis of studies on anticoagulation versus antiplatelet therapy for stroke prevention.
- Evaluation of stroke treatment options in the context of recent MI.
Main Results:
- Anticoagulation is superior to antiplatelet therapy for established LVT, with a recommended duration of 3-6 months.
- No evidence supports anticoagulation over antiplatelet therapy for stroke prevention in patients with low ejection fraction or WMA.
- Stroke treatment decisions (thrombolysis, thrombectomy) in recent MI patients require consideration of MI type, timing, and location.
Conclusions:
- Anticoagulation is the preferred strategy for stroke prevention in established LVT.
- Further high-quality research is needed to guide stroke prevention in patients with reduced ejection fraction or WMA post-MI.
- Current guidelines for stroke prevention in these cardiac conditions are largely based on expert opinion.
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