Cardiovascular treatment and prevention of stroke: The problem of cross-disciplinary interaction

The incidence of stroke and mortality rate of patients who suffer from stroke varies widely between European countries.1,2 This may be explained by differences in cardiovascular care systems in these countries, but also by the specificity of data gathering. The importance of efficient cardiovascular disease prevention system in a cohort of patients with high risk of stroke and with stroke requires a coordinated set of multidisciplinary actions.3–5 This challenge necessitates long-term co-operation not only between cardiologists, but also with general practitioners, therapeutists, neurologists, stroke physicians, vascular surgeons and other specialists.6,7 A multidimensional treatment-and-care approach across different specialisms remains key to improving outcomes.8,9 This problem mandates a greater number of doctors and level of resource than cardiologists alone are able to provide in conventional medical practice. So, it is absolutely necessary to co-ordinate with other specialists both in outpatient and hospital settings. Cardiologists may offer greater expertise in cardiovascular care when compared with other specialists, potentially placing them in a strong position to coordinate efforts across multidisciplinary teams. In the recent report from the European Society of Cardiology (ESC) Cardiovascular Round Table the main aspects of cardiovascular care in patients after stroke and at high risk of stroke were analysed.6 The consensus between experts from the ESC and the European Stroke Organisation and other related scientific societies underlined the need for interdisciplinary action in both treatment and prevention of stroke. This publication paid special attention to cardiovascular care during hospital admissions and essentially completed recommendations developed in the previous position paper from the ESC Council on stroke.7 Based on this guidance it is possible to divide specific aspects of cardiovascular care at the hospital and outpatient stages into three main groups: patients with a high risk of stroke, peri acute stroke and after stroke. Which members of the multidisciplinary team should be assigned to each group for interventional and preventive activities in hospital or in the outpatient setting may also be defined (Table 1). Stages of cardiovascular care and multidisciplinary teams in prevention and treatment of stroke. A = outpatient setting; B = hospital setting. CV: cardiovascular. Stages of cardiovascular care and multidisciplinary teams in prevention and treatment of stroke. A = outpatient setting; B = hospital setting. CV: cardiovascular. The majority of fatal outcomes in patients after stroke occur after discharge from hospital, that is, during the follow-up period. Data from recent epidemiological trials and prospective registries of stroke patients reveal high mortality in this group at: 28 days – 13.2%;10 one year – 20–33%;11 2–3 years – overall 28–35%, and 43.2% in patients ≥75 years old;12–14 seven years – 58%.13 A high mortality rate during follow-up after stroke was seen in both men and women, across the socioeconomic spectrum.11,12 This ‘post hospital discharge from initial stroke’ stage represents a key area to focus efforts on lifelong prevention of recurrent stroke along with fatal and non-fatal cardiovascular events and is therefore no less important than ‘acute peri stroke’ in hospital care. General practitioners and therapeutists represent the largest group of health care professionals managing cardiovascular care for the ‘high risk primary prevention’ and ‘post hospital discharge’ populations in routine outpatient clinical practice. Improved collaboration between cardiologists and this large professional cohort is of paramount importance and, if effective, could significantly improve stroke prevention and decrease of mortality in patients with high risk of stroke and after stroke. The role of the stroke physician in the care of patients with acute stroke is central during the index hospital admission. However, the benefits of specially trained neurologists should not be underestimated.6,7,15 In addition, highly qualified therapeutists and internal medicine specialists in co-operation with cardiologists may also offer a valuable contribution to the care of these patients within the multidisciplinary group. Less clear in the in- and outpatient setting is the role of stroke physicians in the treatment of patients with cardiovascular diseases at high risk of (but without previous) stroke. The hospitalization of patients without acute stroke but with cardiovascular diseases and worsening of symptoms presents an important opportunity for intervention to optimize both primary and secondary prevention of stroke by different specialists of a multidisciplinary team and should not be missed. It is not realistic to analyse in detail all aspects of this multi-faceted problem with the consensuses of experts or clinical guidelines. So, it is reasonable to define some additional important questions for further discussion between experts that may be useful for future consensus documents. These include: Cross-disciplinary interaction and outcomes in patients with history of stroke during long-term follow-up. The order of cooperation between cardiologists and therapeutists, general practitioners and other specialists in the outpatient setting. The continuity of cardiovascular care between hospital and outpatient settings in patients at risk for stroke and after stroke. Interdisciplinary cooperation and risk of first-ever and recurrent stroke in patients with cardiovascular and non-cardiovascular multimorbidity. Multimorbidity is typical for the majority of patients with cardiovascular diseases and is pronounced in patients after stroke.16,17 Some recent studies have revealed that in more than 50% of stroke cases, at least four chronic comorbid diseases were diagnosed.14,18,19 Organization of the multidisciplinary team to target individual-specific cardiovascular care can dramatically improve the risk profile and outcome in this cohort of patients. Other important results from this cross-disciplinary cooperation may be realized as the evidence base improves and strengthens future consensus documents for the wider medical audience. The author(s) declared no potential conflicts of interest with respect to research, authorship and/or publication of this article. The author(s) received no financial support for the research, authorship and/or publication of this article.