Clinical management of many disorders of the heart and brain cannot be viewed in isolation. Cardiac issues frequently factor into the care of neurological patients, and neurological considerations are critical in the treatment of several types of heart disease. The heart cannot be ignored by the neurologist, and the cerebral consequences of cardiac disease must be considered by the cardiologist. The importance of heart-brain and brain-heart relationships is supported by a growing clinical and experimental literature. These interactions are significant and common in clinical practice. A closer collaboration between neurologists and cardiologists/electrophysiologists can help to improve the care of patients suffering from strokes caused by unknown factors. If you have had a stroke, you will almost certainly be seen by a neurologist and a cardiologist as part of your healthcare team. Both of these are specialists who have received extensive training in their respective fields. By housing both of these specialists in the same office space, their ability to effectively treat patients becomes significantly stronger. Practice Nomad can assist these two specialists in finding a shared space to practice.
Diagnosis
Several pathogenetic mechanisms link brain infarction and heart disease. Coronary artery disease, which is frequently asymptomatic, is common in patients suffering from transient ischemic attacks. The majority of patients who have transient ischemic attacks will die from a myocardial infarction. Even when severe, asymptomatic carotid artery stenosis is a better predictor of fatal myocardial infarction than an ipsilateral stroke. Stroke in the setting of a patent foramen ovale (PFO) is one of the few diseases in which stroke neurologists and cardiologists work closely together.
Functional assessment
Clearly, an aggressive surgical approach to both symptomatic and asymptomatic carotid artery atherosclerosis must be balanced against the possibility of life-threatening coronary artery disease. In these and many other clinical situations, optimal care necessitates recognition of heart-brain interactions. Cardiologists and neurologists must continue to collaborate to improve their understanding of these interactions, particularly their mechanisms and management. Neurocardiology, also known as cardioneurology, has matured. The single most important variable in the effective and safe delivery of PFO treatment is patient selection. Collaboration with neurologists, particularly stroke neurologists, is an important first step in patient selection. Prior to any PFO closure, a formal neurological consultation is required. In fact, no patient with a PFO and a stroke should have their PFO closed without first consulting with a stroke neurologist.
Principles of treatment
A thorough investigation into the possible causes of stroke should be conducted. A battery of tests, including a transthoracic echocardiogram with a bubble study to rule out a right-to left shunt, a heart rhythm monitor for at least 30 days to rule out atrial fibrillation, a hypercoagulable work up, bilateral carotid ultrasound, and Doppler ultrasound to rule out lower extremity venous thrombosis, should be initiated by either the stroke neurologist or cardiologist. The heart team concept should be adopted by interventional cardiologists and stroke neurologists. In medicine, close collaboration between two different specialties in treating patients is not a novel concept. In order to offer the procedure to those who will benefit the most, a strong PFO program must have a very rigorous selection process. In PFO patients, some institutions have already implemented a heart-brain team approach. A "PFO clinic" could use the tried-and-true concept of a valve clinic for TAVR (Transcatheter aortic valve replacement) patients. A heart-brain team includes stroke neurologists, general cardiologists, interventional cardiologists, interventional neurologists, electrophysiologists, hematologists, nurse practitioners, and social workers, among others. Bringing together expertise in all fields in the same clinical setting allows complex clinical issues in PFO closure to be addressed in the most efficient and shortest amount of time for patients and their families.