Factor XI/XIa Inhibitor Therapies: Emerging Approaches to SSP Episode 2

Yeah, so it sounds like this question about etiology, for example, is atrial fibrillation present would actually be something that's really important to ascertain.

Absolutely, and I think anyone who manages patients who have cerebrovascular disease, especially in the setting of an ischemic stroke, you're always asking yourself, "Could this have been cardioembolic?" And a big piece of that is looking for atrial fibrillation.

So those patients are very commonly placed on telemetry to make sure there's no atrial fibrillation that's happening while they're in the hospital.

Many of them will go home on extended monitors.

I don't know, Mike, if you want to talk a little bit about what your practice is, how long you tend to screen for atrial fibrillation, but it's critical 'cause it changes your treatment path.

It absolutely does.

So, you know, there are a few things that won't change.

So if you see a patient with an ischemic stroke, you have to exclude surgically addressable clotted disease and atrial fibrillation.

So what we tend to do is monitor in hospital and out of hospital with an external monitor for about four weeks.

Patients where we're very suspicious, so the topography is embolic, they have an enlarged left atrium on echo, those are ones that we target for implanted monitors.

Now, practice varies across the world.

In the US, implanted monitors are very common.

One of the things that we know is that The finding of asymptomatic brief bursts of atrial fibrillation after stroke does increase the risk for recurrence.

We also now know that sometimes it happens only after the stroke, not having been there before, but it doesn't change the treatment recommendations.

You still have to look, and you should switch to anticoagulation in that setting.

So those patients will likely have their antiplatelets and other medications stopped and switched to a DOAC most usually.

We need to look for atrial fibrillation.

We need to think carefully about all of the antithrombotic strategies, but we can't forget the other parts of management, the lipid management, often with statins.

We need to think about hypertension management, smoking cessation, all the other important things for anyone who presents with cerebrovascular disease.

It's critically important, right? And, and if I was going to ask people to do one thing, it would be treat the blood pressure and then treat it again.

A reduction in blood pressure of 10 over six reduces recurrent stroke risk by 40%.

It is a very potent therapy, so do it.

It also decreases the risk of hemorrhage.

So for a multiplicity of reasons, you're absolutely right.

It needs to be in that basket of care, that whole patient approach to prevention.