Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting the Heart Brain Clinic at UAB Medicine. Joining me in this panel is Dr. Ekaterina Bakradze, she's a stroke neurologist and an assistant professor; and Dr. Mustafa Ahmed, he's the Director in interventional and Structural Heart, an associate professor and the Section Chief in Interventional Cardiology, and they're both with UAB Medicine. Doctors, thank you so much for joining us today. Dr. Ahmed, I'd like to start with you. Please tell us a little bit about the UAB Heart Brain Clinic. What is it and why did you see a need?

Dr. Mustafa Ahmed: In many conditions that cardiologists would see patients for and also neurologists would see patients for, there's this overlap where decisions made by either team without seeking the expertise of the other team, almost limit the opinion given. But also, there's no doubt now that when you take neurologists and cardiologists and approach problems as a team, for example, strokes that may be caused by heart issues or other such things, but if you get everyone together in the same place with the same patient, you get to share opinions in this joint decision-making where you share your expertise.

And what often happened in the past was patients sent for an evaluation for certain cardiac procedures would be seen by neurologist in one hospital. They may never see a neurologist. They may just be sent by cardiologist to another one, and decisions would be made without all the expertise available because these things are very hard to get together and everyone on the same page. So, what we said is, you know, we have world-class expertise from Dr. Bakradze and her teams over here at UAB for Neurology and we have, in Structural Heart Disease and Interventional cardiology, world class teams also. We wanted to combine the expertise of both teams, put them in the same place so they could share that expertise, which almost exponentially increases the power of an opinion and really benefit-- you know, the whole thing is how do we get our patients the single best care possible? That's by creating this joint entity called a Heart Brain Clinic, where stroke neurologists, interventional and structural cardiologists, imaging cardiologists, radiologists, hematologists, all of the above can get together, share their expertise, and give the single best opinion possible to patients in complex decision-making and complex diseases.

Melanie Cole, MS: Thank you so much, Dr. Ahmed. So Dr. Bakradze, tell us about the services you offer for evaluation and management of patients who've had a stroke or transient ischemic attack that could be attributable to cardiac etiology.

Dr. Ekaterina Bakradze: As Dr. Ahmed just eloquently described our heart brain clinic, we really ensure that patients who had stroke or transient ischemic attack that is attributed to the cardiac etiology and particularly to a patent foramen ovale or so-called PFO get timely evaluation by two experts in stroke and interventional cardiology.

PFO is a very interesting structure in the heart. And it is very common in general population. Twenty-five percent of the general population has PFO. And in most of us, it does not cause any problem, but it can be in rare circumstance linked to a cause of the stroke. So, our job is to really identify those patients by extensive evaluation, ones that had stroke due to PFO and then ones that may benefit from PFO closure for stroke prevention. And that is a pretty vigorous process. We have to ensure that patients had thorough evaluation to exclude other causes, other more common causes of stroke, and really ensure that the given stroke is related to PFO and then identify patients that may benefit from PFO closure.

So, we get referrals in Heart Brain Clinic from within the UAB from stroke or cardiology team, but also from different subspecialists. But we also get really large number of referrals from outside UAB across the state. You would be surprised at times patients come from Florida and neighborhood states. So, we really pretty much cover the entire state as well. And we ensure that patients are seen timely. We have appropriate records on time to be able review what was already done. We ensure that if something is missing in the workup, we make sure that the workup is complete and then really decide on the same day and review everything and talk to each other, and decide whose stroke or TIA was related to PFO and who is the best candidate for PFO closure.

Melanie Cole, MS: Dr. Ahmed, I'd like you to expand on what Dr. Bakradze was just discussing on this same-day evaluation, how these joint recommendations on management are made and further evaluation and to educate patients and facilities.

Dr. Mustafa Ahmed: I'm going to give you some examples where such a clinic is so critical in providing the best care for patients. You know, the best term to use is excellence. And excellence means you are practicing at the very highest levels, leaving no stone unturned.

So, let me start with a very strong statement, which is, I can't think of many-- and I'm telling you this as a cardiologist that deals with heart attacks-- I don't mind dealing with heart attacks. When someone comes in with one, you can fix that thing. If you get there in time, it's fine. When it comes to stroke and you have a stroke, it's scary. The consequences of a stroke is potential lifelong disability. And many of the patients that come to us in this heart brain clinic are sent to us and they have experienced these neurologic problems, which may be a stroke or may be a mini-stroke. And fortunately, many people come with a lot of function. But many of the people, if this happens again, they may suffer such debilitating consequences that I can't stress enough that everyone needs to do whatever they can to prevent that happening again.

And when a patient is sent over with A PFO, we want to know, "Okay, should we close it?" Let's just say there's a PFO and let's imagine that we saw the stroke neurologist and it doesn't matter what hospital they're in. A good stroke neurologist says, "Hey, this PFO needs closing, and we think that's the cause." And they get sent to us and we say, "Okay, let's close it." That's fine. But what about the overall care? Because, you know, amongst patients that get sent for PFO closure, I would estimate only 50% actually need it. And then, you would send the patient back and they would get on with their life. But that leaves us with a huge problem with why did that happen in the first place? What was the cause? Was the evaluation done in the first place thorough enough? Not just saying that doesn't need to be closed is not enough.

What happens in a heart brain clinic in terms of decision-making is patient comes along. You have the stroke neurology team and all of his expertise here reviewing the scan. I can remember cases where the scans reviewed was thought to be a stroke was not a stroke or other findings were found such as neurologic conditions, other vasculitic conditions or vascular conditions within the heart and brain where the stroke neurologist has picked that up, looked at the pattern on the scan and said, "Hold on a second. I don't think this is a PFO. It doesn't need closing. But I think it may be this, this, this, and this. These are the next five tests I would recommend," and it goes on. So, it really is a comprehensive opinion. It's not just people coming and saying like would normally be done for an interventional cardiologist, where someone would send someone along and say, "Close this hole." And even if you're particularly good at your job and you pride yourself on appropriateness and you are very good at picking out the patients that doesn't need to be done, that still leaves a huge problem. Why did this happen? What do we need to do next? And when you get a clinic like this and get everyone together, you change management for these patients. Not just the patients needing a procedure, but lifelong medication management.

And I'll take this one little step further. We have been collecting data on this for a couple of years now. And I'll let Dr. Bakradze kind of talk about this more. But the expertise of our stroke neurology team has resulted in most patients that turn up and are sent even for simple closure of a PFO that doesn't need doing, most patients end up with serious significant changes in their management, many patients end up finding alternative causes. And I would argue because of that approach, many future strokes are prevented. And I let Dr. Bakradze give her kind of viewpoint on that.

Dr. Ekaterina Bakradze: And I completely second what you just said. We do not just focus on the simple answer whether PFO contributed to stroke and whether we need to close it or not, but we approach patients with our expertise and really just manage stroke or any cardiac need they may have. As Dr. Ahmed just said, we've been collecting data and we can say that roughly a little bit less than 50% of our referrals actually undergo PFO closure. Half of the patients that get referred either did not have a stroke or TIA and the etiology of their symptoms is something different or their stroke was related to something else.

So then, we take thorough history, look at all the testing, require farther testing to be done. And we say, "This was a migraine and you did not have a stroke, or this was something else" or, you know, "When I looked at your blood vessel pictures, we found that you have narrowing in the major blood vessels or you have a different heart disease." And a lot of time, it leads to management, whether it is change in their blood thinners or more tight control of their cholesterol numbers. And most of our patients that we've seen in the Heart Brain Clinic had change in management. If we do not close PFO again, we do medical management. And a majority of these patients actually then I follow in stroke clinic, they may not need to come back in the Heart Brain Clinic because the PFO question is answered. However, they still need a stroke neurologist to follow. Again, this is a multidisciplinary approach to a complicated medical problem.

Melanie Cole, MS: Well, Dr. Bakradze, sticking with you for just a minute. As you just mentioned that multidisciplinary approach, and that's been the running theme of this podcast today, and you two here represent two specialties, I'd like you to tell other physicians about early referral. When is it important that they refer to the Heart Brain Clinic?

Dr. Ekaterina Bakradze: It is really important to get as early referral as possible, right? When patients have completed stroke workup during their inpatient stay when they're in a hospital with a stroke and now it's a time to set up the outpatient evaluation, this is the time to refer the patients to us. The reason we're looking into stroke etiology at the first place and trying to identify the cause of the stroke and manage patients appropriately is to prevent another stroke. And we know that the risk of having another stroke is soon after the first stroke. So, we want to see the patients as early as possible after their first event, whether it's stroke or TIA, to ensure that we complete workup, we find the stroke etiology, and then manage patients appropriately.

Unfortunately, that doesn't always happen. We get sometimes patients referred years later from their events, or sometimes patients move, they change provider and they have a new doctor now, whether it's primary care doctor or cardiologist who tells them, "Well, you had a stroke two years ago and you also have a PFO so you know what? Your stroke might have been from PFO. So, why don't I send you to Heart Brain Clinic?" And that's great. We still encourage that. We want providers to send patients to us at any moment if they think that the heart brain evaluation is needed. But we strongly encourage referrals early on, immediately after your index event when you're setting up the outpatient referrals.

Melanie Cole, MS: Dr. Ahmed, last word to you. You've been on with us before, and I'd like you to speak a little bit about the clinic, some final thoughts about the conditions under which you believe patients would benefit most from the experience and this multidisciplinary approach at the Heart Brain Clinic at UAB Medicine.

Dr. Mustafa Ahmed: We've talked about PFO today. We've concentrated on that because that's, you know, a classic condition people would be sent for. There's other things, you know, complex strokes in the setting of some carotid disease, sometimes with our electrophysiologist and interventionalists with atrial fibrillation and strokes related to that and whether they come. But the classic is the stroke that has occurred in someone which may be associated with the hole in the heart.

And the final points, you know, I'd like to make on this are whenever you have a hole in the heart, closing it, and I can tell you this, I don't think it's difficult, particularly if you do a lot of it and you're experienced at it. But what is common and unfortunate is many of these things are closed when they don't need to be closed. And then, people think that the hole was closed and so they're protected against stroke and then they end up actually having another etiology. And it's for that reason that I personally in my practice, and people in our section that deal with this, our practices, we do not close PFOs in the setting of cryptogenic stroke unless they are evaluated by the Heart Brain Clinic. And that's how strongly we believe in this because we've just seen the good that it can do.

The time for referral for this is, you know, again, in my opinion, anyone considering even having a PFO closed should be evaluated in a good multidisciplinary setting, experienced heart brain clinic. And ideally, people would come or be referred after they've immediately had an event in a hospital or had a stroke. And, you know, that's when you can really catch someone and say, "Okay, we're going to get you really early follow up in Heart Brain Clinic." Sometimes patients go back to their. Primary care physicians and they've been discharged after a stroke, and they go and follow up with them a few weeks later. That also is a wonderful time to say, "Okay, you've had this stroke. Someone told you it may be a PFO. Let's go ahead and send you to a heart brain clinic to get evaluated" or people that have had multiple strokes, etiology unknown, relatively young, no other obvious causes, maybe they would get sent to a heart brain clinic for evaluation to see if there's a PFO or to see if that happens. And the gatekeepers typically are the stroke neurologists or the neurologists in-hospital and then often the cardiologists that are asked to evaluate them for potential, you know, shunts or intracardiac sources. But then after that, they can be the primary care doctors where the patients follow up. And then after that, it could be other practitioners, or it could be the patients themselves that maybe it falls through the cracks and then they resonate with what they're kind of hearing today and say, "Okay, this sounds very familiar. I was told I may have a hole in the heart and it mainly closing," go and get evaluated for that.

So, it really spans the entire spectrum from initial emergency provider to patient. And the earlier the referral, obviously the better. But even a bit later, we've had people where they've had an event a couple years later, they have another event, then they're sent and they end up there. So, many different avenues to get there, but an important term to look up for people that want this is, you know, if you've been told you have something called a cryptogenic stroke, which means, "Hey, we've ruled out all the obvious stuff and we don't know why that happened," that's the typical kind of patient I would say, regardless of timing or whenever that is be seen in the heart brain clinic, they can reach out.

And there's another important thing, which is if someone is sent for a referral, we see many patients from 4, 6, 8, 10, 12 hours away, sometimes that fly in, we would say to them, you know, "We can get the records and look through it. And if we feel that we would be beneficial, great." If we feel that it would not be beneficial, we would just say, you know, "We don't really think you need this evaluation. It can save you a trip." So, that's a possibility also.

Melanie Cole, MS: Thank you both so much for joining us today and telling us about the Heart Brain Clinic at UAB Medicine. For more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.