Heart-Brain program offers ‘closed-loop’ continuum of care to patients with PFO-associated stroke

Patients who have strokes that might be related to a hole in the heart that didn’t close properly now have a place to go to see both a neurologist and cardiologist: the Heart-Brain Program at The University of Texas Health Science Center at Houston (UTHealth Houston).

The program is led by Abhijeet Dhoble, MD, associate professor of cardiovascular medicine and director of structural heart interventions at McGovern Medical School at UTHealth Houston, and Anjail Z. Sharrief, MD, MPH, associate professor of neurology with the medical school and director of stroke prevention at UTHealth Houston Institute of Stroke and Cerebrovascular Disease.

Formed in 2018 by Dhoble and Nicole R. Gonzales, MD, former professor of neurology at UTHealth Houston, the program provides multidisciplinary care for patients with strokes that are potentially associated with a patent foramen ovale (PFO) – a hole in the heart that didn’t close the way it should after birth, leaving a small flaplike opening between the right and left upper chambers of the heart. That small opening can allow a blood clot to travel to the brain and cause a stroke.

“Patients prefer to be seen in a multidisciplinary fashion – they like a one-stop shop,” Dhoble said. “Rather than giving them competing messages, when we see them, we have a targeted plan for them.”

Before the Heart-Brain Program, patients with PFO-associated ischemic stroke were referred for PFO closure in one of two ways. They were either referred to the UTHealth Houston stroke team for stroke evaluation and subsequently referred to the cardiology clinic for additional PFO evaluation, or they were directly referred to the cardiology clinic for PFO closure by a community physician, without any direct neurology consultation.

“The first point of contact for most of these patients – who tend to be younger – is the hospital emergency room rather than a primary care provider or cardiologist. So, historically, these patients were going home and being asked to follow up with a cardiologist or primary care physician,” Dhoble said. “They were overwhelmed with information. Some were not following up with a physician and were suffering a second stroke.”

This created the need for a “closed-loop” system, Dhoble said, in which patients at Memorial Hermann-Texas Medical Center and other hospitals in the Houston area are directed to a single clinical setting in an effort to expedite the appropriate workup and improve shared decision-making about PFO closure among neurologists, cardiologists, and patients.

Thanks to the coordination between McGovern Medical School’s Department of Neurology and Division of Cardiovascular Medicine, both teams continue to work together three years later, seeing patients at UT Physicians, the clinical practice of McGovern Medical School, on the second Friday of each month. Appointments have been held virtually since the pandemic began.

The clinical team includes an interventional cardiologist, a stroke neurologist, neurology and cardiology fellows, advanced practice providers, and research coordinators.

“There are less than a handful of these kinds of programs in the U.S.,” Sharrief said. “Whether in person or virtual, the most important thing we offer is combined expertise, making sure our patients know the latest on stroke prevention and management as the guidelines continue to change.”

An internal study, which compared outcomes in patients sent to the Heart-Brain Program versus patients undergoing routine care from February 2017 to July 2020, found that the Heart-Brain group required fewer clinic visits from stroke to closure decision. According to Sharrief and Dhoble, less visits reduce costs, save time, and improve overall quality of care for patients.

While additional work is needed to determine whether this approach improves other aspects of care and outcomes, Sharrief and Dhoble believe their preliminary findings demonstrate that a multidisciplinary, patient-centered approach to the care of patients with PFO-associated ischemic stroke is the way of the future.

“The American Heart Association and others are already supportive of the idea of developing this kind of program which promotes multidisciplinary collaboration and shared-decision making for these patients,” Sharrief said. “We’re living in the future right now, here.”

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