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Answers to 3 questions the heart doctor needs to know about neurologically ill patients
2ND ANNUAL PVHMC CARDIOVASCULAR
SYMPOSIUM14 MARCH 2020
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Conflicts of interest• Sometimes neurologists and cardiologists
seem like they have conflicts of interest with each other, regarding: – Blood pressure: aim low (cardiology) vs aim high
(neurology)– Anticoagulation: the more the better (cardiology)
vs less is more (neurology)– Doing something (cardiology) vs doing nothing
(neurology)
©2012 Pomona Valley Hospital Medical Center 2
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How high how low?BLOOD PRESSURE
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ACC/AHA BP guidelines• Normal< 120/80 mm Hg• Elevated: SBP 120-129 and DBP< 80 mm Hg;• Stage 1: SBP 130-139 or DBP 80-89;• Stage 2: SBP >/=140 or DBP>/=90 mm Hg;• Hypertensive crisis: SBP>180 and/or DBP>120• GOAL < 130/80 mm Hg
• But neurologists seem to always want high BP post stroke!!
©2012 Pomona Valley Hospital Medical Center 4
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ASA ischemic stroke guidelines
©2012 Pomona Valley Hospital Medical Center 5
“Blood pressure level that should be maintained in patients with AIS….is not known”“…no data…”
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Brain metabolic demand• Constant energy expenditure• Brain has poor capacity for anaerobic
metabolism, poor O2 storing capacity
©2012 Pomona Valley Hospital Medical Center 7
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Permissive hypertension and penumbra
©2012 Pomona Valley Hospital Medical Center 8
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Arterioles and autoregulation
©2012 Pomona Valley Hospital Medical Center 9
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PVHMC Stroke order sets
©2012 Pomona Valley Hospital Medical Center 11
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Ischemic Stroke Non TPA
©2012 Pomona Valley Hospital Medical Center 12
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Ischemic stroke pre/post TPA
©2012 Pomona Valley Hospital Medical Center 13
Pre TPA
Post TPA
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Ischemic stroke post thrombectomy
©2012 Pomona Valley Hospital Medical Center 14
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SAH unsecured protocol
©2012 Pomona Valley Hospital Medical Center 15
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SAH secured aneurysm and/or clinical vasospasm
©2012 Pomona Valley Hospital Medical Center 16
Vasoactive agents
Antihypertensive therapy
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Vasospasm after SAH• Develops 3-10 days following SAH• theories: OxyHb stimulates endothelin 1 • vasoconstrictor• inhibits the vasodilator nitric oxide
• Tx of SAH: nimodipine, L type Ca channel blocker
©2012 Pomona Valley Hospital Medical Center 17
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Case: 67 F, H/A x 3 days, SAH, lethargy
• Found to have L ICA aneurysm
• Hosp day 1, emboof L PCOM aneurysm
• VSP• Induced HTN
©2012 Pomona Valley Hospital Medical Center 18
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LEFT ICA ANGIOGRAM
©2012 Pomona Valley Hospital Medical Center 19
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Case, BP trends
©2012 Pomona Valley Hospital Medical Center 20
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Chest X ray hospital day 1 and 5
©2012 Pomona Valley Hospital Medical Center 21
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Neurogenic stunned myocardium and pulmonary edema
• Related to catecholamine surges• Globalized vs regional hypokinesis• Takotsubo cardiomyopathy
– Echocardiography in patient:– 12/27/19, EF 60-65%– 12/30/19, < 20%– 1/7/20, 40-45%, small pericardial effusion– 1/21/20, EF 60-65%, small ant, mod post peri. eff.
• Pulmonary edema: rapid changes on CXR
©2012 Pomona Valley Hospital Medical Center 22
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Case, BP trends
©2012 Pomona Valley Hospital Medical Center 23
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Cardiac output and cerebral perfusion• 15-20% CO directed to brain• 750 mL/min at rest• Cerebral perfusion pressure= mean arterial
pressure-intracranial pressure • CPP =MAP-ICP
©2012 Pomona Valley Hospital Medical Center 24
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SBP, MAP, CPP trends
©2012 Pomona Valley Hospital Medical Center 27
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SBP, ICP trends (fx of ICP modulation) day 6
©2012 Pomona Valley Hospital Medical Center 28
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CPP, CO, CI trends
©2012 Pomona Valley Hospital Medical Center 29
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CPP, CO, CI trends, day 8
©2012 Pomona Valley Hospital Medical Center 31
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Further course• extubated• Vasospasm improved• Echocardiography
– 12/27/19, EF 60-65%– 12/30/19, < 20%– 1/7/20, 40-45%, small pericardial effusion– 1/21/20, EF 60-65%, small ant, mod post peri. eff.
©2012 Pomona Valley Hospital Medical Center 32
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HTN and cerebrovascular remodeling• increase vascular resistance• Decreased lumen• Greater wall to lumen ratio• ?capillary pruning
©2012 Pomona Valley Hospital Medical Center 33
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©2012 Pomona Valley Hospital Medical Center 34
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SAMMPRIS trial secondary risk factor mgt• Stenting vs aggressive Medical Management
in Prevention of Recurrent Ischemic Stroke• Goal blood pressure < 140/90 mm Hg (<
130/80 if diabetic)
©2012 Pomona Valley Hospital Medical Center 35
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WHEN AND WHAT TO STARTBLOOD THINNERS
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Clinical Scenarios• Hemorrhagic stroke and cardiac history (CAD
or AFIB)– Unknown source, – Known source treated– Known source untreated
• Ischemic stroke and cardiac history as above– Recanalized– Non recanalized– Large stroke– Small or moderate sized stroke
©2012 Pomona Valley Hospital Medical Center 38
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76 year old woman, w/SAH
• 1 month prior, PCI for NSTEMI. Mid LAD DES
• Moderate stenosis of the distal left circumflex artery of 60 to 70%Chronic total occlusion of the right coronary artery
• On aspirin and ticagrelor
©2012 Pomona Valley Hospital Medical Center 39
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Unclear source of hemorrhage• Unable to initiate antiplatelets• Worsening renal failure, unable to do standard
protocol repeat catheter angio at SAH day 7-10
• Repeat MRA brain planned, if negative, may consider starting single antiplatelet therapy
• Ultimately may have initiated antiplatelets but she expired (renal failure and complications of that)
©2012 Pomona Valley Hospital Medical Center 40
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82 F, SAH, h/o AFIB, on warfarin
©2012 Pomona Valley Hospital Medical Center 41
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©2012 Pomona Valley Hospital Medical Center 42
Left vertebral artery
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Hospital course• L PICA aneurysm coiling hospital day 1• d/c on aspirin• In clinic 1 month post bleed, started on
warfarin
©2012 Pomona Valley Hospital Medical Center 43
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38 M, AFIB, intracranial R ICA occlusion• 3rd stroke
– 1 few years ago L MCA– 1 in December R MCA
• On warfarin->dabigatran->riveroxaban (current). Planned for LAA closure but last TEE showed thrombus
• Successful recan, no enlargement start aspirin immediately
• d/c on warfarin (hospday 2)
©2012 Pomona Valley Hospital Medical Center 44
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Other scenarios• Ischemic stroke, no AFIB, no hemorrhagic
conversion, small to moderate size: start antiplatelets soon
• Small/mod isch. stroke + AFIB: NOAC or warfarin-bridge w/aspirin, SQ UH or LMWH VTE proph. Dose)
• Ischemic stroke, + AFIB (or no AFIB), large stroke or hemorrhagic conversion, ? Wait 1-2 weeks for anticoag. Start antiplatelet sooner if feasible
©2012 Pomona Valley Hospital Medical Center 45
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Hypertensive ICH with cardiac hx or AFIB• 70 F, R BG ICH, AFIB
on riveroxiban• European stroke
initiative rec. starting AC 10-14 days post bleed
• CHADSVASC2 vs HASBLED score
• High TE risk, start early 2 wks, high ICH risk start late 4 weeks
©2012 Pomona Valley Hospital Medical Center 46
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Intracranial stent • Tx of symptomatic intracranial atherosclerotic
disease causing recurrent stroke despite maximal medical therapy
• Including with aneurysm, may need dual antiplatelet therapy for 6-12 months (single antiplatelet therapy indef.)
• Flow diverter for aneurysm, similar antiplatelet strategy
©2012 Pomona Valley Hospital Medical Center 47
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We’re right here, why can’t we open the vessel
Post cardiac cath stroke
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Post cath lab• Causes of stroke• Small plaque dislodgement causing small stroke• Ostial injury• Usually detected in the cath lab recovery area• TPA time window 3 hours, broad pool of patients,
4.5 hours up to 80 years/more selective criteria• Thrombectomy (for large vessel occlusion only,
not lacunar stroke) up to 24 hours
©2012 Pomona Valley Hospital Medical Center 49
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Management• TPA depends on any anticoagulation received
during procedure (if heparin given, need to document normal PTT, similarly with other anticoagulants)
• If anticoagulation given during procedure, may need to rule out intracranial hemorrhage with head CT
• Acute ICH may cause sudden confusion, agitation, increased BP (Cushing reaction)n
©2012 Pomona Valley Hospital Medical Center 50
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Causes of stroke during cardiac cath• Internal thoracic artery opposite vertebral
artery origin. May injure that• Vertebral artery is post circ. Supplies thalamus• Thalamic stroke can mimic hemispheric
syndrome so can be hard to differentiate post circ from ant circ
©2012 Pomona Valley Hospital Medical Center 51
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options• If ICH suspected, need brain parenchymal
imaging• 3D software• Lci protocol• Vascular imaging
©2012 Pomona Valley Hospital Medical Center 52
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LCI Protocol, fluoroscopy equipment
©2012 Pomona Valley Hospital Medical Center 53
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Conclusion• One patient, one physiological system• Optimize all organ systems for best
performance
©2012 Pomona Valley Hospital Medical Center 54