monitoring: what, when and how long? george ntaios university of thessaly, larissa, greece
TRANSCRIPT
Monitoring:
What, when and how long?
George Ntaios
University of Thessaly, Larissa, Greece
Disclosures
Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis.Honoraria: Medtronic; Quintiles; Boehringer-Ingelheim.Speaker fees: Sanofi; Boehringer-Ingelheim; Galenica; Bayer.Support for educational events: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Galenica; Elpen; Bristol Myers Squibb. Participation in trials:
– NAVIGATE-ESUS / National coordinator (Greece)– PRECIOUS / National coordinator (Greece).– ENOS / National coordinator (Greece).– BIOSIGNAL / Principal Investigator (Larissa).– EBBINGHAUS / Principal Investigator (Larissa).– FOURIER / Principal investigator (Larissa).– PREVISE / Principal investigator (Larissa).– GLORIA-AF / Sub-investigator (Larissa).
Stroke is an earthquake
San Francisco Bay Area, California, USA. August 24, 2014 10:20 AM
Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECG
Monitor for diagnostic reasons
Continuous ECG monitoring vs. Holter
Rizos. Stroke 2012; 43:2689-94
Rizos. Stroke 2012; 43:2689-94
Continuous monitoring vs. Holter
Sanna. N Engl J Med 2014;370:2478-86
CRYSTAL-AF
CRYSTAL-AF: the more you look, the more you find
Sanna. N Engl J Med 2014;370:2478-86
EMBRACE
Gladstone. N Engl J Med 2014;370:2467-77
EMBRACE : the more you look, the more you find
Gladstone. N Engl J Med 2014;370:2467-77
Monitor ECG – for how long?
Gladstone. Stroke 2015; 46:936-41
Atrial extrasystoles predict AF
Gladstone. Stroke 2015; 46:936-41
Atrial extrasystoles predict AF
Gladstone. Stroke 2015; 46:936-41
Atrial extrasystoles predict AF
Monitor ECG in lacunar strokes ?
Sacco. Neurology 2006; 66:1335-8
Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Monitor for diagnostic reasons
Microemboli monitoring
Microemboli monitoring
Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressure
Monitor Blood Pressure
Jorgensen. Cerebrovasc Dis 2002;13:204-9
Monitor Blood Pressure
Vemmos. Journ Intern Med 2004; 255: 257–265
Monitor Blood Pressure
Sandset. Lancet 2011; 377:741-50
Monitor Blood Pressure
Sandset. Lancet 2011; 377:741-50
Monitor Blood Pressure
Sandset. Lancet 2011; 377:741-50
Monitor Blood Pressure
ENOS. Lancet 2015; 385:617-28
Monitor Blood Pressure
ENOS. Lancet 2015; 385:617-28
ESO Guidelines
Cautious BP lowering is recommended in patients with extremely high BPs (>220/120mmHg) (Class IV, GCP)
It is recommended that BP of >185/110mmHg lowered before thrombolysis (Class IV, GCP)
ESO Guidelines. CVD 2008
Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucose
Monitor glycemia
Quinn. Cerebrovasc Dis 2009;27:148–155
Monitor glycemia
Previously diagnosed DM
Newlydiagnosed DM
Stress hyperglycemia
Fasting Glu ≥ 126Random Glu ≥ 200HbA1c ≥ 6.5%
Fasting Glu ≥ 126Random Glu ≥ 200HbA1c < 6.5%
Monitor glycemia
Ntaios, Michel. Stroke 2010; 41:2366-70
Monitor glycemia
Gray. Lancet Neurol 2007; 6: 397–406
Monitor glycemia
Gray. Lancet Neurol 2007; 6: 397–406
Insulin treatment – functional outcome
Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013
Insulin treatment - mortality
Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013
Insulin treatment - hypoglycemia
Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013
Monitor glycemia
https://clinicaltrials.gov/ct2/show/NCT01369069
AHA guidelines
Jausch. Stroke 2013
it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to
180 mg/dL and to closely monitor to prevent hypoglycemia in patients with acute
ischemic stroke
(Class IIa; Level of Evidence C).
Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucoseDysphagia
Monitor for dysphagia
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
Videofluoroscopy
Monitor for dysphagia
ESO guidelines
ESO Guidelines. CVD 2008
Swallowing assessment is recommended but there are
insufficient data to recommend a specific approach for
treatment (Class III, GCP)
Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucoseDysphagiaTemperature
Monitor temperature
Kakaletsis/Ntaios/Michel. Larissa 2015
Monitor temperature
Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucoseDysphagiaTemperatureOxygen
ESO guidelines
ESO Guidelines. CVD 2008
Intermittent monitoring of oxygen saturation is recommended
for 72 h in patients with significant persisting neurological
deficits (Class IV, GCP)
It is recommended that oxygen should be administered if the
oxygen saturation falls <95% (Class IV, GCP)
Monitor 02
Roffe. Nice 2014
Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucoseDysphagiaTemperatureOxygenLab tests (CRP, WBC…)Clinically
Monitor clinically
- Physical examination- Neurological status
- NIHSS- yawning- vomit- headache- GCS
Why monitor?
Monitor
Diagnostic reasons
Vital signs & complications
Response to treatment
ECGMicroemboli
Arterial pressureGlucoseDysphagiaTemperatureOxygenLab tests (CRP, WBC…)Clinically
Repeat imaging
Stroke unit works
Langhorne, Cochrane 2009; CD000197
One size does not fit all
Take-home messages
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