Preventing Strokes One at a Time

Acute Interventions and Management

2009

Acute Interventions & Management

Upon completion, participants will be able to: State the goal of managing patients with

medications following a transient ischemic attack (TIA) or minor stroke

Teach patients about their medications and the importance of medication adherence

Practice according to the Canadian Best Practice Recommendations for Stroke Care as they relate to interventional & medication management

Learning Objectives

Implement Interventions

3.2. Acute management of TIA and minor stroke Patients who present with symptoms

suggestive of minor stroke or TIA must undergo a comprehensive evaluation to confirm the diagnosis and begin treatment to reduce the risk of major stroke as soon as it is appropriate to the clinical situation.

Canadian Best Practice Recommendations for Stroke Care, 2008

CMAJ 2008;179(12 Suppl):E1-E93 #3.2

Implement Interventions

Medication Management Antihypertensives

ACEI (Angiotensin Converting enzyme)

ARB (Angiotensin Receptor Blocker)

Diuretics Calcium Channel Blockers

Lipid lowering agents Statins

Antithrombotic Antiplatelet Anticoagulant (Atrial

fibrillation) Optimize diabetes management

Interventional Procedures

Carotid Stenosis Carotid

Endarterectomy Carotid Artery

Stenting

Medication Management

Medication Management

Goals of managing patients with medications following a TIA or minor stroke: Minimize plaque formation Stabilize existing plaque Lowering risk of emboli in appropriate

individuals

Medications include: Antihypertensive Statin Antithrombotic

Blood Pressure & Antihypertensives

Blood Pressure

Hypertension is the most significant modifiable risk factor for stroke

Hypertension contributes up to 75% of all strokes

Injury to the blood vessel walls↓

Scar is formed↓

Build-up of plaque in arteries ↓

• Atherosclerosis• Fragile arteries

• Left Ventricle dysfunction

Blood Pressure

2.2 Blood Pressure Assessment All persons at risk for stroke should have their blood

pressure measured at each healthcare encounter but no less than once annually.

Proper standardized techniques, as described by the Canadian Hypertension Education Program, should be followed for blood pressure measurement

Patients found to have elevated blood pressure should undergo thorough assessment for the diagnosis of hypertension following the current guidelines of the Canadian Hypertension Education Program.

Patients with hypertension or at risk for hypertension should be advised on lifestyle modifications.

CMAJ 2008;179(12 Suppl):E1-E93.

Canadian Best Practice Recommendations for Stroke Care, 2008

Blood Pressure

2.2 Blood Pressure Management The Canadian Stroke Strategy recommends target

blood pressure levels as defined by CHEP guidelines for prevention of first stroke, recurrent stroke and other vascular events.

RCTs have not defined the optimal time to initiate blood pressure lowering therapy after stroke/TIA. It is recommended that blood pressure lowering treatment be initiated (or modified) prior to discharge from hospital. For patients with non-disabling stroke or TIA not requiring hospitalization, it is recommended that blood pressure lowering treatment be initiated (or modified) at the time of first medical assessment.

CMAJ 2008;179(12 Suppl):E1-E93.

Canadian Best Practice Recommendations for Stroke Care, 2008

Blood Pressure

Blood pressure is to be assessed at all appropriate visits

Encourage patients to use appropriate devices and proper techniques for home BP measuring

Home measurement aids blood pressure control Helps to diagnose white coat and masked

hypertension Improves medication adherence Aids in faster diagnosis

2009 Canadian Hypertension Education Program Recommendations

Assessment Highlights (CHEP, 2009)

Blood Pressure

Management Highlights, (CHEP, 2009) Treat to target

<140/90 mmHg <130/80 mmHg (diabetes or chronic kidney

disease) Age should not be a consideration in treatment Sustained lifestyle modification to manage overall

cardiovascular risk Self efficacy and engagement are key to adherence Treat hypertension with multiple antihypertensives Reduce dietary sodium www.hypertension.ca/bpc

2009 Canadian Hypertension Education Program Recommendations

Blood Pressure

Treatment in TIA/Previous stroke (CHEP, 2009) Initial therapy:

Treatment with combination of ACEI & diuretic preferred

Choice of agent will depend on comorbiditieso Other choices: ARB, Calcium Channel Blocker, Beta

Blockers Second–line therapy:

Combinations of additional agents Notes/Cautions:

Recommendations do not apply to acute stroke BP reduction reduces CV events in stable patients Combination of an ACEI & ARB is not recommended2009 Canadian Hypertension Education Program

Recommendations

Blood Pressure

Patient Education: Angiotensin Converting Enzyme Inhibitor Take same time every day Contraindicated in patients with renal stenosis May increase creatinine, urea and potassium May have a persistent, dry cough Can cause angioedema (1/500) Other S/E:

Dizziness, feeling faint Swelling of feet Diarrhea Taste disturbance HA

Blood Pressure

Patient Education: Angiotensin II Receptor Blockers

Well tolerated Contraindicated in patients with renal

stenosis May increase creatinine, urea and

potassium

LIPIDS & STATINS

“High cholesterol and lipids in the blood are associated with a higher

risk of both stroke and heart attack.”

CMAJ 2008;179(12 Suppl):E1-E93 #2.3.

Lipids

What is a “lipid profile” Made up of cholesterol and

triglycerideso LDL: “bad” cholesterol o HDL: good cholesterolo Triglycerides: “bad”

Impacted by gender, age, genetics, lifestyle and eating habits

Lipids

Fasting lipid levels (TC,TG,LDL-C,HDL-C) should be measured every 1-3 years for all men 40 years or older and post menopausal women and/or 50 years or older.

More frequent testing should be done for patients with abnormal values or if treatment is initiated.

Adults at any age should have their blood lipid levels measured if they have a history of diabetes, smoking, hypertension, obesity, ischemic heart disease, renal vascular disease, peripheral vascular disease, ischemic stroke, TIA or symptomatic carotid stenosis.

Canadian Best Practice Recommendations for Stroke Care, 2008

CMAJ 2008;179(12 Suppl):E1-E93 #2.3a

2.3a Lipid Assessment

Lipids

Canadian Best Practice Recommendations for Stroke Care

2.3b. Lipid Management Ischemic stroke patients with LDL-C of

>2mmol/L should be managed with lifestyle modification and dietary guidelines.

Statin agents should be prescribed for most patients who have had an ischemic stroke or TIA to achieve current recommended lipid levels.

CMAJ 2008;179(12 Suppl):E1-E93.

Lipids

Statins First line agents for dyslipidemia Reduce stroke risk by 25-30% Target LDL-C< 2.0 mmol/L Decrease progression and/or induce

regression of carotid artery plaque Treatment based on assessment of

absolute risk of CVD not just LDL value

Heart Protection Study

Lipids

How do statins prevent ischemic stroke? Lipid effects

LDL lowering Non-Lipid effects

Stabilizing plaques Improving endothelial function Decreasing inflammation Decreasing platelet aggregation Directly lowering blood pressure Decreasing cardiac emboli

Lipids

Statins: Patient Education Points Take once a day with largest meal in evening May be prescribed when cholesterol levels are

normal Blood work required for follow-up May interact with antidepressants, antibiotics &

immunosuppressants Avoid grapefruit juice Possible side effects:

Mild nausea, diarrhea, constipation Some muscle pain/weakness is normal (2-10%) Extreme muscle pain/weakness (serious but rare)

Antithrombotics

AntiplateletsAnticoagulants

2.5 Antiplatelet TherapyCanadian Best Practice Recommendations for Stroke Care, 2008

All patients with ischemic stroke or transient ischemic attack should be prescribed antiplatelet therapy for secondary prevention of recurrent stroke unless there is an indication for anticoagulation. ASA, combined ASA (25 mg) and extended-release

dipyridamole (200mg) or Clopidogrel may be used depending on the clinical circumstances.

CMAJ 2008;179(12 Suppl):E1-E93 #2.5

2.5 Antiplatelet Therapy continued For adult patients on ASA, the usual

maintenance dosage is 80-325 mg/day and in children with stroke the usual maintenance dosage of ASA is 3-5 mg/kg/day for the prevention of recurrent stroke

Long term combination of ASA & Clopidogrel are not recommended for secondary stroke prevention

Canadian Best Practice Recommendations for Stroke Care, 2008

CMAJ 2008;179(12 Suppl):E1-E93 #2.5

Aspirin: Patient Education Points Take one pill, once a day, everyday More is not better Most common side effects include

GI upset (take with meals, use EC-ASA) bruise easier bleed longer

Consult a doctor immediately if you have unusual or excessive bleeding

Aggrenox: Patient Education Do not chew or crush 1/5 people will have a headache in first 5 days Always have a “plan B”

If by the 5th day HA is intolerable, call the physician and resume ASA

Other side effects: GI upset (take with food or water) Bleeding

Clopidogrel: Patient Education Take once a day, every day Best to take with meals Side effects:

Usually mild & improve on their own GI upset Bleeding Skin rash

2.6 Antithrombotic therapy in atrial fibrillation

“Patients with stroke and atrial fibrillation should be treated with warfarin at a target INR of 2.5, range 2.0-3.0 (target INR of 3.0 for mechanical cardiac valves, range 2.5-3.5) if they are likely to be compliant with the required monitoring and are not at high risk for bleeding complications.”

CMAJ 2008;179(12 Suppl):E1-E93 #2.6

Canadian Best Practice Recommendations for Stroke Care, 2008

Antithrombotic therapy in atrial fibrillation

Patients with atrial fibrillation properly anticoagulated = 68% RRR in recurrent strokeCochrane, 2003

Optimal time to begin anticoagulation varies but should be prior to discharge

Warfarin: Patient Education Points

Doses of warfarin vary based on INR INR testing

Initially every few days Repeat 5-7 days after changing the dose of any drug

Take same time every day Patient compliance essential to therapeutic levels Avoid contact sports; report falls/unusual

bleeding Avoid drastic changes in diet/eating habits

Keep dietary vitamin K consistent in diet Alcohol may affect action of warfarin

Adherence

Those who self administer their medications typically take less than ½ of the prescribed doses

Complex issue affected by patient factors, physician based factors and health care factors

Implement Interventional Procedures

Options for the TIA patient with carotid stenosis Carotid Endarterectomy Carotid Stenting

2.7a Symptomatic Carotid Stenosis

Patients with transient ischemic attack or nondisabling stroke and ipsilateral 70-99% internal carotid artery stenosis (measured on a catheter angiogram or by 2 concordant non invasive imaging modalities) should be offered carotid endarterectomy within 2 weeks of the incident TIA or stroke unless contraindicated.

Canadian Best Practice Recommendations for Stroke Care, 2008

CMAJ 2008;179(12 Suppl):E1-E93 #2.7a

2.7a Symptomatic Carotid Stenosis cont.

Carotid endarterectomy is recommended for selected patients with moderate (50 to 69%) symptomatic stenosis and these patients should be evaluated by a physician with expertise in stroke management

Carotid endarterectomy should be performed by a surgeon with a known perioperative morbidity and mortality of <6%.

Carotid stenting may be considered for patients who are not operative candidates for technical, anatomical or medical reasons.

Carotid endarterectomy is contraindicated for patients with mild (<50%) stenosis.

Canadian Best Practice Recommendations for Stroke Care, 2008

CMAJ 2008;179(12 Suppl):E1-E93 #2.7a

2.7b Asymptomatic Carotid Stenosis

Carotid endarterectomy may be considered for selected patients with asymptomatic 60-99% carotid stenosis. Patients should be less than 75 years old with

a surgical risk <3%, a life expectancy >5 years, and be evaluated by a physician with expertise in stroke management.

Canadian Best Practice Recommendations for Stroke Care, 2008

CMAJ 2008;179(12 Suppl):E1-E93 #2.7b

Studies to Support Acting Fast

EXPRESS Study (Rothwell et al. Lancet; 2007:370: 1432-1442) Studied the effect of providing urgent treatment

with existing secondary stroke preventative strategies to TIA/minor strokes not admitted to hospital

Result: 80% reduction in risk of recurrent stroke in 90 days

SOS-TIA (Lavallee et al, 2007, Neurology) Suspected TIAs admitted to 24 hr clinic,

investigations completed within 4 hrs of admission

Results: 90 day stroke rate=1.24% predicted rate estimated from the ABCD2 score was 5.92%

Systems/Strategies Needed?

Role of a stroke prevention clinic is key to evaluation and triage of all TIA and minor stroke patients….treated surgically and medically

A process is needed to triage TIA and stroke patients urgently

Timely investigations need to be completed to determine etiology

Appropriate medications need to be initiated Access to timely carotid intervention is

required when implicated

CMAJ 2008;179(12 Suppl):E1-E93.

An Approach to Secondary Stroke Prevention

Four Step Process Evaluate the Event √ Initiate Medications √ Implement Interventions √ Modify Stroke Risk Factors

APSS, February 2009

Canadian Best Practice Recommendations for Stroke Care, updated 2008

www.canadianstrokestrategy.ca