Preventing Strokes One at a Time

Evaluating the Event2009

Acknowledgements

The Heart and Stroke Foundation and Canadian Stroke Strategy gratefully acknowledges the collaborative contributions of healthcare professionals and stroke programs across the country in the development of this tool kit.

This resource and its components are based upon the Canadian Best Practice Recommendations for Stroke Care, updated 2008, and was developed to support the implementation of the recommendations for stroke prevention.

Canadian Stroke Strategy

Resources available at: www.heartandstroke.ca/profed Acute Stroke Management Resource Toolkit for the Canadian Best Practice

Recommendations for Stroke Care, updated 2008

Pocket Reference Cards Faaast FAQ’s for Nurses National Professional Education Atlas NEW!! Stroke Prevention Tool Kit

2.0 Prevention of Stroke2.1 Lifestyle and risk

factor management2.2 Blood pressure

management2.3 Lipid management2.4 Diabetes

management2.5 Antiplatelet

therapy2.6 Antithrombotic

therapy for atrial fibrillation

2.7 Carotid intervention

3.0 Hyperacute Stroke Management3.2 Acute

management of transient ischemic attack and minor stroke

Canadian Best Practice Recommendations for Stroke Care, updated 2008: Prevention Sections

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

Preventing Strokes One at a Time

Upon completion, participants will be able to:

Discuss the incidence of TIA/minor stroke and the risk of recurrent stroke

Describe four steps of secondary stroke prevention

Implement Canadian Best Practice Recommendations for Stroke Care in the evaluation and identification of risk with TIA and minor stroke patients

Identify patients at high risk of recurrent stroke

Workshop Learning Objectives

Outline

Overview of Stroke & TIA Etiology Stroke Risk Diagnostic investigations

Impact of Stroke in Canada

Someone has a stroke

every 10 minutes

~ 50,000 strokes/year

300,000 Canadians living with stroke

20% chance of second stroke within 2 years

16,000 Canadians die from stroke

each year

Price Tag:$3.6 billion annually

For every symptomatic stroke there are 9 ‘silent’

strokes resulting in cognitive impairment

Stroke TIA

Sudden onset Focal neurological

symptoms Interruption in

blood supply to a part of the brain

WHO >24 hours Typical > 1 hour Permanent damage

Sudden onset Focal neurological

symptoms Transient lack of

blood supply and focal ischemia

WHO < 24 hours Typical < 1 hour No permanent

damage to the brain

Warning Signs: Stroke/TIA

Sudden loss of strength or sudden numbness in the face, arm or leg, even if temporary

Sudden difficulty speaking or understanding or sudden confusion, even if temporary

Sudden trouble with vision, even if temporary

Sudden severe and unusual headache

Sudden loss of balance especially with any of the above signs

CALL 911HSFC, 2006

Evaluate the Event: Investigating and Stratifying Risk

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 is appropriate to the clinical situation.”

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

Canadian Best Practice Recommendations for Stroke Care, 2008

ETIOLOGY

“The approach to secondary stroke prevention is dependent upon the underlying cause, or mechanism of the initial event and the existing stroke risk factors.” (APSS, Feb 2009)

Ischemic (80%)

Hemorrhagic (20%)

Ischemic Stroke: Etiology

Large Vessel DiseaseAtherosclerosis

Small Vessel DiseaseLacunar Infarction

CardioembolicCryptogenic

Stroke Mimics

Patients can present with deficits that initially can resemble stroke making TIA difficult to diagnose

History, assessment, and imaging all contribute to the assessment and identification of stroke mimics

Stroke Prevention Primary:

an individually based clinical approach to disease prevention

directed toward preventing the initial occurrence of a disorder in otherwise healthy individuals

Recommendations related to stroke emphasize the importance of screening and monitoring those patient at high risk of a first stroke

Secondary: An individually based clinical approach to reducing the

risk of recurrent vascular events in individuals who have already experienced a stroke or TIA and in those who have one or more of the medical conditions or risk factors that place them at high “risk of stroke”

Recommendations are directed to those risk factors most relevant to stroke

CMAJ 2008;179(12 Suppl):E1-E93, p. E16

The Road to Prevention

Are all TIA/minor stroke patients at risk of subsequent stroke?

Is early identification of those at highest risk of stroke critical?

STROKE RISK

Risk of Recurrent Stroke

People with symptoms of a TIA are at higher risk for subsequent stroke 11.5 % will have a stroke within 90 days Of these patients 50% will have a stroke

within 48 hoursJohnston et al (2000) & Gladstone et al (2004)

20%-40% of strokes are preceded by a TIA or non disabling stroke

(Rothwell et al. Lancet Neurol 2006; 5: 323-331)

Risk Factors

Hypertension Obesity Atrial Fibrillation Diabetes Cardiac Disease Dyslipidemia Excessive Alcohol Intake Physical Inactivity Smoking Stress Diet

Age Gender Family History Ethnicity Previous TIA or

Stroke

Modifiable Non-Modifiable

An Approach to Secondary Stroke Prevention

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

Adapted from APSS, February 2009

Step 1: Evaluate the Event

TIA/Minor Stroke Risk Assessment Clinical Predictors

Investigations CT or MRI, ECG, Carotid Imaging, Blood

work

Evaluate the Event: Investigating and Stratifying Risk

3.2a.i “All patients with suspected TIA or Minor Stroke should have an immediate clinical evaluation and additional investigations as required to establish the diagnosis, rule out stroke mimics and develop a plan of care

3.2a.ii “Use of a standardized risk stratification tool at the initial point of health care contact-whether first seen in primary, secondary or tertiary care-should be used to guide the triage process.”

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

Canadian Best Practice Recommendations for Stroke Care, 2008

Evaluate the Event: Risk Stratification

Emergent Symptoms within previous 24 hours with 2 or

more high risk clinical features Acute/persistent or fluctuating stroke symptoms 1 positive investigation Other factors based on individual presentation

and clinical judgement Urgent

TIA within 72 hours Semiurgent

Does not fit in urgent or emergent

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

Evaluate the Event: Investigating and Stratifying Risk

3.2a.iii “Patients with suspected TIA or minor stroke should be referred to a designated stroke prevention clinic or to a physician with expertise in stroke assessment and management, or if these options are not available, to an emergency department that has access to neurovascular imaging facilities and stroke expertise.”

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

Canadian Best Practice Recommendations for Stroke Care, 2008

Evaluate the Event: Timing of Tests

Diagnostic Test Emergent

Urgent Semiurgent

Assessment by medical specialist trained in stroke

24 h 7 d 30 d

CT or MRI 24 h 7 d 30 d

Carotid Imaging 24 h 7 d 30 d

ECG 24 h 7 d 30 d

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

Evaluate the Event: Example of a Risk Stratification Tool

Age 1 point for age >60 /1

BP 1 point for BP> 140/90 /1

Clinical Features

2 points for focal weakness1 point for speech disturbance without weakness

/2

Duration 2 points for duration >60 minutes1 point for duration >10min<59 minutes

/2

Diabetes 1 point for presence of diabetes /1

Johnston, Rothwell et al. Lancet; 2007; 368: 283-292

Total score / 7

ABCD2 Score * not endorsed by the Canadian Stroke Strategy

Evaluate the Event: Investigations

Labs

CBC, Electrolytes, Urea,

Creatinine, LFT’s, CK INR Fasting Glucose Hb A 1C

Fasting Lipid Profileo Total Cholesterolo HDLo LDLo Triglycerides

Diagnostics CT head, MRI Carotid Imaging

(Carotid Doppler, CTA, MRA)

CXR ECG Echocardiogram Holter Monitor

Evaluate the Event: Investigations

Test Rationale Outcome

CT or MRI

Rule out mimics, Identify stroke typeMRI: Better visualization of acute stroke

Diagnosis; begin appropriate interventions. All TIA minor stroke patients should receive a CT scan of the head ASAP.

Carotid Imaging(Carotid Doppler, CTA, MRA)

Identify carotid stenosis. Prompt carotid imaging is essential

Goal to TX within 2 weeks (70-99% stenosis:90 day risk of stroke is 25%)

Neurovascular Imaging

Evaluate the Event: InvestigationsTest Rationale Outcome

Other Labs:CK, LFTs, INR, PTT, Fasting lipids & glucose, HbA1C

CK, LFT: Baseline values prior to statin ; INR: risk of hemorrhage & assessment of Coumadin efficacy: Glucose: Identify & treat early diabetes, HbA1C (if diabetic)

Statins can ↓ further vascular events by 25%; Sub-therapeutic INR (<2) puts patients at High risk for further event

ECG Screen for Atrial Fibrillation.

Treat with Coumadin.

ECHO/ TEE If suspicion of cardiac source. TEE Assists to identify PFO, shunts

Expedites proper treatment &management.

Holter Monitor

If you suspect atrial fibrillation

Expedites proper treatment & management

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