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The Big Deal About Mini-Strokes: Treating TIA. 2012. 12. 07. Andre Douen MD , PhD, FRCPC, FAHA Director West GTA Regional Stroke Program, Chief, Division of Neurology, Trillium Health Centre, Mississauga. Disclosures: Ad Board: BI, Sanofi -Aventis, BMS, Bayer Speaker: BI, BMS. - PowerPoint PPT Presentation
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All rights reserved. This document contains the confidential and proprietary information of Innovate Research and Development and its affiliates, and any disclosure, copying, distribution or unauthorized use of this document without the express written consent of Innovate Research and Development is strictly prohibited.
Andre Douen MD, PhD, FRCPC, FAHADirector West GTA Regional Stroke Program,Chief, Division of Neurology,Trillium Health Centre, Mississauga
2012. 12. 07
Disclosures: Ad Board: BI, Sanofi-Aventis, BMS, BayerSpeaker: BI, BMS
The Big Deal About Mini-Strokes: Treating TIA
So…what is the big deal ? Or
Should there be a big deal ?
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Transient ischemic attack• A forthcoming stroke is often announced by a
transient ischemic attack (TIA)• Like ischemic strokes, TIAs are caused by
vessel occlusion or reduction of blood flow• The symptoms are the same as stroke
symptoms, and may include: Impaired vision, speech disruption, weakness and numbness
• TIAs are brief due to early revascularization/reperfusion
Johnston et al. National Stroke Association. Ann Neurol 2006; 60: 301–13.
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The work-up and management is similar to a stroke
• Etiology not different from definite stroke• Clinically < 24-hour duration, but....• New MRI lesions seen in up to 80% of patients
with clinical course of TIA• Frequently followed by more severe stroke• TIA and stroke have a similar risk for early
recurrent stroke, ~ up to 14% within the first 2 weeks
• Opportunities for prevention – Rapid W/U in SPCJohnston et al. JAMA 2000; 284: 2901–2906.
Warach, Kidwell. Neurology 2004; 62: 359–360.Mohr. Neurology 2004; 62 (8 Suppl 6): S3–S6.
Case 1 Mrs W.S., LLM
• 62 y/o obese lawyer with GERD • PMH:
– Smoking 1ppd x 30 yrs– No HTN, No DM, No Cholesterol at her last
visit in Jan 2010
Douen www.educatehealth.ca
Case 1 Mrs W.S.• HPI
Speaking with niece regarding a legal matter when..
Slurred speech Loss of speech Right facial droop, Right arm weak and
incoordinated
• EMS – Symptoms resolved with 15 min– Patient declines transfer to ER– Elects to way overnight and call fam doc in
AM for a quick visit and head to office after to prepare for prosecuting a medico-legal case
Douen www.educatehealth.ca
CaseExamination in office the next day:
BP = 160/90 ; HR 90 and regular. No neurological deficits, but with right carotid Bruits.Current Meds: Losec, Tylenol prn for back pain
Next steps:– DDX ? [Is this a TIA, if not what could it be ?]– If TIA, what’s her risk of recurrent stroke ? – Is there a tool that can help assess this ? – What investigations is needed now ?– What should I do...panic ? [Will I get sued if I make
the wrong decision ? ]– Should I start Meds ?– Maybe the ER might be a safe bet ?
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Stroke Mimics• Migraine (aura)• Vertigo • Syncope (vaso-vagal, cardiogenic, metabolic)• Seizure (simple, CPSz, grand mal with “Todd’s”)• Structural brain lesions (tumors, AVM, subdurals,
abscess)• Carpal tunnel (focal numbness)• Radiculopathies (focal numb/weak)• Neuropathies (more diffuse numb +/- weak)• Dementia (confusion)• Neuroses• Stress/Anxiety• Malingering
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Case 1 Mrs W.S.• Needs to get back to office ASAP• Thinks this “TIA” thing is non-sense, as she
feels she was a bit stressed over the case and that caused her symptoms
• Not keen on extensive investigations for such a minor episode
• She might comply if she can schedule these in between her practice over the next 2 months
• If it was a “TIA” (she is skeptical) then she wants to estimate her risk of recurrence
Douen www.educatehealth.ca
www.educatehealth.ca
1. What do you think her stroke risk might be within the next month:a. ~ 2%b. ~ 8%c. ~ 20%d. She’ll almost certainly re-strokee. Her risk can only be measured over 3 months
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1. What do you think her stroke risk might be with in the next month:a. ~ 2%b. ~ 8%c. ~ 20%d. She’ll almost certainly re-strokee. Her risk can only be measured over 3 months
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Stroke Recurrence • Antecedent stroke/TIA is the most
significant indicator of a possible recurrent stroke
• High incidence of early recurrent stroke following either TIA or minor stroke
• Early recognition and treatment significantly reduces the risk of stroke recurrence
Johnston et al. JAMA 2000; 284: 2901–2906.Warach, Kidwell. Neurology 2004; 62: 359–360.
Mohr. Neurology 2004; 62 (8 Suppl 6): S3–S6.
www.educatehealth.ca
0
5
20
15
10
7-daystroke risk
30-daystroke risk
3-monthstroke risk
Stro
ke p
atie
nts
(%)
0
5
20
15
10
7-daystroke risk
30-daystroke risk
3-monthstroke risk
TIA
patie
nts
(%)
Stroke patients: risk of recurrent event TIA patients: risk of recurrent event
Coull et al. BMJ 2004; 328: 326.
11.5
15.0
18.5
8.0
11.5
17.3
Nearly 1 in 5 stroke/TIA patients is at risk of a recurrent event within 3 months
The ABCD2 Score
Indicator Criteria Score
A Age 1 point for age 60 /1B Blood pressure 1 point for BP >140/90 mmHg /1C Clinical features 2 points for focal weakness or
1 point for speech disturbance /2
D Duration of symptoms 1 point for duration 10-59 minutes2 points for duration >60 minutes
/2
D Diabetes 1 point for presence of diabetes /1 Total Score /7
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The ABCD2 Score
Indicator Criteria Score
A Age 1 point for age 60 /1B Blood pressure 1 point for BP >140/90 mmHg /1C Clinical features 2 points for focal weakness or
1 point for speech disturbance /2
D Duration of symptoms 1 point for duration 10-59 minutes2 points for duration >60 minutes
/2
D Diabetes 1 point for presence of diabetes /1 Total Score /7
112
1
05
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Risk Factors for Stroke Within 90 Days of a TIAThe ABCD2 Score
0
5
10
15
20
25
0 1 2 3 4 5 6 7
2 Days7 Days30 Days90 Days
StrokeRisk(%)
ABCD2 Score
LowRisk
HighRisk
IntermediateRisk
Lancet 2007;369:283-92.
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Case 1 Mrs W.S.• After reviewing ABCD2 and showing her
these charts, she is now more agreeable to comply with investigations
• She wants to know, how do stroke and TIA occur, and also what investigations she would need
• She also wants to know about how soon she can have the studies completed
• She will reluctantly cancel appointments to attend these investigations
• What can she take to prevent this from recurring?
Douen www.educatehealth.ca
www.educatehealth.ca
(Anticoagulation)
Antiplatelet
Pathophysiology: Multiple Mechanisms requiring urgent W/U
Douen
Case
Next steps:– DDX ? [Is this a TIA, if not what could it be ?]– If TIA, what’s her risk of recurrent stroke ? – Is there a tool that can help assess this ? – What investigations are needed now ? How soon ?– What should I do...panic ? [Will I get sued if I make the
wrong decision ? ]– Should I start Meds ?– Maybe the ER might be a safe bet ?
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What investigations would you consider for this patient (why, when)?
ECHO (TEE,TTE) Routine labs Carotid doppler CT scan ECG, Echo (TTE/TEE) Holter Angiogram (CTA / MRA)
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4. What priority would you give these investigations?
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a) ECG > ECHO> Telemetry/Holter>Carotid Doppler>CT
b) CT>Telemetry/Holter>ECHO>Carotid Doppler> ECG
c) ECHO > Holter > CT>Carotid Doppler > ECG
d) CT> Carotid Doppler = ECG > Holter > ECHO e) CT = ECG = Carotid Doppler > Holter > ECHO
4. What priority would you give these investigations?
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a) ECG > ECHO> Telemetry/Holter>Carotid Doppler>CT
b) CT>Telemetry/Holter>ECHO>Carotid Doppler> ECG
c) ECHO > Holter > CT>Carotid Doppler > ECG
d) CT> Carotid Doppler = ECG > Holter > ECHO e) CT = ECG = Carotid Doppler > Holter > ECHO
CaseNext steps:
– DDX ? [Is this a TIA, if not what could it be ?]– If TIA, what’s her risk of recurrent stroke ? – Is there a tool that can help assess this ? – What investigations are needed now ? How soon ?– What should I do...panic ? [Will I get sued if I make
the wrong decision ? ]– Should I start Meds ?– Maybe the ER might be a safe bet ?
www.educatehealth.ca
www.educatehealth.ca
3. Which of the following statements about the management of patients with TIA or minor stroke are correct:a. If possible work-up should be completed within 2-3
daysb. Early treatment and intervention could reduce stroke
recurrence by 80%c. Early management through a stroke clinic is likely
superior to routine out patient management.d. For those with ipsilateral severe stenosis
revascularization is recommended within 2 weekse. All of the above
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3. Which of the following statements about the management of patients with TIA or minor stroke are correct:a. If possible work-up should be completed within 2-3
daysb. Early treatment and intervention could reduce stroke
recurrence by 80%c. Early management through a stroke clinic is likely
superior to routine out patient management.d. For those with ipsilateral severe stenosis
revascularization is recommended within 2 weekse. All of the above
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Outcome Phase 1 Phase 2 Time to clinic visit - 3 days ( 2 -5) 1 day (0-3) Time to prescription- *20 days (8 -53) 1 day (0-3) 90 day risk of stroke- ~10.3% 2.1%**
*No prescriptions given. Patients advised to see family MD
**80% reduction in risk of recurrent stroke
EXPRESSUrgent treatment of TIA and minor stroke
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Timeliness of Care In Patients with TIA The OXVASC Study
Neurology 2005;65:371-5.
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The Consequences of Delaying Access to CareThe OXVASC Study
Neurology 2005;65:371-5.
Stroke Patients
30.2
14.817.6
3.3
11.4
48.9
-2.9
-10
0
10
20
30
40 70-99% Stenosis50-69% Stenosis
0-2 4-122-4 >12
Time From Event to Randomization (weeks)
5 Year ARRIn Stroke
(%)
Timing of Surgical InterventionThe NASCET and ECST Studies
Lancet 2004;363:915-24.
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CaseNext steps :
– DDX ? [Is this a TIA, if not what could it be ?]– If TIA, what’s her risk of recurrent stroke ? – Is there a tool that can help assess this ? – What investigations are needed now ? How soon ?– What should I do...panic ? [Will I get sued if I make
the wrong decision ? ]– Should I start Meds ?– Maybe the ER might be a safe bet ?
www.educatehealth.ca
www.educatehealth.ca
2. Following and ischemic stroke it is best to wait 3 - 4 days before initiating antiplatelet therapy because of increased risk of bleeding.
a. True b. False
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2. Following and ischemic stroke it is best to wait 3 - 4 days before initiating antiplatelet therapy because of increased risk of bleeding.
a. True b. False
Stroke / TIA
Medical
Risk factor management
Interventional
RevascularizationCEA vs Stent
Antiplatelet Anticoagulant
Antithrombotic
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5. In an ASA naive patient which of the following Antitrhombotic agents is recommended for secondary prevention of Non- Cardioembolic stroke
a. ASAb. ASA/ER Dipyridamolec. Clopidogreld. Clopidogrel + ASAe. Warfarinf. Either b) or c) g. Any of a) , b) or c)
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5. In an ASA naive patient which of the following Antitrhombotic agents is recommended for secondary prevention of Non-Cardioembolic stroke
a. ASAb. ASA/ER Dipyridamolec. Clopidogreld. Clopidogrel + ASAe. Warfarinf. Either b) or c) g. Any of a) , b) or c)
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ASA vs. Placebo: Efficacy by Dose*
ASA Dose Relative Risk of Vascular Events**
1,000 – 1,300 mg/d
300 mg/d
50 – 75 mg/d
Overall
0.8†
ASA better Placebo better
* A meta-analysis of 10 controlled trials comparing acetylsalicylic acid (ASA) with placebo. ** Vascular events comprise stroke, MI, or vascular death.† Signifies a 20% relative risk reduction
Prevention of Vascular Events in Stroke/TIA Patients with ASA Following First Stroke
Adapted from Albers GW et al. Neurology. 1999; 53(suppl 4): S25-S38.
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6. For patients already on ASA which of the following Antitrhombotic agents is recommended for secondary prevention of Non-Cardioembolic stroke
a. ASAb. ASA/ER Dipyridamolec. Clopidogreld. Clopidogrel + ASAe. Warfarinf. Either b) or c) g. Any of a) , b) or c)
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6. For patients already on ASA which of the following Antitrhombotic agents is recommended for secondary prevention of non- cardioembolic stroke
a. ASAb. ASA/ER Dipyridamolec. Clopidogreld. Clopidogrel + ASAe. Warfarinf. Either b) or c) g. Any of a) , b) or c)
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Clopidogrel + Placebo (n=3,781)
Num
ber (
n/%
) with
eve
nt
Life-threateningbleeding
0
20
40
60
80
100
Majorbleeding
Minorbleeding
Clopidogrel + ASA (n=3,759)
96 (3%)
49 (1%)
73 (2%)
22 (1%)
120 (3%)
39 (1%)
120
Diener et al. Lancet 2004; 364: 331–337.
p<0·0001
p<0·0001
p<0·0001
MATCH: Bleeding Complications Increased Significantly
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0.0
0.01
0.02
0.03
0.04
0.0 0.5 1.0 1.5
OAC
Clopidogrel+ASA
Major BleedingC
umul
ativ
e H
azar
d R
ates
Years
# at Risk
C+A 3335 3172 2403 914OAC 3371 3212 2423 901
2.4 %/year
2.2 %/year
RR = 1.06P = 0.67
7. For patients already on Plavix which of the following Antitrhombotic agents is recommended for secondary prevention of Non-Cardioembolic stroke
a. ASA/ER Dipyridamoleb. Clopidogrelc. Clopidogrel + ASAd. Warfarine. Either a) or b)
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7. For patients already on Plavix which of the following Antitrhombotic agents is recommended for secondary prevention of Non-Cardioembolic stroke
a. ASA/ER Dipyridamoleb. Clopidogrelc. Clopidogrel + ASAd. Warfarine. Either a) or b)
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8. In terms of the efficacy for non-cardioembolic prophylaxis which of the following are true:
a) ASA/ER Dipyridamole > ASA > warfarinb) Clopidogrel >ASA > warfarinc) Warfarin > Clopidogrel = ASA/ER Dipyridamoled) Warfarin = ASAe) Clopidogrel = ASA/ER Dipyridamolef) D) and e) correct
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8. In terms of the efficacy for non-cardioembolic prophylaxis which of the following are true:
a) ASA/ER Dipyridamole > ASA > warfarinb) Clopidogrel >ASA > warfarinc) Warfarin > Clopidogrel = ASA/ER Dipyridamoled) Warfarin = ASAe) Clopidogrel = ASA/ER Dipyridamolef) d) and e) correct
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Secondary prevention- Which Antiplatelet ?
• Physician’s choice• Compliance• Cost
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Case
CT brain: Nil acute.
ECG: AF with HR of 95
Is a Doppler still required ??
Meds: …. ???
what is incidence of AF in acute stroke ??
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Case
CT brain: Nil acute.
ECG: AF with HR of 95
Is a Doppler still required ?? YES
Meds: …. ???
what is incidence of AF in acute stroke ??
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Cardioemboli
• AF: – High incidence of paroxysmal AF in acute stroke– 13.5% detection of new onset AF– Overall ~20 % of acute stroke patient with AF.
(Douen et al, Stroke 2008)
• Up to 3 million people worldwide suffer strokes related to AF each year1-3
1. Atlas of Heart Disease and Stroke, World Health Organization, September 2004. Viewed at http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf
2. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 2. 1991:22(8);983-8
3. Lin HJ, Wolf PA, Kelly-Hayes M, et al. Stroke severity in atrial fibrillation: the Framingham study. Stroke 1996;27:1760-4
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AF increases the risk of stroke• AF is associated with a pro-thrombotic state
– ~5- 17 fold increase in stroke risk
• Risk of stroke is the same in patients with chronic of PAF2,3
• There is a high 30-day mortality (~25%) following cardioembolic stroke4
• AF-related stroke has a 1-year mortality of ~50%5
1. Wolf PA, et al. Stroke 1991;22:983-988; 2. Rosamond W et al. Circulation. 2008;117:e25–146; 3.Hart RG, et al. J Am Coll Cardiol 2000;35:183-187; 4. Lin H-J, et al. Stroke 1996; 27:1760-1764; 5. Marini C, et al. Stroke 2005;36:1115-1119.
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Effect of first ischemic stroke in patients with AF (n=597)%
of p
atie
nts
Disabling(discharge mRS ≥ 2)
Fatal
60%
40%
0%
50%
30%
20%
10%
59.7%
20%
Stroke Severity in Patients with AF
mRS=modified Rankin ScaleAF=atrial fibrillationGladstone DJ et al. Stroke. 2009; 40:235-240
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% b
edrid
den
patie
nts
on a
dmiss
ion
(mRs
* = 5
)
(P < 0.0005)
40
30
20
10
0
5041.2%
23.7%
With AF Without AF
Dulli DA, et al. Neuroepidemiology. 2003;22:118-123.
Odds ratio for bedridden state following stroke due to AF was 2.23 (95% CI, 1.87-2.59; P < 0.0005)
*mRS=modified Rankin ScaleAF=atrial fibrillation
Ischemic Stroke Associated With AF is Typically More Severe Than Stroke due to Other Etiologies
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CHADS 2CHADS2 Score* Stroke rate
0 1.9 (1.2 -3.0)
1 2.8 (2.0-3.8)
2 4.0 (3.1-5.1)
3 5.9 (4.6-7.3)
4 8.5 (6.3 -11.1)
5 12.5 (8.2-17.5)
6 18.2 (10.5-17.4)
*Score 0: Patients can be administered aspirin*Score 1: Patients can be on aspirin and anticoagulant therapy*Score ≥2: Patients should be on anticoagulant therapy
• 1 point for Congestive Heart Failure
• 1 point for Hypertension
• 1 point for Age ≥ 75 years• 1 point for Diabetes Mellitus • 2 points for Prior Stroke or
TIA
CHA2DS2-VASc Score• 1 point for Congestive Heart
Failure/LV Dysfunction
• 1 point for Hypertension
• 2 points for Age ≥ 75 years
• 1 point for Diabetes Mellitus
• 2 points for Prior Stroke or TIA1 or TE2
• 1 point for Vascular Disease3
• 1 point for Age 65-74 years
• 1 point for Sex category (female gender)
CHA2DS2-VASc Score*
One year event rate (95% CI) of hospital admission and death due to thromboembolism† per 100 person
year0 0.78 (0.78 – 1.04)1 2.01 (1.70 – 2.36)2 3.71 (3.36 – 4.09)3 5.92 (5.53 – 6.34)4 9.27 (8.71 – 9.86)5 15.26 (14.35 – 16.24)6 19.74 (18.21 – 21.41)7 21.5 (18.75 – 24.64)8 22.38 (16.29 – 30.76)
9 23.64 (10.62 – 52.61)*Score 0: Patients can be administered aspirin*Score 1: Patients can be administered aspirin or anticoagulant therapy*Score ≥2: Patients should be administered anticoagulant therapy†Includes peripheral artery embolism, ischemic stroke, and pulmonary embolism
1TIA = Transient ischemic attack; 2TE = Thromboembolism3Prior myocardial infarction, peripheral artery disease, aortic plaque1. Lip GY et al. Chest 2010;137:263-272
2. Olesen JB, et al. BMJ 2011;342:d1243. Task Force or the Management of Atrial Fibrillation of the ESC.
Eur Heart J 2010;31:236902429
CHA2DS2-Vasc score Mrs W.S. = 4 (hypertension, age 65-74 yr, female)
CHA2DS2-VAScScore
One year event rate (95% Cl) of hospital admission and death due to thromboembolism† per 100 person
year
CCS 2012 Update to AF Guidelines
CHADS2 = 0
*Aspirin is a reasonable alternative in some as indicated by risk/benefit
CHADS2 = 1 CHADS2 ≥ 2
No anti-thrombotic
Assess Thromboembolic Risk (CHADS2)
No additional
risk factors for stroke
Increasing stroke risk
ASA OAC* OAC* OAC*
Either female sex or vascular
disease
Age ≥ 65 yrs or combination
of female sex and vascular
disease
*OAC = Oral anticoagulant ASA = Aspirin
Consider stroke risk vs. bleeding risk
Only when the stroke risk is low and bleeding risk is high does the risk/benefit ratio favor no antithrombotic therapy
1. Skanes AC, et al. Can J Cardiol 2012;28:125-136.
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Case - Paul
Mrs W.S. Risk: 62-year-old - < 75 : 0HTN : 1No h/o CHF : 0No DM : 0TIA symptoms : 2
CHADS Risk = 3
CHADS-VASC Risk = 4 (HTN, F, Stroke symptoms)
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Stroke / TIA
Medical
Risk factor management
Interventional
RevascularizationCEA vs Stent
Antiplatelet Anticoagulant
Antithrombotic
www.educatehealth.ca
9. The patients who benefit the most from warfarin therapy are those with AF in the age group 65-75 and with no other medical issues.– True– False
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9. The patients who benefit the most from warfarin therapy are those with AF in the age group 65-75 and with no other medical issues– True– False
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10. Recent studies have shown that ASA+Plavix is equally efficacious to warfarin for cardio-embolic stroke prophylaxis in patients with AF– True– False
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10. Recent studies have shown that ASA+Plavix is equally efficacious to warfarin for cardio-embolic stroke prophylaxis in patients with AF– True– False
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11. Patients with AF who has spontaneous intracranial hemorrhage while using OAC should never be placed back on OAC– Ture– False
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11. Patients with AF who has spontaneous intracranial
hemorrhage while using OAC should never be placed back on OAC– Ture– False
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12. For patient with cardioembolic (AF) stroke/TIA which of the following Antitrhombotic Agents is recommended for secondary prevention
a. Warfarinb. Dabigatran (Pradax)c. Rivaroxaban (Xaralto)e. Apixaban (Eliqus)f. Clopidogrel + ASAg. ASA/ER Dipyridamole
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12. For patient with cardioembolic (AF) stroke/TIA which of the following Antitrhombotic Agents is recommended for secondary prevention
a. Warfarinb. Dabigatran (Pradax)c. Rivaroxaban (Xaralto)e. Apixaban (Eliqus)f. Clopidogrel + ASAg. ASA/ER Dipyridamole
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13. Because older patients (> 80 yrs old) with AF are generally at high risk of falls and spontaneous bleeding and so should not in general be treated with OAC– True – False
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13. Because older patients (> 80 yrs old) with AF are generally at high risk of falls and spontaneous bleeding and so should not in general be treated with OAC– True – False
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AF prevalence increases with age
1. Go AS, et al. JAMA 2001;285:2370-2375.
Age
AF
prev
alen
ce (%
)
General population
>60 years >80 years
9
8
7
6
5
4
3
2
1
0
AF prevalence increases with age
1. Go AS, et al. JAMA 2001;285:2370-2375.
Age
AF
prev
alen
ce (%
)
General population
>60 years >80 years
9
8
7
6
5
4
3
2
1
0
INR control: clinical trials v. clinical practice
INR* control in clinical trial versus clinical practice (TTR**)
1. Kalra L, et al. BMJ 2000;320:1236-1239 * Pooled data: up to 83% to 71% in individualized trials; 2. Matchar DB, et al. Am J Med 2002; 113:42-51.
** TTR = Time in Therapeutic Range (INR2.0-3.0)
66%
44%
9%
18%
38%
25%
<2.0 2.0 – 3.0 >3.0 INR
% o
f elig
ible
pat
ient
s re
ceiv
ing
war
farin
Clinical trial1
Clinical practice2
*INR = International normalized ratio
INR control: clinical trials v. clinical practice
INR* control in clinical trial versus clinical practice (TTR**)
1. Kalra L, et al. BMJ 2000;320:1236-1239 * Pooled data: up to 83% to 71% in individualized trials; 2. Matchar DB, et al. Am J Med 2002; 113:42-51.
** TTR = Time in Therapeutic Range (INR2.0-3.0)
66%
44%
9%
18%
38%
25%
<2.0 2.0 – 3.0 >3.0 INR
% o
f elig
ible
pat
ient
s re
ceiv
ing
war
farin
Clinical trial1
Clinical practice2
*INR = International normalized ratio
New OAC• Dabigatran Etexilate (Direct Thrombin Inhibitor) in Atrial Fibrillation (RE-LY)
• Rivaroxaban (Factor Xa inhibitor)in Atrial Fibrillation (ROCKET-AF)
• Apixaban (Factor Xa inhibitor)in Atrial Fibrillation (AVERROES; ARISTOTLE)
Pros : No MonitoringRapid onset of actionSimilar or better bleeding profile to warfarin
Con : No antidote, no clear way of measuring effect
www.educatehealth.ca
Recent Oral Anticoagulation Trials:Stroke or Systemic Embolism
The new oral anticoagulant agents are consistently associated with a numerically lower risk for stroke or systemic embolism compared to warfarin†
Data obtained from intention-to-treat analysis†Not intended as cross-trial comparison
1. Connoly SJ, et al. N Engl J Med 2009;361:1139-1151.2. Patel MR, et al. N Engl J Med 2011;365:883-891.3. Granger C, et al. N Engl J Med 2011;365:981-992
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Recent Oral Anticoagulation Trials:Hemorrhagic Stroke
The new oral anticoagulants are consistently associated with a numerically lower risk of hemorrhagic stroke compared with warfarin†
Data obtained from intention-to-treat analysis†Not intended as cross-trial comparison
1. Connoly SJ, et al. N Engl J Med 2009;361:1139-1151.2. Patel MR, et al. N Engl J Med 2011;365:883-891.3. Granger C, et al. N Engl J Med 2011;365:981-992
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Recent Oral Anticoagulation Trials:Major Bleeding
HR (95% CI)New Agent Better Warfarin Better
Data obtained from intention-to-treat analysis†Not intended as cross-trial comparison
1. Connoly SJ, et al. N Engl J Med 2009;361:1139-1151.2. Patel MR, et al. N Engl J Med 2011;365:883-891.3. Granger C, et al. N Engl J Med 2011;365:981-992
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Stroke / TIA
Medical
Risk factor management
Interventional
RevascularizationCEA vs Stent
Antiplatelet Anticoagulant
Antithrombotic
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ASA naive patients vs those previously on ASA
a. ASAb. ASA/ER Dipyridamolec. Clopidogrel________________________d. Warfarin e. Clopidogrel + ASA
Antiplatelet choices – Summary Non-cardioembolic stroke
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Stroke / TIA
Medical
Risk factor management
Interventional
RevascularizationCEA vs Stent
Antiplatelet Anticoagulant
Antithrombotic
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For patient with cardioembolic (AF) stroke/TIA
a. Dabigatran (Pradax)b. Apixaban (Eliqus)c. Rivaroxaban (Xaralto)d. Warfarin_______________________e. Clopidogrel + ASAf. ASA
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Recommendations - Antithrombotic We recommend that patients at very low risk of stroke
(CHADS2 = 0) should receive aspirin (75-325 mg/day). (Strong recommendation, High Quality Evidence). We suggest that some young persons with no standard risk factors for stroke may not require ay antithrombotic therapy. (Conditional recommendation, Moderate Quality Evidence).
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Recommendations - Antithrombotic We recommend that patients at low risk of stroke
(CHADS2 = 1) should receive OAC therapy (either warfarin [INR 2 – 3] or dabigatran). (Strong recommendation, High Quality Evidence). We suggest, based on individual risk/benefit considerations, that aspirin is a reasonable alternative for some. (Conditional recommendation, Moderate Quality Evidence).
We recommend that patients at moderate risk of stroke (CHADS2 ≥ 2) should receive OAC therapy (either warfarin [INR 2 – 3] or dabigatran). (Strong recommendation, High Quality Evidence)
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Recommendations - Antithrombotic We suggest, that when OAC therapy is indicated, most
patients should receive dabigatran in preference to warfarin. In general, the dose of dabigatran 150 mg po bid is preferable to a dose of 110 mg po (exceptions discussed in text). (Conditional recommendation. High Quality Evidence).
R e g i s t e r a t w w w. e D u c a t e h e a l t h . c a
Simple NavigationRich Multimedia
Peer Reviewed Content Interactive Models
R e g i s t e r a t w w w. e d u c a t e h e a l t h . c a
In-depth Content Medical Models and Images
Interactive Design Simple Navigation
What is eDucate™ (www.educatehealth.ca)
eDucate is a unique e-learning portal specifically designed to address the current challenges of retrieving pertinent, user-specific information from an ever expanding diffusely disseminated body of literature currently available to healthcare professionals.
eDucate is an on-line repository of disease specific information that has been comprehensively reviewed by key opinion leaders in their respective fields and presents users with a standardized review of core disease information, as well as an approach to patient care, as it relates to data gleaned from landmark trials and current guidelines. Quick review (executive summaries), and lecture slides are currently available. Audio, video, and high resolution images are forthcoming.
Main landing page: Left control panel shows main user types. “Start Living” icon provides brief tutorial of website.
Example of drop down menu functionality.
Main disease detail page showing the icon based approach to selective data retrieval. Top 5 icons provides background disease information and remains constant among user types. The bottom 7 icons provides specfic information for a given user type. The “Quick Review” opens the executive summary. “User Tools” provides additional learning material by way of lecture slides, graphs etc. “Interactive medicine” allows disease search with an organ.
Interaactive Medicine: Allows a search within an organ. Clicking on any of the red dots generates a list of diseases associated with the corresponding organ, from which the disease of interest could be selected.