Stroke

Judith Coombes

Princess Alexandra Hospital 2018

Objectives

• Overview of Stroke

• Focus on secondary prevention

• Ischemic atherosclerosis case

• AF case

Importance of Stroke

• In Australia 2nd greatest cause of death

after coronary artery disease

• 1/3 die, 1/3 permanent disability

• 4.5% of burden of disease (Aus)

• 1 in 6 will have had a stroke by the age of

85

Stroke in Sri Lanka

• 1 in 6 will develop a stroke

• Dr Ramawaka senior lecturer Kelaniya

• - fastest aging population

– Non communicable diseases eg diabetes

• 7 stroke units only 50 dedicated beds

• 2015 prevalence study showed 1 in 100

have a stroke

Case Study Mrs EC

• Mrs EC 69yr Female

• about to cook when she became (left

sided) weak, called 000 (14.56)

• National Institute of stroke scale (NIHSS-

9)

• Code stroke- lysis is Alteplase 0.9mg/kg

max 90mg 10% bolus then infusion

– Endovascular Clot retrieval –

– admit under stroke unit

FAST

FaceCheck their face. Has

their mouth drooped?

ArmCan they lift both

arms?

Speech

Is their speech

slurred? Do they

understand you?

Time

Is critical. If you see

any of these signs call

emergency number

straight away.

Stroke Severity

• 0= no symptoms

• 1-4 Minor Stroke

• 5-15 Moderate Stroke

• 16-20 Moderate to severe stroke

• 21-42 Severe stroke

A stroke occurs when there is no blood flow

to the brain has been interrupted by either :

– A blockage of the

cerebral artery or

• Bleeding due to rupture of

the artery

Categorisation

• Ischemic Stroke

– Atherosclerosis

– Embolism

• Haemorrhagic Stroke

Haemorrhagic

• High blood pressure

• Cerebral aneurysms

– Weak or thin spot on blood vessel wall

• Arteriovenous malformations (AVM)

Ischemic

Two main causes

• Atherosclerosis • Embolic

Atherosclerotic stroke (cartoon for patients

by Shannon Doyle)

Embolic stroke in AF (cartoon for patients

by Shannon Doyle)

Carotid artery dissection (cartoon for

patients by Shannon Doyle)

Transient Ischemic Attack-TIA

Definition – Symptoms resolve within 24

hours

New Definition- Symptoms resolve and no

Stroke pathology detected on CT scan or

MRI

TIA and Stroke

• TIA- no permanent disability

• 1/3 strokes –no permanent disability

• Recurrence is about 12% in the first year

• So secondary prevention to reduce risk

Acute Medical treatment

• Lysis- TARGET:STROKE cuts door to needle

time improves stroke outcome (JAMA 22/4/14)

• Use tissue plasminogen activator tPA

• Clot retrieval with or without Lysis

• Aspirin 300mg- but take care if poor

swallow

Acute Medical treatment-

Endovascular Clot Retrieval

• Interventional Neuro-radiologists (INRs)

• Mr Clean study showed benefit

Clot Retrieval

Solitaire device

Post ECR result

• NIHSS 0

• Still some stenosis needs Carotid

endarterectomy in a week

• Dual antiplatelets until then

Recurrence

• cumulative incidence 30-43%,

– highest occurrence in the first 12 months of 12% reducing to about 4 % per year

• After a transient Ischemic attack (TIA) 90 day incidence of stroke is 9.2-17.3%

After TIA first week is critical ABCD2 Age BP Clinical features(speech weakness) Duration less 10 min

Diabetes

>=4/7 high 0-3/7 low

Secondary prevention

RISK REDUCTION

Australian clinical guidelines for stroke management 2017

Non pharmacological

*Control of Diabetes

Smoking cessation

Weight loss

Exercise

Reduce alcohol

Carotid surgery if appropriate

Pharmacological

*Blood Pressure control

*Anti-thrombotics

*Cholesterol lowering

Guidelines

Australian clinical guidelines for stroke

management 2017

• BP-All >140/90 should have treatment

– ACE/ARB, Calcium Chanel Blocker, Thiazide

(not beta-blocker first line)

• High dose statin (Atorvastatin 80mg) if

atherosclerotic contribution and life

expectancy (?greater than 1 year)

Guidelines- antithrombotic

• Aspirin or Clopidogrel or Aspirin with

dipyridamole

Unless

Anticoagulated

• If AF anticoagulate

Mrs EC

• Anti platelet- is individualised

– Stenosis so discharged on Dual oral antiplatelet therapy(Aspirin and Clopidogrel)

– Plan a CEA (carotid endarterectomy) in 1 week then stop Aspirin after 3 weeks

• Antihypertensive

– Blood pressure 140/80 and cause embolic in this case no antihypertensive

• Lipid lowering

– Atorvastatin 80mg

To guide treatment decisions

Assess risk factors for bleeding with

aspirin including:

*increasing age

*any bleeding predisposition

*history of peptic ulcer

*uncontrolled hypertension

*severe renal or hepatic impairment

*concurrent use of NSAIDs or

anticoagulants

aspirin + dipyridamole SR

Reduces stroke risk over Aspirin alone, but

less well tolerated

Previous stroke or TIA relative risk reduction

of non-fatal stroke compared with Aspirin

alone without causing extra bleeding

ESPRIT Trial - 34% (A+D) vs 13% (Aspirin

alone) but many stopped treatment, mainly

because of headache

We do 1 A+D mane and 1 aspirin nocte for a

week the 1 A+D BD and stop aspirin

clopidogrel - a more suitable choice for

some patients

Similar efficacy to Aspirin + Dipyridamole SR in

preventing recurrent stroke

Comparable bleeding risk

Useful if intolerance to Aspirin + Dipyridamole SR OR

co-existing coronary heart disease

CAPRIE - v small benefit for Clopidogrel vs

aspirin(saves 1 more in 200 per year), similar overall

bleed risk.

Avoid aspirin + clopidogrel

• MATCH - Aspirin + Clopidogrel no more

effective than Clopidogrel alone to

prevent vascular events after ischaemic

stroke, TIA. Caused more life-

threatening bleeding.

• Benefit of Aspirin + Clopidogrel exceeds

bleed risk in acute coronary syndrome

or coronary stent

Adherence

• Like all chronic diseases adherence is

reported at 30-70%

• Educate the patient about

– Medications are to reduce risk of further

stroke

– This is lifelong therapy

– Report adverse events or stroke symptoms---

to clinic

Adverse Medication Events

• BP lowering- fainting and falls

• Statins- muscle weakness or pain

• Anti platelets- bleeding and Dipyridamole

causes headache

• Anti diabetes – cause hypoglycaemia

Detailing Tool for intervention

Changes is the last 3 years

• CODE Stroke

• Endovascular Clot Retrieval

• AF and DOACS

– Give a booklet

Embolic stroke in AF (cartoon for patients

by Shannon Doyle)

Mr AF 50yr male

• PC –embolic stroke

• PMH

– Hypertension

– High cholesterol

– Atrial fibrillation

Mr AF – Question 1What are Mr AFs risk factors for stroke?

• Hypertension

• Cholesterol risk of atherosclerosis

• Atrial fibrillation

BP

• Keep below 140 mmHg

• No benefits of further intensive lowering

Mr AF Question 2What is the most appropriate antithrombitic

therapy for stroke prevention?

• Prior to his stroke

• After his stroke

CHA2DS2-VASc----AF only

C=congestive heart failure

H=hypertension

A=greater or equal to 75yrs get 2

D=diabetes

S=stroke gets 2

V= vascular disease (MI, Aortic Plaque, Peripheral

Arterial Disease)

A= 65 to 74 get 1

Sc= sex female

CHA2DS2-VASc Score Stroke Risk %

0 0

1 1.3

2 2.2

3 3.2

4 4.0

5 6.7

6 9.8

7 9.6

8 12.5

9 15.2

Adjusted stroke rate %per year (guidelines say anticoagulate 2 and greater)

National Heart Foundation

Australia

•The sexless CHA2DS2-VA score is recommended to assess stroke

risk, which standardises thresholds across men and women;

anticoagulation is not recommended for a score of 0, and is

recommended for a score of ≥ 2. If anticoagulation is indicated, non-

vitamin K oral anticoagulants are recommended in preference to

warfarin.

https://www.heartfoundation.org.au/for-

professionals/clinical-information

Higher risk of bleeding

HASBLED• Uncontrolled HTN

• Abnormal liver or renal function

• Stroke

• History of bleeding

• Labile INR or INR > 3.0

• Use of alcohol

• Drug interaction

Mr AF – Question 2What is the most appropriate antithrombitic

therapy for stroke prevention?

Warfarin

New/or Direct oral

anticoagulants • Dabigatran (thrombin inhibitor)

• Apixaban (Xa inhibitor)

• Rivaroxaban(Xa inhibitor)

Cholesterol lowering

• All patients with Ischemic stroke or TIA

• And possible atherosclerotic contribution

• Reasonable life expectancy

• Should have high potency statin

• Atorvastatin 80mg

Safety Strategies

• Rash

• Dizziness

• Muscle Weakness

• Bleeding or bruising

Simvastatin

Atorvastatin

Metabolism:

substrates/inhibitors

(CYP 3A4)

Age

> 70

Diseases: DM,

Hypothyroidism

High dose

> 40mg d

Renal/ hepatic

Dysfunction

Inhibitors

of elimination

(gemfibrozil)

Known risk factors for myopathyADRAC Bulletin , Feb 2004; 23: 1

Useful Reference

• Stroke

– The lancet.com

– Graeme J Hankey

– Published online September 13, 2016

• Australian stroke guidelines 2017

(https://informme.org.au/en/Guidelines/Clinic

al-Guidelines-for-Stroke-Management-2017)

Warfarin Counselling

• Video

• Groups of 3 with warfarin book

– Patient

– Counselling

– Feedback

Then change roles