Stroke / TIAStroke / TIA

Rich Derby, LtCol, USAFRich Derby, LtCol, USAF

MGMC Family Practice ProgramMGMC Family Practice Program

ObjectiveObjective

Review evaluation & management of Stroke/TIA Review evaluation & management of Stroke/TIA using current AHA/ASA guidelinesusing current AHA/ASA guidelines

Primary PreventionPrimary Prevention Acute Stroke / TIAAcute Stroke / TIA Post-stroke / TIA historyPost-stroke / TIA history

Focus Focus ScenariosScenarios

Primary PreventionPrimary Prevention

55 year old black male for routine physical55 year old black male for routine physical PMHx: Hypertension, Tobacco usePMHx: Hypertension, Tobacco use

Meds: HCTZ Meds: HCTZ

FHx: Mother had stroke in 60’sFHx: Mother had stroke in 60’s Data: 132/88 BP, BMI: 27 Data: 132/88 BP, BMI: 27

TC: 213/LDL: 145/HDL: 37 - EKG normal TC: 213/LDL: 145/HDL: 37 - EKG normal

What are your Interventions for What are your Interventions for Primary Stroke Prevention?Primary Stroke Prevention?

To answer this question you To answer this question you need to be aware of…need to be aware of…

Stroke risk factorsStroke risk factors ModifiableModifiable Non-modifiableNon-modifiable

How risk factors quantify into actual stroke riskHow risk factors quantify into actual stroke risk Use of stroke risk assessment toolUse of stroke risk assessment tool

What interventions lower riskWhat interventions lower risk

Modifiable risksModifiable risks Cardiovascular DiseaseCardiovascular Disease

HypertensionHypertension CAD/CHFCAD/CHF

DiabetesDiabetes DyslipidemiaDyslipidemia

High total Cholesterol High total Cholesterol

and/or Low HDLand/or Low HDL Atrial FibrillationAtrial Fibrillation Asymptomatic Carotid Asymptomatic Carotid

Artery StenosisArtery Stenosis

Cigarette smokingCigarette smoking Sickle Cell DiseaseSickle Cell Disease Dietary FactorsDietary Factors ObesityObesity Physical ActivityPhysical Activity Hormone Replacement Hormone Replacement

TherapyTherapy

Less Well-Documented or Potentially Modifiable Risk Factors

Metabolic syndrome Alcohol abuse Hyperhomocysteinemia Drug abuse Hypercoagulability Oral contraceptive use Inflammatory processes

Periodontal disease, C pneumoniae, Cytomegalovirus, H pylori CagA seropositivity, Acute infection, elevated hs-CRP

Migraine Sleep disordered breathing

Non-modifiable risksNon-modifiable risks

AGE Doubling of stroke rate each 10 years after age 55

White BlackMen Women Men Women

45–54 1.4 0.8 2.1 2.5 55–64 2.6 1.6 4.9 4.6 65–74 6.7 4.2 10.4 9.8 75–84 11.8 11.3 23.3 13.5 85 16.8 16.5 24.7 21.8

Prevalence (per 100,000)

Non-modifiable risksNon-modifiable risks

RACE Blacks 233

Hispanics 196

Whites 93

SEX

Men 174

Women 122

Prevalence (Per 100,000) FAMILY Hx (Relative Risk)

Paternal 2.4

Maternal 1.4

Equating risk factors Equating risk factors with actual riskwith actual risk

Patients should have stroke risk assessment (Class I, Level A)

Risk assessment tools should be considered

(Class IIa, Level B) Helps identify individuals who could benefit from

therapeutic interventions and who may not be treated on the basis of any 1 risk factor

Modified Framingham Stroke Risk Profile (men)

Age 54–56 57–59 60–62 63–65 66–68 69–72 73–75 76–78 79–81 82–84 85

SBP 97–105 106–115 116–125 126–135 136–145 146–155 156–165 166–175 176–185 186–195 196–205

(Untreated)

SBP 97–105 106–112 113–117 118–123 124–129 130–135 136–142 143–150 151–161 162–176 177–205

(Treated)

Diabetes No Yes

Cigarette No Yes

CVD No Yes

A Fib No Yes

LVH on No Yes

EKG

Points

_ 0 +1 +2 +3 +4 +5 +6 +7 +8 +9 +10__

10-Year Probability, %

Points Men Women 1 3 1 2 3 1 3 4 2 4 4 2 5 5 2 6 5 3 7 6 4 8 7 4 9 8 5 10 10 6 11 11 8 12 13 9 13 15 11 14 17 13 15 20 16

Points Men Women 16 22 19 17 26 23 18 29 27 19 33 32 20 37 37 21 42 43 22 47 50 23 52 57 24 57 64 25 63 71 26 68 78 27 74 84 28 79 29 84 30 88

10-Year Probability, %

Modified Framingham Stroke Risk Score

Risk Factor High Risk Caution Low Risk Blood Pressure > 140/90 120-139/80-89 <120/80 or I don’t knowCholesterol > 240 200-239 <200 or I don’t knowDiabetes Yes Borderline NoSmoking I still smokeAtrial Fibrillation I have an irregular I don’t know My heartbeat is heartbeat regularDiet I am overweight I am slightly My weight is overweight healthyExercise I am a couch potato I exercise sometimes I exercise regularly

I have stroke in Yes not sure noMy family

Score (each box=1)

TO REDUCE YOUR RISK FOR STROKE:1. Know your blood pressure. If high, work with your doctor to lower it.2. Find out from your doctor if you have atrial fibrillation.3. If you smoke, stop.4. If you drink alcohol, do so in moderation.5. Find out if you have high cholesterol.If so, work with your doctor to control it.6. If you are diabetic, follow your doctor's recommendationscarefully to control your diabetes.7. Include exercise in the activities you enjoy in your daily routine.8. Enjoy a lower sodium (salt), lower fat diet.9. “Ask your doctor” how you can lower your risk of stroke.10. KNOW THE SYMPTOMS OF STROKE.If you have any stroke symptoms, seek immediate medical attention.Symptoms include:• Sudden numbness or weakness of face, arm or leg - especially on one side of the body.• Sudden confusion, trouble speaking or understanding.• Sudden trouble seeing in one or both eyes.• Sudden trouble walking, dizziness, loss of balance or coordination.• Sudden severe headache with no known cause.

If your RED score is 3 or more, please ask your doctor about stroke prevention right away

If your yellow score is 4-6, you’re off to a good start. Keep working on it!

If your green score is 6-8, congratulations! You’re doing very well at controlling your risk for stroke!

If you have experienced any of these symptoms, you may have had a TIA or a stroke – call911 immediately!

1-800-STROKES 1-800-787-6537www.stroke.org

Risk assessment tool pitfallsRisk assessment tool pitfalls

Each tool has limitationsEach tool has limitations Do not account for all risk factorsDo not account for all risk factors Need to be validated against different ethnic/race Need to be validated against different ethnic/race

groupsgroups

Have not yet been shown to improve stroke Have not yet been shown to improve stroke prevention programsprevention programs

Interventions of worthInterventions of worth(Class I, Level A & B)(Class I, Level A & B)

HTNHTN (JNC-7): (JNC-7): regular screening (more frequent in regular screening (more frequent in minorities) & appropriate managementminorities) & appropriate management

DiabetesDiabetes: : BP < 130/80, statin use for LDL< 100BP < 130/80, statin use for LDL< 100

DislipidemiaDislipidemia (NCEP III): (NCEP III): Physical InactivityPhysical Inactivity: : increase physical activityincrease physical activity

Obesity:Obesity: weight reduction weight reduction

Diet:Diet: lower sodium / increase potassium / DASH dietlower sodium / increase potassium / DASH diet

Smoking CessationSmoking Cessation

Assume recommendations from established guidelinesAssume recommendations from established guidelines

Atrial FibrillationAtrial Fibrillation

Warfarin anticoagulation Warfarin anticoagulation (Class I, Level A)(Class I, Level A)

Valvular heart diseaseValvular heart disease Normal valves but high Normal valves but high

stroke risk stroke risk (>4% annually)(>4% annually)

IntermediateIntermediate risk for risk for stroke & no warfarin stroke & no warfarin contraindicationcontraindication

Aspirin Aspirin (Class I, Level A)(Class I, Level A)

Low stroke risk Low stroke risk IntermediateIntermediate risk risk

CHADS 2CHADS 2Risk Assessment Risk Assessment

Tool usefulTool useful

Asymptomatic Asymptomatic Carotid StenosisCarotid Stenosis

ScreenScreen for additional risk for additional risk factors and manage factors and manage aggressivelyaggressively (Class I, Level C) (Class I, Level C)

Aspirin recommendedAspirin recommended (Class I, Level B)(Class I, Level B)

Prophylactic EndarterectomyProphylactic Endarterectomy (Class I, level A)(Class I, level A) In selected pts with high-grade In selected pts with high-grade

(60-99%) stenosis(60-99%) stenosis If Surgeon has 3% If Surgeon has 3%

morbidity/mortality ratesmorbidity/mortality rates

* 5-10% (men & women) > 65 * 5-10% (men & women) > 65 have carotid stenosis > 50% have carotid stenosis > 50%

* 1% with carotid stenosis > 80%* 1% with carotid stenosis > 80%

* General population screening * General population screening not cost-effectivenot cost-effective

* Angioplasty/stenting alternative * Angioplasty/stenting alternative being studiedbeing studied

Aspirin alone?Aspirin alone?

Not recommended for primary prevention in men Not recommended for primary prevention in men (Class III, Level A)(Class III, Level A)

Recommended for patient’s with 10-year risk of Recommended for patient’s with 10-year risk of cardiovascular events >6% (or 5-year > 3%) cardiovascular events >6% (or 5-year > 3%) (Class I, Level A)(Class I, Level A)

May be useful among women whose risk is May be useful among women whose risk is sufficiently high for benefits to outweigh risks sufficiently high for benefits to outweigh risks (Class IIa, Level B)(Class IIa, Level B)

Summary - Primary PreventionSummary - Primary Prevention

Know stroke risk factors & how to quantify into Know stroke risk factors & how to quantify into a patient’s individual riska patient’s individual risk

Manage modifiable risks aggressivelyManage modifiable risks aggressively BP, Lipids, Tob use, Wt, DietBP, Lipids, Tob use, Wt, Diet

Warfarin vs. aspirin in Atrial Fib based on riskWarfarin vs. aspirin in Atrial Fib based on risk

Consider endarterctomy in asymptomatic carotid Consider endarterctomy in asymptomatic carotid stenosis 60-90%stenosis 60-90%

Our caseOur case Risk Factors:Risk Factors:

Male, 55 Male, 55 y/o y/o , black, , black, ++FHxFHx HTN, Tobacco use, LDL > 130HTN, Tobacco use, LDL > 130

Risk Assessment:Risk Assessment: 7%7% 10-year risk of stroke by 10-year risk of stroke by

Modified Framingham Stroke Risk ScoreModified Framingham Stroke Risk Score 23%23% 10-year risk of cardiovascular event by 10-year risk of cardiovascular event by

NCEP III risk assessment toolNCEP III risk assessment tool

Interventions Interventions Aspirin, Diet, Exercise, Tob cessation, better BP control Aspirin, Diet, Exercise, Tob cessation, better BP control

and LDL <100, consider carotid exam/imagingand LDL <100, consider carotid exam/imaging

Acute Stroke / TIAAcute Stroke / TIA

See same patient in ER next daySee same patient in ER next day Slurring speech, trouble finding wordsSlurring speech, trouble finding words DrowsyDrowsy Unable to move rt arm/leg effectivelyUnable to move rt arm/leg effectively

What are your Evaluation and Management What are your Evaluation and Management Plans for Acute Stroke / TIA?Plans for Acute Stroke / TIA?

Brain Attack! Brain Attack!

StrokeStroke A sudden focal neurological A sudden focal neurological

deficit or acute neurological deficit or acute neurological impairment caused by the impairment caused by the interruption of blood flow to a interruption of blood flow to a specific region of the brainspecific region of the brain

700,000700,000 suffer a new suffer a new or repeat stroke in or repeat stroke in U.S. each yearU.S. each year

Third leading cause Third leading cause of death in the US of death in the US ((> 150,000> 150,000 yearly) yearly)

Ischemic StrokeIschemic Stroke85% of all strokes85% of all strokes

CauseCause ThromboticThrombotic (atherosclerosis) (atherosclerosis) EmbolicEmbolic (A fib, prosthetic valve) (A fib, prosthetic valve) VasoconstrictionVasoconstriction (eclampsia) (eclampsia)

ManifestationManifestation Occlusion of artery to specific area Occlusion of artery to specific area

of brain causes specific neurologic of brain causes specific neurologic syndromesyndrome

middle cerebral artery:middle cerebral artery: contralateral contralateral hemiplegia, hemianesthesia, hemiplegia, hemianesthesia, homonymous hemianopiahomonymous hemianopia

KEY POINTSKEY POINTSEvaluate appropriatenessEvaluate appropriatenessof thrombolytic therapyof thrombolytic therapy

- 3 hour window- 3 hour window - Non-contrast CT - Non-contrast CT

negative for bleednegative for bleed - No contraindications- No contraindications

Hemorrhagic strokeHemorrhagic stroke15% of all stroke15% of all stroke

Cause Cause Primary Primary (70-90%)(70-90%)

- Hypertension, amyloid angiopathy- Hypertension, amyloid angiopathy Secondary Secondary (10-30%)(10-30%)

- Vascular malformation (aneurysm, - Vascular malformation (aneurysm, avm), tumor, thrombolytic agents,avm), tumor, thrombolytic agents,

ManifestationManifestation Rupture of blood vessel with Rupture of blood vessel with

surrounding tissue damage surrounding tissue damage

- symptoms of increased ICP - symptoms of increased ICP (severe headache, nausea/vomitting, (severe headache, nausea/vomitting, altered mental status/coma)altered mental status/coma)

KEY POINTSKEY POINTS - Non-contrast CT - Non-contrast CT

positive for bleedpositive for bleed

- 50% mortality - 50% mortality (80% of survivors with (80% of survivors with permanent disability)permanent disability)

- ICP monitoring- ICP monitoring

- Neurosurgical - Neurosurgical interventionintervention

Acute ManagementAcute Management

Medical StabilizationMedical Stabilization Focused historyFocused history Neurologic assessmentNeurologic assessment Brain ImagingBrain Imaging Negative CT – Evaluate for thrombolyticsNegative CT – Evaluate for thrombolytics

Medical StabilizationMedical Stabilization Airway and BreathingAirway and Breathing

Protect from aspiration and hypoxemiaProtect from aspiration and hypoxemia Vitals / O2Vitals / O2 IV access IV access (isotonic fluids only)(isotonic fluids only) LabsLabs

Glucose, electrolytesGlucose, electrolytes Consider cardiac markers, tox screen, coagsConsider cardiac markers, tox screen, coags

EKGEKG Order Non-Contrast Head CTOrder Non-Contrast Head CT Neurological AssessmentNeurological Assessment First 10

Minutes!

History / ExamHistory / Exam

History focus pointsHistory focus points Onset and scenarioOnset and scenario Significant comorbidities Significant comorbidities

and medicationsand medications Review contraindication Review contraindication

list for thrombolyticslist for thrombolytics

Exam focus pointsExam focus points Neurological Stroke Neurological Stroke

ScaleScale NIH Stroke ScaleNIH Stroke Scale Canadian Canadian

neurologic scaleneurologic scale

Obtain CT !Obtain CT !Within 25 Minutes!

NIH Stroke ScaleNIH Stroke ScaleTitle Responses and scores

1a Level of consciousness

0 = Alert1 = Drowsy2 = Obtunded3 = Coma/unresponsive

1b Orientation questions (two)

0 = Answers both correctly1 = Answers one correctly2 = Answers neither correctly

1c Response to commands (two)

0 = Performs both tasks correctly1 = Performs one task correctly2 = Performs neither task

2 Gaze 0 = Normal horizontal movements1 = Partial gaze palsy2 = Complete gaze palsy

3 Visual fields 0 = No visual field defect1 = Partial hemianopsia2 = Complete hemianopsia3 = Bilateral hemianopsia

4 Facial movement 0 = Normal1 = Minor facial weakness2 = Partial facial weakness3 = Complete unilateral paralysis

5 Motor function arma. left

b. right

0 = No drift1 = Drift before 10 seconds2 = Falls before 10 seconds3 = No effort against gravity4 = No movement

6 Motor function lega. left

b. right

0 = No drift1 = Drift before 5 seconds2 = Falls before 5 seconds3 = No effort against gravity4 = No movement

7 Ataxia 0 = Absent1 = Ataxia in one limb2 = Ataxia in two limbs

8 Sensory 0 = Normal1 = Mild sensory loss2 = Severe sensory loss

9 Language 0 = Normal1 = Mild aphasia2 = Severe aphasia3 = Mute or global aphasia

10 Articulation 0 = Normal1 = Mild dysarthria2 = Severe dysarthria

11 Extinction or inattention

0 = Normal1 = Mild (loss 1 sensory modality)2 = Severe (loss 2 modalities)

CT Read – CT Read – within 45 minwithin 45 min

HemorrhagicHemorrhagic

Ischemic Ischemic

Hemorrhagic stroke (ICH)Hemorrhagic stroke (ICH)

Neurosurgery consultNeurosurgery consult Manage ICPManage ICP

MannitolMannitol Surgical decompressionSurgical decompression

ICUICU Mangage comorbiditiesMangage comorbidities Delineate causeDelineate cause Speech/OT/PT c/sSpeech/OT/PT c/s

Blood PressureBlood Pressure 90% have acutely elevated 90% have acutely elevated

BP (usually >160/90)BP (usually >160/90) Goal of MAP <130Goal of MAP <130 Safe to reduce by 20% in Safe to reduce by 20% in

controlled fashioncontrolled fashion Labetolol, esmolol, Labetolol, esmolol,

nitroprussidenitroprusside

Ischemic StrokeIschemic Stroke

Is this a candidate for tPA Thrombolysis?Is this a candidate for tPA Thrombolysis? >18 years old>18 years old < 3 hours onset symptoms< 3 hours onset symptoms Measurable neurologic deficit dx as ischemic strokeMeasurable neurologic deficit dx as ischemic stroke No contraindicationsNo contraindications

Review ChecklistReview Checklist

If appropriate candidate then tPA is indicated If appropriate candidate then tPA is indicated (Class I, Level A)(Class I, Level A)

Thrombolytic CriteriaThrombolytic CriteriaDiagnosis of ischemic stroke causing measurable neurologic deficitNeurologic signs should not be clearing spontaneouslyNeurologic signs should not be minor and isolatedCaution should be exercised in treating a patient with major deficitsSymptoms of stroke should not suggest subarachnoid hemorrhageOnset of symptoms less than 3 hours before beginning treatmentNo head trauma or prior stroke in previous 3 monthsNo myocardial infarction in the previous 3 monthsNo gastrointestinal or urinary tract hemorrhage in previous 21 daysNo major surgery in the previous 14 daysNo arterial puncture at a noncompressible site in the previous 7 daysNo history of previous intracranial hemorrhageBlood pressure not elevated (systolic <185 mm Hg and diastolic <110 mm Hg)No evidence of active bleeding or acute trauma (fracture) on examinationNot taking an oral anticoagulant, or if anticoagulant being taken, INR is 1.7 or lessIf receiving heparin in previous 48 hours, aPTT must be in normal rangePlatelet count equal to or greater than 100,000 mm3 Blood glucose concentration equal to or greater than 50 mg/dL (≥2.7 mmol/L)No seizure with postictal residual neurologic impairmentsCT does not show a multilobar infarction (hypodensity >1/3 cerebral hemisphere)Patient or family members understand the potential risks and benefits from treatment

Meets Thrombolytic CriteriaMeets Thrombolytic Criteria

tPA only FDA approved agent for ischemic stroketPA only FDA approved agent for ischemic stroke

Consent patientConsent patient RiskRisk - ICH rate of 6% - ICH rate of 6% (up to 15% if guidelines not followed)(up to 15% if guidelines not followed)

BenefitBenefit - improved 24 hour recovery ( mean 8 vs 12 on NIHSS)- improved 24 hour recovery ( mean 8 vs 12 on NIHSS) - improved 3 month recovery (30% improvement)- improved 3 month recovery (30% improvement) - death/severe disability reduction (4% reduction)- death/severe disability reduction (4% reduction) - 11-13% absolute increase in patients with excellent outcomes- 11-13% absolute increase in patients with excellent outcomes

tPA TherapytPA Therapy

0.9mg/kg tPA IV 10% 0.9mg/kg tPA IV 10% bolus & rest over 60 minbolus & rest over 60 min

Monitor for ICHMonitor for ICH No anticoagulants or No anticoagulants or

antiplatlets for 24 hoursantiplatlets for 24 hours Manage comorbiditiesManage comorbidities Delineate CauseDelineate Cause Speech/OT/PT c/sSpeech/OT/PT c/s

Blood PressureBlood Pressure Pretreatment goal Pretreatment goal

SBP<185 DBP<110SBP<185 DBP<110 Labetalol, esmolol, Labetalol, esmolol,

Nitropaste, Nicardipine Nitropaste, Nicardipine infusion, Nitroprussideinfusion, Nitroprusside

During/Post-treatmentDuring/Post-treatment Maintain at or below Maintain at or below

goal in controlled goal in controlled fashionfashion

Ischemic strokeIschemic stroke – – but but not tPA candidatenot tPA candidate

Neuro status Neuro status monitoringmonitoring

Aspirin Aspirin (Class I, Level A)(Class I, Level A)

Manage Manage co-morbiditiesco-morbidities

Delineate causeDelineate cause Speech/OT/PT c/sSpeech/OT/PT c/s

Blood PressureBlood Pressure Benign neglect up to 220/120Benign neglect up to 220/120

If greater 220/120If greater 220/120 10-15% reduction10-15% reduction Labetelol, esmolol, Labetelol, esmolol,

nitroprusside, nicardinpinenitroprusside, nicardinpine

TIATIA Focal neurologic deficit that resolves completely and Focal neurologic deficit that resolves completely and

spontaneously within 24 hoursspontaneously within 24 hours

Often occur as heralding sign to Often occur as heralding sign to acute stroke within 48 acute stroke within 48 hourshours – – up to 5% of TIA patientsup to 5% of TIA patients

5-10% of patients with TIA will have stroke within 90 5-10% of patients with TIA will have stroke within 90 days (up to 20% for those with carotid artery disease)days (up to 20% for those with carotid artery disease)

Warrants more aggressive evaluation & management

TIATIAInitial EvaluationInitial Evaluation

Predicting impending strokePredicting impending stroke AAge 60 = 1 ge 60 = 1 BBlood pressure lood pressure

(systolic >140 mmHg and/or (systolic >140 mmHg and/or diastolic 90 mmHg = 1) diastolic 90 mmHg = 1)

CClinical features linical features (unilateral (unilateral weakness = 2, isolated speech weakness = 2, isolated speech disturbance = 1, other = 0) disturbance = 1, other = 0)

DDuration of symptoms in minutes uration of symptoms in minutes ( 60 = 2, 10 to ( 60 = 2, 10 to 59 = 1, <10 = 0)59 = 1, <10 = 0)

Chance of stroke Chance of stroke within 7 dayswithin 7 days

ScoreScore6 = 24 - 31%6 = 24 - 31%

5 = 12 %5 = 12 %

4 = 1 - 9%4 = 1 - 9%

<< 3 = 0 3 = 0

A simple score (ABCD) to identify individuals at high early

risk of stroke after transient ischaemic attack.

Rothwell PM et al.; Lancet 2005 Jul 2;366(9479):29-36.

TIATIAInitial EvaluationInitial Evaluation

Consider hospitalization Consider hospitalization (especially for higher risk patients)(especially for higher risk patients)

Relevant medical assessmentRelevant medical assessment Focus on Cardiac Risk Factors, Carotid dz, embolic dzFocus on Cardiac Risk Factors, Carotid dz, embolic dz Neurologic assessment (timing, degree, resolution)Neurologic assessment (timing, degree, resolution)

Brain imagingBrain imaging

Carotid imaging (within 48hrs)Carotid imaging (within 48hrs)

Cardiac assessment (holter, echo, TEE)Cardiac assessment (holter, echo, TEE)

TIA TIA ManagementManagement

Manage comorbidities aggressivelyManage comorbidities aggressively BP <130/85BP <130/85 LDL <100LDL <100 FBS < 126 FBS < 126 Discontinue Tobacco, excessive EtOHDiscontinue Tobacco, excessive EtOH Physical activity (30-60min 3-4 x wk)Physical activity (30-60min 3-4 x wk) Discontinue HRTDiscontinue HRT

Utilize antithrombotic agentsUtilize antithrombotic agents

TIATIA Antithrombotic TherapyAntithrombotic Therapy

Cardioembolic source Cardioembolic source (Atrial Fibrillation)(Atrial Fibrillation)

Warfarin – INR goal 2.5Warfarin – INR goal 2.5

Atherothrombotic sourceAtherothrombotic source (Class IIa, Level A)(Class IIa, Level A)

ASA ASA (50-325mg)(50-325mg) qd qd Ext Release Dipyridamole Ext Release Dipyridamole (200mg)+(200mg)+ASA ASA (25mg)(25mg) bid bid

****best outcomes in studies thus farbest outcomes in studies thus far Clopidogrel Clopidogrel (75mg)(75mg) qd qd

Summary - Acute Stroke / TIASummary - Acute Stroke / TIA

Assess for thrombolysisAssess for thrombolysis < 3 hours - ischemic stroke - no contraindications< 3 hours - ischemic stroke - no contraindications Measurable neuro deficit scoring and Head CT vital Measurable neuro deficit scoring and Head CT vital

components of initial assessmentcomponents of initial assessment

Blood pressure management of acute stroke Blood pressure management of acute stroke depends on scenario depends on scenario (ischemic/hemorrhagic/use of tPA)(ischemic/hemorrhagic/use of tPA)

TIA is more concerning than previously thoughtTIA is more concerning than previously thought Evaluate for more aggressive managementEvaluate for more aggressive management

Secondary Prevention of Secondary Prevention of Stroke / TIAStroke / TIA

Modify Vascular RisksModify Vascular Risks Antihypertensive treatment Antihypertensive treatment

per JNC VII (Class I, A)per JNC VII (Class I, A)

Tight control in diabetics Tight control in diabetics (A1C < 7) (Class I, A)(A1C < 7) (Class I, A)

LipidsLipids LDL <100 (<70 in very LDL <100 (<70 in very

high risk) (Class I, A)high risk) (Class I, A) If normal TC may still rx If normal TC may still rx

with statin (Class IIa, B)with statin (Class IIa, B) High TG, Low HDL – High TG, Low HDL –

Niacin or Gemfibrazil Niacin or Gemfibrazil (Class IIb, B)(Class IIb, B)

Modify Behavioral RisksModify Behavioral Risks Smoking – STOP Smoking – STOP

(Class I, C)(Class I, C)

EtOH – Stop if heavy EtOH – Stop if heavy drinker; < 2 daily otherwisedrinker; < 2 daily otherwise

Obesity – get to BMI of Obesity – get to BMI of 18-25 (Class IIb, C)18-25 (Class IIb, C)

Physical Activity – increase Physical Activity – increase to 30min most days of week to 30min most days of week (Class IIb, C)(Class IIb, C)

Secondary PreventionSecondary Prevention

Carotid disease and history of stroke / TIACarotid disease and history of stroke / TIA 70-99% stenosis70-99% stenosis (Class I, level A)(Class I, level A)

CEA with surgeon who has < 6% complication rateCEA with surgeon who has < 6% complication rate 50-69% stenosis50-69% stenosis (Class I, level A)(Class I, level A)

CEA depending on patient risks (age, gender, comorbidities)CEA depending on patient risks (age, gender, comorbidities) Less than 50% stenosisLess than 50% stenosis (Class III, level A)(Class III, level A)

CEA not recommendedCEA not recommended >70% stenosis with high surgical risks>70% stenosis with high surgical risks (class IIb, level B)(class IIb, level B)

May consider carotid artery stenting May consider carotid artery stenting

Primary prevention recall

Asymptomatic Patient without stroke/TIA History Prophylactic Endarterectomy ( (Class I, level A)

- In selected pts with high-grade (60-99%) stenosis- In selected pts with high-grade (60-99%) stenosis - If Surgeon has 3% morbidity/mortality rates- If Surgeon has 3% morbidity/mortality rates

Secondary PreventionSecondary Prevention

Cardioembolic risksCardioembolic risks Atrial FibrillationAtrial Fibrillation

Warfarin for target INR 2.5 Warfarin for target INR 2.5 Aspirin if unable to use Warfarin Aspirin if unable to use Warfarin (Class I, level A)(Class I, level A)

Valvular heart diseaseValvular heart disease Warfarin or aspirin depending on type of valvular diseaseWarfarin or aspirin depending on type of valvular disease

MI with LV mural thrombusMI with LV mural thrombus Warfarin 3 months to 1 yearWarfarin 3 months to 1 year

CardiomyopathyCardiomyopathy Warfarin or antiplatelet therapyWarfarin or antiplatelet therapy

Antithrombotic Therapy for Antithrombotic Therapy for Noncardioembolic Stroke or TIANoncardioembolic Stroke or TIA

Antiplatelet better than anticoagulation Antiplatelet better than anticoagulation (Class I, level A)(Class I, level A)

Acceptable antiplatelet agents Acceptable antiplatelet agents (Class IIa, level A)(Class IIa, level A) Aspirin (50-325mg) dailyAspirin (50-325mg) daily Aspirin and extended-release dipyridamoleAspirin and extended-release dipyridamole ClopidogrelClopidogrel

Aspirin and extended-release dipyridamole suggested Aspirin and extended-release dipyridamole suggested instead of aspirin alone instead of aspirin alone (Class IIa, level A)(Class IIa, level A)

Aspirin and Clopidogrel not recommended due to Aspirin and Clopidogrel not recommended due to increased hemorrhage risk increased hemorrhage risk (Class III, level A)(Class III, level A)

Summary – Secondary preventionSummary – Secondary prevention Manage behaviors & diseases that elevate vascular risk Manage behaviors & diseases that elevate vascular risk

(HTN, Lipids, DM, Tob, Obesity, Activity level)(HTN, Lipids, DM, Tob, Obesity, Activity level)

Carotid endarterectomy may be indicated in patients Carotid endarterectomy may be indicated in patients with stenosis 50-99%with stenosis 50-99%

Generally warfarin for cardioembolic risk patientsGenerally warfarin for cardioembolic risk patients

Antiplatelet therapy Antiplatelet therapy (non-cardioembolic stroke/TIA(non-cardioembolic stroke/TIA)) Aspirin + extended-release dipyridamole preferredAspirin + extended-release dipyridamole preferred Aspirin + Clopidogrel NOT RECOMMENDEDAspirin + Clopidogrel NOT RECOMMENDED

QuestionsQuestions