Transcript Document

Preventing Strokes
One at a Time
Putting It All
Together
2009
Learning Objectives
Upon completion, participants will be able to:
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Triage and participate in the appropriate timely
management of a TIA or minor stroke patient using
the four steps of secondary stroke prevention
Practice according to the Canadian Best Practice
Recommendations for Stroke Care.
Identify the local strategies designed to address
the needs of the Emergent, Urgent and Semiurgent TIA or minor stroke patient.
Insert Picture
Patient #1
Mrs. Ivanna Nomore
Mrs. Ivanna Nomore
63 year old female
 Mortgage consultant
 Presenting complaint in ED: sudden onset
of weakness and numbness to right leg
and arm
 Resolved 60 minutes later
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Four Step Process
Evaluate the Event
 Initiate Medications
 Implement Interventions
 Modify Stroke Risk Factors
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Adapted from APSS, February 2009
Evaluate the Event: Mrs. Ivanna Nomore
History:
 HTN x 6 years: was on antihypertensive
but stopped taking it a while ago
 Dyslipidemia: was on statin in the past
 Not presently taking any medications
Evaluate the Event: Mrs. Ivanna Nomore
Exam and Investigations
ECG: Normal sinus rhythm
 Neuro exam: Normal
 BP: 146/95
 CT: Normal
 Blood work:
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 INR= 0.9, BUN= 5.5mmol/L, Cr = 80umol/L
Evaluate the Event: Risk of stroke?
Is Mrs. Ivanna Nomore at risk of a stroke? Urgency?
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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
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Urgent
 TIA within 72 hours
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Semiurgent
 Does not fit in urgent or emergent
CMAJ 2008;179(12 Suppl):E1-E93.
Evaluate the Event: Timing of Tests
Canadian Best Practice Recommendations for Stroke Care, 2008
Diagnostic Test
Emergent
Urgent
Semiurgent
Assessment by
medical specialist
trained in stroke
24 h
7d
30 d
CT or MRI
24 h
7d
30 d
Carotid Imaging
24 h
7d
30 d
ECG
24 h
7d
30 d
CMAJ 2008;179(12 Suppl):E1-E93 #3.2
Acute Interventions & Management:
Mrs. Ivanna Nomore
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Consult to stroke prevention
clinic/physician responsible for and capable
of urgent triage and implementation of
appropriate TIA/stroke management
Acute Interventions & Management:
Mrs. Ivanna Nomore
Next Steps…
 Initiate Medications
 Which medications?
o
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Patient was started on ASA in ED
Implement Interventions
Acute Interventions and Management:
Mrs. Ivanna Nomore
Antiplatelet
Dosage
Considerations
ECASA
81-325 mg OD
(adults)
3-5 mg/kg/day
children
If aspirin naïve- load with
160mg then 81 mg OD
(adults)
Aggrenox
(ASA/SR
dypiridamole)
25/200 mg BID
Possible severe headache x
first 5-7 days
Plavix
(Clopidogrel)
75 mg OD
Consider loading with 300
mg
CMAJ 2008;179(12 Suppl):E1-E93 #3.2
Acute Interventions and Management:
Mrs. Ivanna Nomore (cont’d)
Other tests ordered:
 Echocardiogram
 Carotid Doppler
 Fasting Blood Glucose
 Fasting Lipid Profile
Results:
 No thrombosis
 Left carotid stenosis <50%
 6.5 mmol/L
 T-Chol= 5.7mmol/L
 HDL= 0.8mmol/L
 LDL = 3.6mmol/L
 TG= 1.5mmol/L
Next Steps…
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Initiate Medications
 Should you consider any other medications?
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Implement Interventions:
 Based on carotid Doppler results what is next?
Diagnosis: TIA most likely due to small
vessel disease
Further investigations and medical management..
 Holter Monitor
 ASA changed to Plavix
 Samples of ACEI and Statin given with family
physician to follow up in 1 week.
Hypertension and Stroke
HTN & Stroke
Assessment & Management
Injury to the blood
 Proper assessment technique
vessel walls
 Target BP < 140/90,
↓
< 130/80 (Diabetes/Chronic
Scar is formed
Kidney Disease)
↓
 ACEI + diuretic= 1st line tx
Build-up of plaque,
 Tx > 1 agent
fragile small arteries,
 Lifestyle modification
extra strain on heart &  Focus on adherence
weakens heart walls
Canadian Hypertension Education Program 2009
CMAJ 2008;179(12 Suppl):E1-E93 #3.2
Acute Interventions & Management:
Mrs. Ivanna Nomore
Statins
 First line agents for dyslipidemia
 Reduce stroke risk by 25-30%
 Target LDL-C< 2.0 mmol/L
 Vascular health bonus: decrease
progression and/or inducing regression of
carotid artery plaque
Acute Interventions & Management:
What if ?
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What if Mrs. Ivanna Nomore’s Doppler
showed 90% stenosis in left internal
carotid..?
 Would her risk stratification be different?
 Would her management be different?
Implement Interventions
Canadian Best Practice Recommendations for Stroke Care, 2008
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2.7a Symptomatic Carotid Stenosis
 Patients with transient ischemic attack or
nondisabling stroke and ipsilateral 70-99% internal
carotid artery stenosis should be offered carotid
endarterectomy (CAE) within 2 weeks of the incident
TIA or stroke unless contraindicated.
o
CAE should be performed by a surgeon with a known perioperative
morbidity and mortality of <6%.
CMAJ 2008;179(12 Suppl):E1-E93 #2.7a
Acute Interventions & Management:
What if ?
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What if Mrs. Ivanna Nomore’s Holter
shows atrial fibrillation?
 Would her risk stratification be different?
 Would her management be different?
Medication Management
Canadian Best Practice Recommendations for Stroke Care, 2008
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 … if
they are likely to be complaint with the
required monitoring and are not at high
risk for bleeding complications.”
CMAJ 2008;179(12 Suppl):E1-E93 #2.6
Modify Stroke Risk Factors
Mrs. Ivanna Nomore
Modify Stroke Risk Factors: Mrs. Ivanna
Nomore
What are her modifiable risk factors?
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Hypertension
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Dyslipidemia
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Smoking
Diabetes
?
Heart Disease (Atrial Fibrillation) ?
Obesity
Dietary Habits
Physical Inactivity
Excess alcohol intake
Modifying Risk Factors: Mrs. Ivanna Nomore
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Reviewed patient education booklets “ You’ve had
a TIA” and/or “Taking Control” (HSFO)
Reviewed modifiable risk factors
Teaching provided on use of home BP monitoring
and trending values
Assisted in creating a plan to address blood
pressure
Discussed medication information sheets
LDL and BP targets reviewed and impact on risk
of recurrent stroke
Discussed stroke warning signs and what to do
Discussed local resources
Putting it all together: Local Resources
Insert Picture
Patient #2
Mr. Les Feeling
Putting it all together: Mr. Les Feeling
52 yr old male
 Presented to ED with complaint of sudden
onset of L arm numbness
 Lasted 5 minutes
 Symptoms now resolved
 Hx: smoker
 Meds: none
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Putting it all together: Mr. Les Feeling
Evaluate the event:
 VS= 35.7, 83, 140/85, 16
Investigations Ordered:
 Blood work
 lytes, INR, BUN, CR, glucose
CT, ECG, Doppler
 Neurological exam: normal
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Putting it all together: Mr. Les Feeling
Evaluate the event: Investigations
 Blood work: normal
 Fasting glucose and lipids ordered
 ECG=NSR
 Doppler booked next week
 CT head= normal
Putting it all together: Mr. Les Feeling
What is the urgency of managing Mr.
Feeling?
 Urgent
 What does this mean for the timing of his
tests?
 7days
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Putting it all together: Mr. Les Feeling
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Lab requisition for:
 LFT, CK, FBS, Lipid Profile
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Results:
 Total Cholesterol=5.2, TG=2.97, HDL= .90,
LDL= 3.7
 Fasting Blood Glucose=6.5mmol/L
 CK & LFT=Normal
Putting it all together: Mr. Les Feeling
It’s not emergent! Are we done?
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Yes
No
What are Mr. Les Feeling’s Risk Factors?
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√ PreHTN
Hypertension
High cholesterol
Smoking
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Diabetes
Heart Disease (Atrial Fibrillation)
Obesity
Physical Inactivity
Excess alcohol intake
Modify Stroke Risk Factors: Smoking
Canadian Best Practice Recommendations for Stroke Care, 2008
2.1.v. Smoking
 Smoking cessation and smoke free
environment; Nicotine replacement
therapy and behavioural therapy
 For nicotine replacement therapy,
nortriptyline therapy, nicotine receptor
partial agonist therapy and/or behavioural
therapy should be considered.
CMAJ 2008;179(12 Suppl):E1-E93 #2.1 v
Putting it all together: Patient Resources
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Health care providers need to know how
to support patients and families become
better at self management
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Local Resources for smoking cessation?
Putting it all together: Mr. Les Feeling
Warning Signs of Stroke, (HSFC, 2006)
•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 911
Putting it all together: System Resources
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Local Systems for rapid evaluation and
triage of TIA and minor stroke patients?
Summary
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Stroke is a leading cause of disability and death
80% of strokes are preventable
Acute management starts with symptom recognition
 Rapid ER protocols make a difference
 Rapid triage of TIAs prevent stroke
Prevention strategies can have a dramatic impact
 HTN, Smoking Cessation, Healthy Lifestyles,
Medication Adherence
Canadian Best Practice Recommendations for Stroke
Care, 2008 www.canadianstrokestrategy.ca
Canadian Best Practice Recommendations for Stroke Care, updated 2008
www.canadianstrokestrategy.ca