Transcript Can We prevent a stroke

BRAIN ATTACK
SECONDARY STROKE PREVENTION STRATEGIES:
Recurrent Stroke Can Be Prevented!
Carolyn Walker RN, BN
January 2011
Learning Objectives
Upon completion of this program, participants
will be able to:
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Discuss the incidence of stroke and the risk of
recurrent stroke
Describe four components of secondary stroke
prevention
Explain strategies to reduce the risk of recurrent stroke
Second Strokes
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Stroke or TIA survivors have an increased risk of a
subsequent stroke
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Recurrent strokes are more likely than initial strokes to
result in disability and death
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~ 20%-40% of strokes are preceded by a TIA or non
disabling stroke
(Rothwell et al. Lancet Neurol 2006; 5: 323-331)
Golden Opportunity for Stroke Prevention!
Risk Factors for Stroke
Modifiable
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Hypertension
Dyslipidemia
Nonmodifiable
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Diabetes
Metabolic syndrome
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Atrial fibrillation
TIA/prior stroke
Carotid stenosis
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Cigarette smoking
Alcohol abuse
Obesity
Physical inactivity
Obstructive sleep apnea
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Age
Gender
Race/ethnicity
Heredity
Cardiovascular Disease
Goldstein L, et al. Circulation. 2001;103:163-182.
Broderick J, et al. Stroke. 1998;29:415-421.
Brown WV. Clin Cornerstone. 2004;6(suppl 3):S30-S34.
Approach to Secondary Stroke Prevention
Components:
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Evaluate the Event
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Implement Interventions
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Initiate Medications
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Modify Stroke Risk Factor: Continuous
Monitoring
Evaluate the Event
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TIA/Minor Stroke Risk Assessment
 Clinical Predictors
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Investigations
 CT, MRI, ECG, Carotid imaging,
echocardiogram
Evaluate the Event:
TIA / Minor Stroke Risk Assessment
TIA Stroke Risk Assessment
High Risk
1. Symptom onset within the last 48 hours with any one of the
following :
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Motor deficit lasting more than 5 minutes
Speech deficit lasting more than 5 minutes
ABCD2 score ≥ 4
2. Atrial fibrillation with TIA
Evaluate the Event:
TIA / Minor Stroke Risk Assessment
TIA Stroke Risk Assessment
Medium Risk
Symptom onset between 48 hours and 7 days with any one of the following :
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Motor deficit lasting more than 5 minutes
Speech deficit lasting more than 5 minutes
ABCD2 score ≥ 4
Low Risk
1. Symptom onset > 7 days
2. Symptom onset ≤ 7 days without the presence of high risk symptoms
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Speech deficit, motor deficit, ABCD2 score ≥ 4, atrial fibrillation with TIA
** Isolated syncope or dizziness is rarely a TIA and may not require Stroke
Prevention Clinic Referral
Evaluate the Event: Investigations
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CT or MRI
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Carotid Imaging (carotid duplex, CTA or MRA)
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Rule out mimics, identify stroke type
Identify stenosis
ECG
? Cardiac cause - afib
 Holter monitor
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Echocardiogram
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If suspect cardiac cause
Labs - CBC, lytes, Cr, gluc, PTT, INR, fasting lipids
IMPLEMENT
INTERVENTIONS
ACT FAST WITH HIGH RISK
PATIENTS!
Carotid Endarterectomy
If TIA due to ≥ 50% stenosis in extracranial internal
carotid artery consider CEA
Greatest benefit if surgery within 2 weeks
Rothwell et al. Lancet; 2004; 363: 915-25
INITIATE
MEDICATIONS
Initiate Medications:
Antithrombotic Therapy
Aspirin (50-325 mg/day) is first line treatment
 If aspirin naïve- load with 160mg then 81 mg OD
 May administer aspirin only if CT not available and
symptoms resolved
 If symptoms not resolved must have CT to exclude hemorrhage
Options:
Aspirin/extended release dipyridamole
 25mg/200mg BID
Clopidogrel
 75 mg OD, consider loading with 300 mg
Initiate Medications:
Antithrombotic Therapy
If cardioembolic source: Atrial Fibrillation
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Long-term anticoagulation (Warfarin)
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Target INR 2.0 - 2.5
Antiplatelet/Anticoagulation
Therapy
If cardioembolic source:
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Long-term anticoagulation – Dabigatran
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Dabigatran 150 mg BID
Recommendations
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1. We recommend that all patients with AF or AFL
(paroxysmal, persistent or permanent), should be
stratified using a predictive index for stroke (e.g.
CHADS2) and for the risk of bleeding (e.g. HASBLED), and that most patients should receive
antithrombotic therapy. (Strong recommendation, High
Quality Evidence)
Leadership. Knowledge. Community.
20
Leadership. Knowledge. Community.
Recommendations
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21
1. We recommend that all patients with AF or AFL
(paroxysmal, persistent or permanent), should be
stratified using a predictive index for stroke (e.g.
CHADS2) and for the risk of bleeding (e.g. HASBLED), and that most patients should receive
antithrombotic therapy. (Strong recommendation, High
Qulaity Evidence)
Leadership. Knowledge. Community.
Bleeding Risk – HAS-BLED Score
www.escardio.org
Recommendations
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23
1. We recommend that all patients with AF or AFL
(paroxysmal, persistant or permanent), should be
stratified using a predictive index for stroke (e.g.
CHADS2) and for the risk of bleeding (e.g. HASBLED), and that most patients should receive
antithrombotic therapy. (Strong
Recommendation, High Quality Evidence)
Leadership. Knowledge. Community.
Recommendations - Antithrombotic
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24
2. We recommend that patients at very low risk of
stroke (CHADS2 = 0) should receive aspirin (75325 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).
Leadership. Knowledge. Community.
Recommendations - Antithrombotic
25
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3. 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).
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4. 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)
Leadership. Knowledge. Community.
Recommendations - Antithrombotic
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26
5. 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).
Leadership. Knowledge. Community.
MODIFY RISK
FACTORS
Add diabetes and afib information
Modifiable Stroke Risk Factors
Medical conditions
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High Blood Pressure
High blood cholesterol
Obesity
Diabetes
Cardiac diseases
 Atrial fibrillation
 Coronary artery disease
Carotid stenosis
Prior TIA or stroke
Behaviors
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Cigarette smoking
Heavy alcohol use
Physical inactivity
Treating Hypertension to Prevent
Stroke
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HTN is the single most important modifiable
risk factor for stroke
HTN contributes to 70% of all strokes
Atheroma in carotids, aortic arch
 Friability of small cerebral end arteries
 LV dysfunction and atrial fibrillation
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Benefits of Treating Hypertension
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Younger than 60 yrs
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Reduces the risk of stroke by 42%
Reduces the risk of coronary event by 14%
Older than 60yrs
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Reduces overall mortality by 20%
Reduces cardiovascular mortality by 33%
Reduces incidence of stroke by 40%
Reduces coronary artery disease by 15%
Treat Hypertension Aggressively
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Target most patients still < 140/90
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Lifestyle Modification:
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Home Measurement: < 135/85
Diabetics or chronic kidney disease:
< 130/80
Sodium restriction, DASH diet, physical activity, weight
loss, alcohol restriction, smoking cessation
Expect to use combination therapy
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ACE inhibitor, ARB, diuretic
Lifestyle Recommendations
1.
Healthy diet; High in fresh fruits, vegetables and low fat dairy
products, low in saturated fat and salt in accordance with the
DASH diet
2.
Regular physical activity: optimum 20-60 minutes of moderate
cardiorespiratory activity 3-5/week or more
3.
Reduction in alcohol consumption in those who drink
excessively (<2 drinks/ day)
4.
Weight loss (> 5 Kg) in those who are over weight (BMI>25)
5.
Smoke free environment
Follow a Healthy Eating Plan
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Blood Pressure can be lowered by:
 Following
the DASH eating plan
 Reducing the amount of sodium intake
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Combination of both gives the biggest
benefit
Dietary Approaches to Stop Hypertension:
DASH Diet
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Rich in fruits, vegetables, low fat dairy
foods, and low in fat, total fat,
cholesterol and salt
The low sodium DASH diet evaluated
the effect of reducing sodium intake in
combination with a DASH diet. BP fell
11.4/5.5 mmHg in hypertensive
persons compared to 3.5/2.1 in
normotensives
Source: Appel et al. N Engl J Med 1997;336:1117.
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The DASH eating plan is available at
www.nhlbi.nih.gov/health/public/heart/hbp
/dash
Sodium Reduction
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For hypertensive patients
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Ask how much fresh foods and
unprocessed foods they consume
Ask about processed and fast foods
 dietary sodium to target range:
65-100mmol/day (2/3-1 tsp table salt/day).
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Counsel to avoid excessive salt intake
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Avoid fast and processed foods
minimize use of salt at the table and
during cooking
Up to 30% of hypertension can be
attributed to high sodium diets
Canadian Stroke Strategy 2010
Recommendation: Sodium
Recommended Daily sodium intake:
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9-50 years: 1500mg
50-70 years:1300mg
> 70 years: 1200mg
Daily upper limit:
2300mg
Tips to Reduce Salt
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Buy fresh, plain frozen or canned “with no salt added”
vegetables
Use fresh poultry, fish and lean meat, rather than canned or
processed
Use herbs, spices & salt-free seasoning blends
Cook rice, pasta & hot cereal without salt. Cut back on
instant or flavoured dishes.
Cut back on frozen dinners, pizza, packaged mixes, canned
soups and salad dressing
Rinse canned foods
Limit cured foods (bacon and ham), foods packed in brine
(pickles, pickled foods) & condiments.
Physical Activity
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Evidence that mild
hypertension can be
treated with moderate
physical activity alone
Of particular note:
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Significant  BP after 4 to 5
wks
Effect persisted as long as
patient exercised,
reversible if training
stopped
Daily physical activity not
essential to get
antihypertensive effect
Age, race, sex has no effect
on the benefit derived
Physical Activity
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The Heart and Stroke Foundation
recommends that clients be prescribed
exercise to reduce blood pressure
Think FITT
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Frequent (4 or more days of the week)
Intensity (moderate)
Time (optimum 30-60 minutes)
Type (dynamic – walking, cycling,
swimming)
Physical activity should be prescribed
as adjunctive therapy for those
patients prescribed pharmacotherapy
Drink Alcohol in Moderation
Low risk alcohol consumption
• 0-2 standard drinks/day
• Men: maximum of 14 standard drinks/week
• Women: maximum of 9 standard drinks/week
A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or 12 oz of
beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).
Aim For A Healthy Weight
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Blood Pressure rises as body weight increases
Losing even 5-10 lbs can lower your BP
Two key measures used:
 Waist
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circumference:
<80 cm for women and <94 cm for men
 BMI
- weight (kg) / height (m2)
an approximation of total body fat.
 Healthy BMI: 18.5-24.9 kg/m2
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Weight Management
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Being overweight puts extra strain on the body
as it creates extra tissue that must be supplied
with blood
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Greater chance of developing:
high blood pressure
 diabetes
 high cholesterol
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Smoking
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Stroke risk may be
doubled in smokers
Smoking:
raises blood pressure
 thickens the blood
 speeds up hardening of the
arteries
 decreases HDL
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Suggested Smoking Cessation Approach:
Using the Stages of Change
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Pre-contemplation
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Contemplation
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Not thinking seriously about quitting
Goal: Encourage smoker to think about the personal
impact of smoking
Thinking about quitting in the next six months
Goal: Discuss health effects of smoking and benefits
of quitting. Offer follow-up and set date for next
appointment.
Preparation
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Preparing to quit in next month and has tried to quit
in the past year
Goal: Assist the patient to select the best plan to be
smoke free. Set date for next appointment.
Suggested Approach, cont…
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Action
 Receptive to cessation advice. Actively trying to quit.
 Goal: Assist the patient in efforts to quit. Discuss relapse
prevention and replacing smoking with other behaviours
(physical activity, hobbies, etc.) Set date for next
appointment.
Maintenance
 Continues to remain smoke free for more than six
months. May “slip” and have occasional cigarette.
 Goal: Congratulate patient. Assist patient to find
strategies to prevent relapse.
Source: Prochaska JO, Diclemente CC. Understanding and using the stages of change. Program Training & Consultation
Centre, Ontario Tobacco Strategy, 1995.
Canadian Stroke Strategy 2010
Recommendation: Smoking
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Combination of pharmaological
therapy and behavioral therapy should
be considered
3 classes of agent should be
considered as first line therapy:
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Nicotine replacement
Bupropion
Varenicline
Smoking
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Two years after smoking cessation - stroke risk
is decreased
Five years after smoking cessation - stroke risk is
similar to that of a non-smoker
It is never too late to quit!!!
Stress Management
“There
is no evidence that stress management
prevents hypertension, but there is some
evidence that stress management can reduce BP
in hypertensive patients.”
Consider how stress contributes to hypertension
(e.g., unhealthy lifestyle choices such as smoking, drinking
and binge eating)
Consider
exercise as a treatment for stress
management
In patients whom stress is an important issue,
individualized cognitive behavioural interventions are
more likely to be effective when relaxation techniques
are employed
CMAJ 1999;160 (9 Suppl):S47 & S48.
Impact of Lifestyle Therapies on Blood
Pressure in Hypertensive Adults
Intervention
Amount
SBP/DBP
1.8g or 78 mmol/d
-5.1 / -2.7
per kg lost
-1.1 / -0.9
- 3.6 drinks/day
-3.9 / -2.4
Aerobic exercise
120-150 min/week
-4.9 / -3.7
Dietary patterns
DASH diet
Hypertensive
Normotensive
-11.4 / -5.5
-3.6 / -1.8
Reduce foods with
added sodium
Weight loss
Alcohol intake
Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat
hypertension Padwal R. et al. CMAJ ･ SEPT. 27, 2005; 173 (7) 749-751
Source: 2008 CHEP Recommendations
Hypercholesterolemia:
Using Statins for Secondary
Prevention of Stroke
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Lipid-lowering trials using statins have shown
benefit in decreasing progression and/or
inducing regression of carotid artery plaque
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Lipid-lowering trials using statins for secondary
prevention (of CHD) have shown benefit in
stroke prevention
Why Should Statins Prevent
Ischemic Stroke?
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Lipid effects = LDL lowering
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Target LDL-C < 2.0 mmol/L (in stroke patients)
Non-lipid effects =
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Stabilizing plaques
Improving endothelial function
Decreasing inflammation
Decreasing platelet aggregation
Directly lowering blood pressure
Decreasing cardiac emboli
Cholesterol Lowering----
Interventions to Control Cholesterol:
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Diet
Exercise
Smoking Cessation
Alcohol Reduction
Glycemic Control
Medications
Secondary Stroke Prevention
Evaluate the Event:
Identify Events requiring Urgent intervention / Identify cause

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TIA / Minor Stroke Risk Assessment
Investigations
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CT, MRI, ECG, Carotid imaging, echocardiogram
Implement Interventions
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Carotid Endarterectomy
Stroke Prevention Clinic
Initiate Medications
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Antiplatelets /anticoagulants, ACE-I, Diuretics, ARB, statins
Modify Stroke Risk Factors
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Vascular Risk Factors
Behavioral/Lifestyle Risk Factors
Impact of Prevention
Strategies
Do they work ?
How Many Strokes Annually
Can Be Prevented by Risk-Factor Control?
Hypertension
360,500
Cholesterol
146,000
Cigarettes
89,500
Atrial Fibrillation
68,500
Heavy Alcohol Use
34,500
0
10,000
6400
5000
2500
100,000
200,000
Number of Preventable Strokes*
*Based on estimated 700,000 annual strokes.
Gorelick PB. Arch Neurol. 1995;52:347-355.
Gorelick PB. Stroke. 2002;33:862-875.
25,000
300,000
400,000
BRAIN ATTACK
STROKE CAN BE PREVENTED!