Transcript Canadian Best Practice Recommendations for Stroke Care

Preventing Strokes
One at a Time
Acute Interventions
and Management
2009
Acute Interventions & Management
Learning Objectives
Upon completion, participants will be able to:
 State the goal of managing patients with
medications following a transient ischemic attack
(TIA) or minor stroke
 Teach patients about their medications and the
importance of medication adherence
 Practice according to the Canadian Best Practice
Recommendations for Stroke Care as they relate
to interventional & medication management
Implement Interventions
Canadian Best Practice Recommendations for Stroke Care, 2008

3.2. Acute management of TIA and minor
stroke
 Patients who present with symptoms suggestive of
minor stroke or TIA must undergo a comprehensive
evaluation to confirm the diagnosis and begin
treatment to reduce the risk of major stroke as soon
as it is appropriate to the clinical situation.
CMAJ 2008;179(12 Suppl):E1-E93 #3.2
Implement Interventions
Medication Management




Interventional
Procedures
Antihypertensives
 ACEI (Angiotensin Converting  Carotid Stenosis
enzyme)
 Carotid Endarterectomy
 ARB (Angiotensin Receptor
 Carotid Artery Stenting
Blocker)
 Diuretics
 Calcium Channel Blockers
Lipid lowering agents
 Statins
Antithrombotic
 Antiplatelet
 Anticoagulant (Atrial fibrillation)
Optimize diabetes management
Medication Management
Medication Management

Goals of managing patients with medications
following a TIA or minor stroke:
 Minimize plaque formation
 Stabilize existing plaque
 Lowering risk of emboli in appropriate individuals

Medications include:
 Antihypertensive
 Statin
 Antithrombotic
Blood Pressure & Antihypertensives
Blood Pressure


Hypertension is the most significant modifiable
risk factor for stroke
Hypertension contributes up to 75% of all strokes
Injury to the blood vessel walls
↓
Scar is formed
↓
Build-up of plaque in arteries
↓
• Atherosclerosis
• Fragile arteries
• Left Ventricle dysfunction
Blood Pressure
Canadian Best Practice Recommendations for Stroke Care, 2008
2.2 Blood Pressure Assessment




All persons at risk for stroke should have their blood
pressure measured at each healthcare encounter but
no less than once annually.
Proper standardized techniques, as described by the
Canadian Hypertension Education Program, should be
followed for blood pressure measurement
Patients found to have elevated blood pressure should
undergo thorough assessment for the diagnosis of
hypertension following the current guidelines of the
Canadian Hypertension Education Program.
Patients with hypertension or at risk for hypertension
should be advised on lifestyle modifications.
CMAJ 2008;179(12 Suppl):E1-E93.
Blood Pressure
Canadian Best Practice Recommendations for Stroke Care, 2008
2.2 Blood Pressure Management
 The Canadian Stroke Strategy recommends target blood
pressure levels as defined by CHEP guidelines for
prevention of first stroke, recurrent stroke and other vascular
events.
 RCTs have not defined the optimal time to initiate blood
pressure lowering therapy after stroke/TIA. It is recommended
that blood pressure lowering treatment be initiated (or
modified) prior to discharge from hospital. For patients
with non-disabling stroke or TIA not requiring
hospitalization, it is recommended that blood pressure lowering
treatment be initiated (or modified) at the time of first
medical assessment.
CMAJ 2008;179(12 Suppl):E1-E93.
Blood Pressure
Assessment Highlights (CHEP, 2009)



Blood pressure is to be assessed at all
appropriate visits
Encourage patients to use appropriate devices
and proper techniques for home BP measuring
Home measurement aids blood pressure control
 Helps to diagnose white coat and masked hypertension
 Improves medication adherence
 Aids in faster diagnosis
2009 Canadian Hypertension Education Program Recommendations
Blood Pressure
Management Highlights, (CHEP, 2009)







Treat to target
 <140/90 mmHg
 <130/80 mmHg (diabetes or chronic kidney disease)
Age should not be a consideration in treatment
Sustained lifestyle modification to manage overall cardiovascular
risk
Self efficacy and engagement are key to adherence
Treat hypertension with multiple antihypertensives
Reduce dietary sodium
www.hypertension.ca/bpc
2009 Canadian Hypertension Education Program Recommendations
Blood Pressure
Treatment in TIA/Previous stroke (CHEP, 2009)
 Initial therapy:
 Treatment with combination of ACEI & diuretic preferred
 Choice of agent will depend on comorbidities
o

Other choices: ARB, Calcium Channel Blocker, Beta Blockers
Second–line therapy:
 Combinations of additional agents

Notes/Cautions:
 Recommendations do not apply to acute stroke
 BP reduction reduces CV events in stable patients
 Combination of an ACEI & ARB is not recommended
2009 Canadian Hypertension Education Program Recommendations
Blood Pressure
Patient Education: Angiotensin Converting Enzyme Inhibitor
 Take same time every day
 Contraindicated in patients with renal stenosis
 May increase creatinine, urea and potassium
 May have a persistent, dry cough
 Can cause angioedema (1/500)
 Other S/E:
 Dizziness, feeling faint
 Swelling of feet
 Diarrhea
 Taste disturbance
 HA
Blood Pressure
Patient Education: Angiotensin II Receptor Blockers
 Well tolerated
 Contraindicated in patients with renal stenosis
 May increase creatinine, urea and potassium
LIPIDS & STATINS
“High cholesterol and lipids in the
blood are associated with a higher risk
of both stroke and heart attack.”
CMAJ 2008;179(12 Suppl):E1-E93 #2.3.
Lipids

What is a “lipid profile”
 Made up of cholesterol and triglycerides
o
o
o
LDL: “bad” cholesterol
HDL: good cholesterol
Triglycerides: “bad”
 Impacted by gender, age, genetics,
lifestyle and eating habits
Lipids
Canadian Best Practice Recommendations for Stroke Care, 2008
2.3a Lipid Assessment



Fasting lipid levels (TC,TG,LDL-C,HDL-C) should
be measured every 1-3 years for all men 40 years
or older and post menopausal women and/or 50 years
or older.
More frequent testing should be done for patients
with abnormal values or if treatment is initiated.
Adults at any age should have their blood lipid levels
measured if they have a history of diabetes, smoking,
hypertension, obesity, ischemic heart disease, renal
vascular disease, peripheral vascular disease, ischemic
stroke, TIA or symptomatic carotid stenosis.
CMAJ 2008;179(12 Suppl):E1-E93 #2.3a
Lipids
Canadian Best Practice Recommendations for Stroke Care
2.3b. Lipid Management
 Ischemic stroke patients with LDL-C of >2mmol/L
should be managed with lifestyle modification and
dietary guidelines.
 Statin agents should be prescribed for most
patients who have had an ischemic stroke or
TIA to achieve current recommended lipid
levels.
CMAJ 2008;179(12 Suppl):E1-E93.
Lipids
Statins
First line agents for dyslipidemia
 Reduce stroke risk by 25-30%
 Target LDL-C< 2.0 mmol/L
 Decrease progression and/or induce
regression of carotid artery plaque
 Treatment based on assessment of
absolute risk of CVD not just LDL value

Heart Protection Study
Lipids
How do statins prevent ischemic stroke?
 Lipid effects
 LDL lowering

Non-Lipid effects






Stabilizing plaques
Improving endothelial function
Decreasing inflammation
Decreasing platelet aggregation
Directly lowering blood pressure
Decreasing cardiac emboli
Lipids
Statins: Patient Education Points






Take once a day with largest meal in evening
May be prescribed when cholesterol levels are normal
Blood work required for follow-up
May interact with antidepressants, antibiotics &
immunosuppressants
Avoid grapefruit juice
Possible side effects:
 Mild nausea, diarrhea, constipation
 Some muscle pain/weakness is normal (2-10%)
 Extreme muscle pain/weakness (serious but rare)
Antithrombotics
Antiplatelets
Anticoagulants
2.5 Antiplatelet Therapy
Canadian Best Practice Recommendations for Stroke Care, 2008

All patients with ischemic stroke or transient
ischemic attack should be prescribed antiplatelet
therapy for secondary prevention of recurrent
stroke unless there is an indication for
anticoagulation.
 ASA, combined ASA (25 mg) and extended-release
dipyridamole (200mg) or Clopidogrel may be used
depending on the clinical circumstances.
CMAJ 2008;179(12 Suppl):E1-E93 #2.5
Canadian Best Practice Recommendations for Stroke Care, 2008
2.5 Antiplatelet Therapy continued


For adult patients on ASA, the usual maintenance
dosage is 80-325 mg/day and in children with
stroke the usual maintenance dosage of ASA is 35 mg/kg/day for the prevention of recurrent
stroke
Long term combination of ASA & Clopidogrel are
not recommended for secondary stroke
prevention
CMAJ 2008;179(12 Suppl):E1-E93 #2.5
Aspirin: Patient Education Points
 Take one pill, once a day, everyday
 More is not better
 Most common side effects include
 GI upset (take with meals, use EC-ASA)
 bruise easier
 bleed longer

Consult a doctor immediately if you have
unusual or excessive bleeding
Aggrenox: Patient Education




Do not chew or crush
1/5 people will have a headache in first 5 days
Always have a “plan B”
 If by the 5th day HA is intolerable, call the
physician and resume ASA
Other side effects:
 GI upset (take with food or water)
 Bleeding
Clopidogrel: Patient Education
 Take once a day, every day
 Best to take with meals
 Side effects:




Usually mild & improve on their own
GI upset
Bleeding
Skin rash
2.6 Antithrombotic therapy in atrial
fibrillation
Canadian Best Practice Recommendations for Stroke Care, 2008

“Patients with stroke and atrial fibrillation
should be treated with warfarin at a target
INR of 2.5, range 2.0-3.0 (target INR of
3.0 for mechanical cardiac valves, range
2.5-3.5) if they are likely to be compliant
with the required monitoring and are not at
high risk for bleeding complications.”
CMAJ 2008;179(12 Suppl):E1-E93 #2.6
Antithrombotic therapy in atrial
fibrillation
Patients with atrial fibrillation properly
anticoagulated = 68% RRR in recurrent
stroke
Cochrane, 2003
 Optimal time to begin anticoagulation
varies but should be prior to discharge

Warfarin: Patient Education Points


Doses of warfarin vary based on INR
INR testing
 Initially every few days
 Repeat 5-7 days after changing the dose of any drug




Take same time every day
Patient compliance essential to therapeutic levels
Avoid contact sports; report falls/unusual bleeding
Avoid drastic changes in diet/eating habits
 Keep dietary vitamin K consistent in diet
 Alcohol may affect action of warfarin
Adherence
Those who self administer their medications
typically take less than ½ of the
prescribed doses
Complex issue affected by patient factors,
physician based factors and health care
factors
Implement Interventional Procedures

Options for the TIA patient with carotid
stenosis
 Carotid Endarterectomy
 Carotid Stenting
2.7a Symptomatic Carotid Stenosis
Canadian Best Practice Recommendations for Stroke Care, 2008

Patients with transient ischemic attack or
nondisabling stroke and ipsilateral 70-99%
internal carotid artery stenosis (measured on a
catheter angiogram or by 2 concordant non invasive
imaging modalities) should be offered carotid
endarterectomy within 2 weeks of the incident TIA
or stroke unless contraindicated.
CMAJ 2008;179(12 Suppl):E1-E93 #2.7a
2.7a Symptomatic Carotid Stenosis cont.
Canadian Best Practice Recommendations for Stroke Care, 2008




Carotid endarterectomy is recommended for selected patients
with moderate (50 to 69%) symptomatic stenosis and these
patients should be evaluated by a physician with expertise in
stroke management
Carotid endarterectomy should be performed by a surgeon
with a known perioperative morbidity and mortality of <6%.
Carotid stenting may be considered for patients who are not
operative candidates for technical, anatomical or medical
reasons.
Carotid endarterectomy is contraindicated for patients with
mild (<50%) stenosis.
CMAJ 2008;179(12 Suppl):E1-E93 #2.7a
2.7b Asymptomatic Carotid Stenosis
Canadian Best Practice Recommendations for Stroke Care, 2008

Carotid endarterectomy may be considered for
selected patients with asymptomatic 60-99%
carotid stenosis.
 Patients should be less than 75 years old with a
surgical risk <3%, a life expectancy >5 years, and be
evaluated by a physician with expertise in stroke
management.
CMAJ 2008;179(12 Suppl):E1-E93 #2.7b
Studies to Support Acting Fast

EXPRESS Study
(Rothwell et al. Lancet; 2007:370: 1432-1442)
 Studied the effect of providing urgent treatment with
existing secondary stroke preventative strategies to
TIA/minor strokes not admitted to hospital
 Result: 80% reduction in risk of recurrent stroke
in 90 days

SOS-TIA
(Lavallee et al, 2007, Neurology)
 Suspected TIAs admitted to 24 hr clinic, investigations
completed within 4 hrs of admission
 Results: 90 day stroke rate=1.24% predicted rate
estimated from the ABCD2 score was 5.92%
Systems/Strategies Needed?





Role of a stroke prevention clinic is key to
evaluation and triage of all TIA and minor stroke
patients….treated surgically and medically
A process is needed to triage TIA and stroke
patients urgently
Timely investigations need to be completed to
determine etiology
Appropriate medications need to be initiated
Access to timely carotid intervention is required
when implicated
CMAJ 2008;179(12 Suppl):E1-E93.
An Approach to Secondary Stroke
Prevention
Four Step Process

Evaluate the Event √

Initiate Medications √

Implement Interventions √

Modify Stroke Risk Factors
APSS, February 2009
Canadian Best Practice Recommendations for Stroke Care, updated 2008
www.canadianstrokestrategy.ca