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The Stroke Continuum
MA Department of Public Health
2010
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CEU’s and CME’s
The Bureau of Infectious Disease Prevention, Response and Services,Massachusetts Department of PublicHealth, designates this educationalactivity for a maximum of 1 Credit.
Credits will be awarded after successfully completing this slide deck and obtaining atleast 80% correct answers on the post- test.
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Learning Objectives
Define 2 most common types of stroke. Identify the stroke continuum. List 4 modifiable stroke risk factors. Name 3 observable stroke signs or
symptoms. Describe reason for calling 9-1-1 for
stroke signs and symptoms. Articulate “door-to-needle” goal for tPA
administration.
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The Stroke Continuum
Prevention
Recognition
9-1-1
Emergency Medical Services
Emergency Department
Inpatient Hospitalization
Rehabilitation
Re-integration to the Community
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Stroke: What is it?
Injury or death of brain tissue from oxygen deprivation.
A life threatening emergency.
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Blood Supply to the Brain
Each artery supplies blood to specific areas of the brain.
Stroke occurs when one of these arteries to the brain either is blocked or bursts.
Source: National Stroke Association
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Motor and Sensory Function
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Transient Ischemic Attacks
Temporary blockage <24 hours duration.
Symptoms of numbness, trouble speaking, and loss of balance or coordination.
Increased risk of having stroke within 90 days.
Source: National Stroke Association
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Ischemic Stroke
Clot cuts off oxygen to a part of the brain.
Most common stroke (80 – 85% of all strokes).
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Types of Ischemic Strokes
Embolic A blood clot or
plaque fragment that forms in the body moving through the bloodstream to the brain.
ThromboticA blood clot thatdoes not travel butforms inside anartery supplyingblood to the brain.
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Hemorrhagic Stroke
Burst blood vessel in brain that spills blood into brain tissue.
Accounts for about 15-20% of all strokes.
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Types of Hemorrhagic Stroke
Intracerebral hemorrhage: Blood vessel bursts into the brain High blood pressure most common cause
Aneurysm: Weak spot on artery wall that balloons out,
forming a thin-walled bubble Leaks blood into or outside of the brain
Subarachnoid hemorrhage: Blood vessel bursts near surface of brain
pouring blood into area outside brain Increases pressure on brain
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Facts About Stroke Stroke can happen at any time,
regardless of race, sex or age. Every 40 seconds someone in the US
has a stroke. Every 3-4 minutes, someone dies from
stroke. Two million brain cells die every minute
during stroke, increasing the risk of permanent brain damage, disability or death.
National Stroke Association
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Facts About Stroke in Massachusetts
In 2007, stroke accounted for 5.1% (2,700) of all deaths and remains the third leading cause of death.
MA Vital Records 2007
In 2007, 2.4% of adults reported having had a stroke.
MA BRFSS 2007 Over 17,000 patients are hospitalized
for stroke every year.
MA Hospital Discharge Data 2004-2007
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Disability
Stroke is a leading cause of adult disability in the US.
With timely treatment, the risk of death and disability from stroke can be lowered.
In 2010, stroke will cost the US $73.7 billion in health care services, medications, and lost productivity.
CDC; AHA
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The Stroke Continuum
Prevention
Recognition
9-1-1
Emergency Medical Services
Emergency Department
Inpatient Hospitalization
Rehabilitation
Re-integration to the Community
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Modifiable Risk Factors for Stroke
High Blood Pressure Overweight/Obesity Diabetes High Cholesterol Tobacco Exposure Excessive alcohol consumption Drug Abuse Atrial Fibrillation
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High Blood Pressure
High blood pressure – higher than 140/90. Approximately 30% of adults are unaware of
their high blood pressure. JNC-7
More than 40% of individuals with high blood pressure are not on treatment. JNC-7
2/3 of people with high blood pressure are not controlled to BP levels <140/90. JNC-7
26% of Massachusetts adults have high blood pressure. MA BRFSS 2007
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47
Extent of Awareness, Treatment and Control of High Blood Extent of Awareness, Treatment and Control of High Blood Pressure by Age Pressure by Age (NHANES: 2005(NHANES: 2005--2006).2006).Source: NCHS and NHLBI.Source: NCHS and NHLBI.
53.8
33.127.9
67.2
48.8
77.279.9 82.4
45.9
0102030405060708090
Awareness Treatment Controlled
Pe
rce
nt
of
Po
pu
lati
on
Wit
h
Hyp
erte
ns
ion
20-39 40-59 60+
Awareness, Treatment and Control of High Blood Pressure by
Age
NHANES: 2005-2006. Source NCHS and NHLBI
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High Blood Pressure in MA Adults by Age and Gender
MA BRFSS 2005, 2007
16%
28%
43%
53%56%
10%
23%
39%
56%62%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
35 - 44 45 - 54 55 - 64 65 - 74 75+
Per
cen
t o
f A
du
lts
age
35 a
nd
old
er Men Women
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High Blood Pressure in MA Adults by Race, Ethnicity and Gender
MA BRFSS 2003,2005, 2007
0%
10%
20%
30%
40%
50%
WNHWomen
BNHWomen
Hisp.Women
WNH Men BNH Men Hisp. Men
Per
cen
t o
f A
du
lts
35 a
nd
old
er
2003 2005 2007
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Overweight and Obesity in Massachusetts
56.1% of adults are overweight or obese.
22% of adults are obese. 73% do not eat the recommended.
five or more servings of vegetables and fruits a day.
49% do not get regular physical activity.
MA BRFSS 2007
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Obesity Trends Among U.S. Adults, 1995
No Data <10% 10%–14% 15%–19%
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Obesity Trends Among U.S. Adults, 2000
No Data <10% 10%–14% 15%–19% ≥20%
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Obesity Trends Among U.S Adults, 2005
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
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Diabetes
In Massachusetts, 7.4% of adults have been diagnosed with diabetes. MA BRFSS 2007
CDC estimates that an additional 2.2%
of Massachusetts adults don’t know that they have diabetes.
People with diabetes are two to four times more likely to have a stroke.
National Stroke Association
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NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). Source: Health, United States, 2006, NCHS.Source: Health, United States, 2006, NCHS.
4.06.16.5
5.0
11.3 10.5
17.017.5
02468
101214161820
6-11 12-19
Per
cent
of P
opul
atio
n
1971-74 1976-80 1988-94 2001-2004
Overweight and Obesity in US Children and Adolescents
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High Cholesterol in MA
35.6% of MA adults have high cholesterol. MA BRFSS 2001-2007
The prevalence of high cholesterol has been increasing each year.
MA BRFSS 2001-2007
Low HDL cholesterol (the “good” kind) in men is a risk factor for stroke. American Stroke Association
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TobaccoCigarette smoking
approximately doubles a person’s risk for stroke. CDC
In MA, the cities of Springfield, Fall River, New Bedford, Lowell, and Worcester have significantly higher rates of smoking than MA overall. MA BRFSS 2007
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Excessive Alcohol Consumption
Chronic, excessive alcohol intake can precipitate hemorrhagic stroke:No more than 2 drinks per day for men
and no more than 1 drink per day for non-pregnant women. AHA
Most risk from excess alcohol intake is likely due to high blood pressure and impaired blood clotting mechanisms. National Stroke Association
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Drug Abuse
Use of cocaine, amphetamines, and heroin associated with an increased risk of stroke.
Strokes caused by drug abuse are often seen in a younger population.
American Heart Association
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Atrial Fibrillation
Characterized by an irregular and frequently fast heartbeat, atrial fibrillation (AFib) is the most common form of heart arrhythmia.
Associated with a five-fold increase in risk for stroke.
About 15% of people with strokes have Afib.
Increases the risk of death from stroke. National Stroke Association
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The Stroke Continuum
Prevention
Recognition
9-1-1
Emergency Medical Services
Emergency Department
Inpatient Hospitalization
Rehabilitation
Re-integration to the Community
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Signs and Symptoms
Only 23.3% of Massachusetts adults recognize all stroke signs and symptoms.
MA BRFSS 2007
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Stroke Heroes Act FASTEducational kit for Train the
Trainer Model. Media campaign – TV, radio,
newspaper and transit ads.Cultural adaptation – English,
Spanish, Portuguese, and Khmer.
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Stroke Heroes Act FAST
ADD ANIMATION HERE
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F = Face Droops on left or right side Sudden drooling Numbness
Ask person to smile
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A = Arms Look for difficulty holding things or putting on
clothing Numbness One arm drifts down or
won’t go up May have trouble walking
Ask person to raise both arms
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S = Speech Slurred speech Doesn’t make sense May not understand what other people are
saying Forgets how to
read or write
Ask to repeat phrase
or name object
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T = Time Time lost is brain lost Save time and brain cells, go in an
ambulance
At any sign, Call 9-1-1
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The “Suddens” SuddenSudden numbness or weakness of face, numbness or weakness of face,
arm, or leg, especially on one side.arm, or leg, especially on one side. SuddenSudden confusion, trouble speaking or confusion, trouble speaking or
understanding speech.understanding speech. SuddenSudden trouble seeing in one or both trouble seeing in one or both
eyes.eyes. SuddenSudden trouble walking, dizziness, loss of trouble walking, dizziness, loss of
balance or coordination.balance or coordination. SuddenSudden severe headache with no known severe headache with no known
cause.cause.
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The Stroke Continuum
Prevention
Recognition
9-1-1
Emergency Medical Services
Emergency Department
Inpatient Hospitalization
Rehabilitation
Re-integration to the Community
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Time Lost = Brain Lost
Delays in calling 9-1-1:Most strokes are painless.Symptoms can be subtle.Person having a stroke may be unaware or unable to communicate.
Observers do not recognize it as a serious problem.
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EMS Care is Critical
Identification of stroke by conducting stroke scale assessment.
Establish “last known well” time.Pre-notification to hospital to
activate stroke team.Transport to most appropriate
hospital for stroke care.
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The Stroke Continuum
Prevention
Recognition
9-1-1
Emergency Medical Services
Emergency Department
Inpatient Hospitalization
Rehabilitation
Re-integration to the Community
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Primary Stroke Service (PSS) in MA
MDPH regulations passed by the state legislature in 2004.
Assure ambulances take patients to hospitals that can provide definitive care.
Improve coordination of care/pre-hospital care for persons experiencing stroke symptoms.
Assure hospitals have systems in place to accurately diagnose and treat, 24 hours per day, 7 days per week.
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Primary Stroke Service (PSS) in MA
Assure data available to monitor system performance.
Emergency diagnostic and therapeutic services provided by a multidisciplinary team.
Time targets: Door-to-stroke team: 15 minutes Door-to-CT scan: 25 minutes Door-to-needle: 60 minutes
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Stroke Treatment
Activase® (alteplase, recombinant, IV-tPA, tPA), was approved by the FDA for the treatment of acute ischemic stroke. IV-tPA is recommended for selected patients
within 3 hours of “last known well”. (Class I, LOE A)
IV-tPA should be administered to eligible patients within 3.0-4.5 hours of “last known well”. (Class I Recommendation, LOE B)
Adams, Stroke 2007
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Meta-Analysis of the major IV tPA trials shows clear benefit up to 3 hrs and NOW beyond
Lancet, 2004; 363: 768–74
NINDS 12% ECASS3 7%
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Door to Needle Time
The benefit of IV-tPA in stroke is strongly time dependent.
It is best right after symptom onset and declines steadily thereafter:1.9 million neurons lost per minute,For every 10 minute delay in tPA
delivery, 1 less patient improves. BAC/AHA/NIH recommendation: door to
needle time < 60 minutes. Only 27% of tPA patients at PSS hospitals
were treated within 60 minutes of arrival.
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Impediments to tPA Use
Patient arrival at Emergency Department beyond 3-hour window.
Clinician acceptance of tPA due to risk of bleeding complications.
Institutional attitude and support related to the ability of medical systems to rapidly evaluate and treat stroke within the timeframe.
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CDC’s Paul Coverdell National Acute Stroke Registry
Goal: to ensure that all Americans receive the highest quality of acute stroke care currently available and to reduce the number of untimely deaths attributable to stroke, prevent stroke-related disability, and prevent stroke patients from suffering recurrent strokes.
Focus: monitoring and improving the quality of stroke care for acute (Emergency Department), inpatient and secondary prevention (discharge) performance measures.
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Get With The Guidelines (GWTG)-Stroke
Quality improvement for in-hospital acute care.
National program with over 1,600 hospitals and 1 million patient entries in registry.
Data management tool by Outcomes Science.
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Stroke Performance Measures
In 2007, The Joint Commission, CDC, and the American Heart Association formed a Consensus Group to harmonize the stroke measures being collected by the three organizations. The result was the set of 10 consensus measures.
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Consensus MeasuresConsensus Measures(* = Get With The Guidelines Performance (* = Get With The Guidelines Performance Measure)Measure)
1. Thrombolytic Therapy Administered*2. Antithrombotic Therapy by end of hospital day 2*3. DVT Prophylaxis*4. Discharged on Cholesterol Reducing Medication*5. Discharged on Antithrombotics* 6. Patients with A-Fib receiving Anticoagulation Therapy*7. Smoking Cessation/Advice/Counseling*8. Dysphagia Screening9. Stroke Education10. Assessed for Rehabilitation
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Massachusetts Stroke Registry
Collaboration between MDPH, American Stroke Association, and PSS Hospitals, focusing on quality improvement, standardized performance measures, and systems changes.
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IV-tPA Use at SCORE Hospitals
Data from 56 SCORE hospitals Registry data from 1/07-12/08~8,000 statewide ischemic stroke patients
entered into registry~1,000 ischemic stroke patients with no
contraindications to tPA arrived within 2 hrs of last known well
~550 eligible ischemic stroke patients or 55% received tPA
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SCORE Acute Measures
67%
56%
68%71%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
tPA within 3hrs of Onset
% A
dhere
nce
2006 2007 2008 2009
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SCORE Inpatient Measures
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Dysphagia Screen DVT Prophylaxis Antithroms by Day 2
% A
dher
ence
Q4 2008 Q1 2009 Q2 2009 Q3 2009 Q4 2009
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SCORE Discharge Measures
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
D/ C onAntithroms
D/ C onAnticoagsfor Afib
SmokingCessation
D/ C on aStatin
StrokeEducation
Rehab
% A
dhere
nce
Q4 2008 Q1 2009 Q2 2009 Q3 2009 Q4 2009
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The Stroke Continuum
Prevention
Recognition
9-1-1
Emergency Medical Services
Emergency Department
Inpatient Hospitalization
Rehabilitation
Re-integration to the Community
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Transition of Care from Hospital to Outpatient Services
Improving hospital discharge. Better coordination of care. Improve communication between
sending and receiving healthcare providers.
Improve patient safety. Reduce medication errors.
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CEU’s and CME’s
To apply for CME/CEU credits, fill out the post-test at:
http://bit.ly/10mJhof
Credits will be awarded after successfully completing this slide deck and obtaining atleast 80% correct answers on the post- test.
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Questions, Comments…
Mirian Barrientos, MPH, CPHQHeart Disease & Stroke Prevention & Control Program
Massachusetts Department of Public Health250 Washington Street, 4th FloorBoston, MA 02108Tel: (617) 624-6065Fax: (617) [email protected]