educational solutions for workforce development pharmacy stroke anne kinnear lead pharmacist nhs...
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Educational Solutions for Workforce Development
Pharmacy
STROKE
Anne Kinnear
Lead Pharmacist
NHS Lothian
Educational Solutions for Workforce Development
PharmacyAim
To update pharmacists on Stroke: the disease and its management and explore ways to implement pharmaceutical care for this patient group as part of normal working practice.
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PharmacyObjectives
• Describe the disease, identify risk factors and signs and symptoms associated with Stroke.
• Define the current therapeutic management of acute Stroke and secondary prevention measures.
• Identify pharmaceutical care issues and respond to symptoms in patient scenarios and identify appropriate management solutions.
• Explore how to implement the principles of a pharmaceutical care needs assessment tool in practice.
Educational Solutions for Workforce Development
Pharmacy
Stroke
Third commonest cause of death in Scotland15,000 stroke patients in Scotland annuallyOne of leading causes of disability in adults
Educational Solutions for Workforce Development
Pharmacy“Time is Brain”
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PharmacyStroke
2 million neurones per minute
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Pharmacy
How do you know if someone is having a stroke?
Educational Solutions for Workforce Development
PharmacyWhat is FAST?
F acial weakness - can the person smile? Has their mouth or eye drooped?
A rm weakness - can the person raise both arms?
S peech problems - can the person speak clearly and understand what you say?
T est – all 3
Educational Solutions for Workforce Development
PharmacyStroke WHO Definition
A neurological deficit (usually loss of function) caused by reduction in blood supply to the brain. This is usually because a blood vessel bursts or is blocked by a clot. This affects the supply of oxygen and nutrients, causing damage to the brain tissue.
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Pharmacy
Chest Heart and Stroke Definition
A stroke is a brain attack.
It happens when the blood supply to the brain is disrupted.
Most strokes occur when a blood clot blocks the flow of blood to the brain.
Some strokes are caused by bleeding in or around the brain from a burst blood vessel.
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PharmacyStroke
• Transient Ischaemic Attack (TIA) – a stroke which resolves within 24 hours
(10% risk of stroke within 7 days)
• Minor Stroke – a stroke resulting in persisting symptoms but not causing significant disability
• Major Stroke – a stroke resulting in persistent deficit
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PharmacyDiagnosis
Computed Tomography scan
(CT scan)
`Immediate`
Cerebral infarct
Cerebral Cerebral haemorrhagehaemorrhage
Diagnosis – stroke typeDiagnosis – stroke type
STROKESTROKE
CT CT scanscan
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PharmacyStroke
Educational Solutions for Workforce Development
PharmacyAtherosclerotic thrombosis
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PharmacyStroke
1 - Anterior cerebral artery 2 - Anterior communicating artery 3 - Internal carotid artery 4 - Posterior communicating
artery 5 - Middle cerebral artery 6 - Posterior cerebral artery 7 - Superior cerebellar artery 8 - Basilar artery 9 - Anterior inferior cerebellar
artery
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Pharmacy
Educational Solutions for Workforce Development
Pharmacy
Cerebrum – intellect, speech, emotion, sensory, movementCerebellum – balance, co-ordinationBrain stem – respiration, heart rate, blood pressure, wakefulness
Cerebrum - left hemisphere – speech and language
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Pharmacy
Risk factors
Risk Factors For Stroke: Treatable
Major
DiabetesHypertension SmokingLifestyleDietCholesterol Heart disease, esp. atrial fibrillation Transient ischaemic attacks
Less Well Documented
Excessive alcohol intake / drug abuse
Acute infection
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PharmacyRisk factors
Risk Factors for Stroke That Cannot Be Changed
Increased age
Being male
Race (e.g., African-Americans)
Family history of stroke
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Pharmacy
Evidence Base for Treatment
ACTIVE
PROGRESS
CHARISMA
SPARCL
ESPRIT
MATCH
PROFESS
RE-LY
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PharmacyAcute Secondary Prevention
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PharmacyAcute treatment
Thrombolysis
Antiplatelets
Blood pressure
Hydration
Oxygen
Blood glucose
Temperature
Educational Solutions for Workforce Development
PharmacyThrombolysis
• Lyses clot by digesting fibrinogen• Intravenous recombinant tissue plasminogen
activator (tPA - Alteplase) 0.9mg/kg after test dose• Within 4.5 hours (6hrs if IST-3 clinical trial)
• Reduces death and disability at 90 days• 2% incidence of symptomatic haemorrhage at 24 hrs• 8% incidence of symptomatic haemorrhage at 7 days
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PharmacyAntiplatelets
Aspirin 300mg within 48 hours continued for 14 days
• reduces 14 day mortality and morbidity
No evidence for: • Anticoagulants• Combinations of antiplatelets or antiplatelets
with anticoagulants• Neuroprotectants
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Pharmacy Blood pressure - not actively managed in acute phase
Hydration – IV Sodium Chloride 0.9% is preferred to glucose 5%
Blood glucose - treat if blood glucose is >11mmol/L
Oxygen - supplemental Oxygen if saturation <95%
Temperature – prescribe antipyretics
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PharmacySecondary Prevention Treatment
Educational Solutions for Workforce Development
PharmacyAntiplatelets
Educational Solutions for Workforce Development
PharmacyAntiplatelets
Evidence
Cochrane ReviewsDipyridamole MRClopidogrel vs Aspirin
Randomised Clinical Trials MATCH Aspirin + Clopidogrel vs Clopidogrel CHARISMA Aspirin + Clopidogrel vs Aspirin ESPRIT Aspirin + Dipyridamole MR vs either alone PROFESS Aspirin + Dipyridamole MR vs Clopidogrel
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PharmacyAntiplatelets
Aspirin and Dipyridamole MR in combination significantly reduces risk of vascular events compared to aspirin alone (approx 25% risk reduction)• without an increase in bleeding The combination of Aspirin and Clopidogrel is no more effective than either alone• is associated with an increase in moderate/life threatening bleeding•only 25% patients in studies had a history of previous stroke•used in acute coronary syndrome (NSTEMI) or carotid stenosis
Educational Solutions for Workforce Development
PharmacyAntiplatelets
The combination of Aspirin and Dipyridamole MR vs Clopidogrel showed no difference in efficacy
Educational Solutions for Workforce Development
PharmacyAntiplatelets
Recommendations
Clopidogrel 75mg daily OR Aspirin 75mg daily and Dipyridamole 200mg MR twice daily should be prescribed after ischaemic stroke for secondary prevention of vascular events
Aspirin alone – if dipyridamole intolerance (headache 26% withdrawal ESPRIT trial) - or if carotid stenosis 70% or unstable angina
The combination of aspirin and clopidogrel is not recommended for prevention of ischaemic stroke or TIA
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Pharmacy
StatinsEvidence2 x Systematic reviews (170000 pts)Randomised Clinical Trial – SPARCL (4700 pts)
• Statins significantly reduce relative risk of ischaemic stroke by 21% but stroke death is not reduced
• Effect occurs without an increase in haemorrhagic stroke
• Statins reduce coronary events and all cause mortality
• Effect occurs irrespective of baseline cholesterol level (proportional to LDL lowering)
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Pharmacy
Statins
Recommendations
A statin should be prescribed to patients who have had an ischaemic stroke irrespective of cholesterol level
Which statin?
Simvastatin 40mg – high risk coronary event
Atorvastatin 80mg – TIA / ischaemic stroke
Should not be used in patients with a prior history of intracerebral haemorrhage
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Pharmacy
AnticoagulantsNon-cardioembolic ischaemic stroke
EvidenceSystematic review Anticoagulant vs antiplateletRandomised clinical trial – ESPRIT
• Anticoagulants no more effective than aspirin• No difference in all cause mortality between antiplatelets
and low or medium anticoagulation• Higher mortality and major bleeding at intensive
anticoagulation
RecommendationAnticoagulation not recommended
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PharmacyAnticoagulantsAtrial fibrillation and ischaemic stroke
EvidenceRE-LY trial
• Warfarin MORE effective for prevention of all vascular events and recurrent stroke
• No significant increase in intracranial bleed• Not within 2 weeks
RecommendationWarfarin should be offered with target INR of 2.0-3.0OR Dabigatran (direct thrombin inhibitor) 110mg or 150mg twice a day may
become an alternative to warfarin
Educational Solutions for Workforce Development
PharmacyAnticoagulants
Atrial fibrillation and ischaemic stroke
Evidence
RE –LY trial (NEJM 2009)
• Warfarin versus Dabigatran in AF with primary outcome of stroke
Recommendation
Equal efficacy for warfarin and dabigatran with no worse safety profile for the dabigatran
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Pharmacy
Antihypertensives
Evidence
Well established link between BP reduction and stroke primary prevention
Systematic review (7 trials)Randomised Clinical Trial - PROGRESS Perindopril/Indapamide
• Lowering BP reduced recurrent stroke and major vascular events• No effect on vascular or all cause mortality• Reduction in stroke related to difference in systolic BP between
groups
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PharmacyAntihypertensives
Recommendation
BP should be assessed in all patients and therapy with an ACE inhibitor and thiazide diuretic should be considered regardless of BP
Target blood pressure is <140/85 – diabetics <130/80 mmHg
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Pharmacy
Summary Secondary Prevention of Ischaemic Stroke
Aspirin 75mg + Dipyridamole 200mg twice daily (or Clopidogrel 75mg if ACS)
Simvastatin 40mg / Atorvastatin 80mgThiazide diureticACE inhibitor
Warfarin or dabigatran if AF
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PharmacyPharmacist Role
Public health, education and information
Pharmaceutical care
Research
Multidisciplinary team membership
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Pharmacy
Public Health, education and information
Awareness and promotion of:
• Public Health campaigns• CHSS campaigns and resources • Risk factors – action to take• Stroke Identification – FAST test• Lifestyle advice – smoking, weight loss/diet, vitamins
Educational Solutions for Workforce Development
PharmacyPharmacist Role
Public health, education and information
Pharmaceutical care
Research
Multidisciplinary team membership
Educational Solutions for Workforce Development
PharmacyPharmaceutical Care
• Transfer of patient information primary/secondary care interface
- continuity of care- reduction of medication errors/discrepancies
• Identification and resolution of pharmaceutical care issues
- level and type of resultant disability
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Pharmacy
Modified Rankin Score (mRS) Disability Score
Score Symptoms
0 No symptoms
1 No significant disabling symptoms
2 Slight disability
3 Moderate disability
4 Moderate/severe disability
5 Severe disability
6 Dead
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PharmacyDisability
Dysphasia Aphasia
Dysphagia Aphagia
Hemiparesis
Hemiplegic
Hemianopia
Speech
Swallow
Weakness
Paralysis
Visual difficulties
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PharmacyPharmaceutical Care Issues
Speech
Comprehension
Swallow
Communication/counselling• carers
Ability to take medicines• aspiration risk and liquids• formulations• bioavailability eg phenytoin• NG and PEG tube feeding
Educational Solutions for Workforce Development
PharmacyStroke
Weakness or paralysis
Visual problems
Ability to operate devices• inhalers, insulin
Ability to open containers
Ability to read instructions• labels, leaflets, charts
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PharmacyPharmacist Role
Public health, education and information
Pharmaceutical care
Research
Multidisciplinary team membership
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PharmacyResearch
Practice development project – MSc Strathclyde University• Standardised pharmaceutical care plan validation• Validation of care issues for transfer – needs assessment tool
Pharmacist Research Fellow• Design and validate transfer document for stroke
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PharmacyResearch
Audit of prescribing adherence to stroke guidelines and design and evaluation of a pharmaceutical care model
• Prospective evaluation of prescribing in acute stroke unit patients against guidelines and development of a pharmaceutical care plan
• Retrospective evaluation of prescribing in the same patients
following discharge to primary care and design of documentation to facilitate information transfer between secondary and primary care
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PharmacyResearch
Primary Care - Results• adherence 75% (hospital 79% 94%)• lower for quality indicators not included in GMS contract• lower for communication criteria
Primary Care - Conclusions
Improvement areas for prescribing• use of warfarin in atrial fibrillation• achievement of clinical target blood pressure and glycaemic
control to audit and clinical standards
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PharmacyPharmacist Role
Public health, education and information
Pharmaceutical care
Research
Multidisciplinary team membership
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PharmacyMultidisciplinary team membership
SIGN – Scottish Intercollegiate Network
Managed Clinical Network for Stroke (MCN)
National Advisory Group for Stroke
Stroke Unit Multidisciplinary Team
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PharmacyStroke Key Messages
Time is brain
Think FAST
Brain attack – dial 999
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PharmacyUseful Contacts