preventing strokes one at a time putting it all together 2009

Preventing Strokes One at a Time

Putting It All Together2009

Learning Objectives

Upon completion, participants will be able to:

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 Semi-urgent TIA or minor stroke patient.

Patient #1

Mrs. Ivanna Nomore

Insert Picture

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

Four Step Process

Evaluate the Event Initiate Medications Implement Interventions Modify Stroke Risk Factors

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

ECG: Normal sinus rhythm Neuro exam: Normal BP: 146/95 CT: Normal Blood work:

INR= 0.9, BUN= 5.5mmol/L, Cr = 80umol/L

Exam and Investigations

Evaluate the Event: Risk of stroke?

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 Urgent

TIA within 72 hours Semiurgent

Does not fit in urgent or emergent

Is Mrs. Ivanna Nomore at risk of a stroke? Urgency?

CMAJ 2008;179(12 Suppl):E1-E93.

Evaluate the Event: Timing of Tests

Diagnostic Test Emergent

Urgent Semiurgent

Assessment by medical specialist trained in stroke

24 h 7 d 30 d

CT or MRI 24 h 7 d 30 d

Carotid Imaging 24 h 7 d 30 d

ECG 24 h 7 d 30 d

CMAJ 2008;179(12 Suppl):E1-E93 #3.2

Canadian Best Practice Recommendations for Stroke Care, 2008

Acute Interventions & Management:Mrs. Ivanna Nomore

Consult to stroke prevention clinic/physician responsible for and capable of urgent triage and implementation of appropriate TIA/stroke management


Next Steps… Initiate Medications

Which medications?o 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…

Initiate Medications Should you consider any other

medications?

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 vessel walls

↓

Scar is formed↓

Build-up of plaque, fragile small arteries, extra strain on heart & weakens heart walls

Proper assessment technique Target BP < 140/90, < 130/80 (Diabetes/Chronic Kidney Disease) ACEI + diuretic= 1st line tx Tx > 1 agent Lifestyle modification Focus on adherenceCanadian Hypertension Education Program 2009

CMAJ 2008;179(12 Suppl):E1-E93 #3.2


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 ?

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

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 ?

What if Mrs. Ivanna Nomore’s Holter shows atrial fibrillation? Would her risk stratification be different? Would her management be different?

Medication Management

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

Hypertension Dyslipidemia Smoking Diabetes Heart Disease (Atrial

Fibrillation) Obesity Dietary Habits Physical Inactivity Excess alcohol intake

√√

??

What are her modifiable risk factors?

Modifying Risk Factors: Mrs. Ivanna Nomore 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

Patient #2

Mr. Les Feeling

Insert Picture

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


Evaluate the event: VS= 35.7, 83, 140/85, 16Investigations Ordered: Blood work

lytes, INR, BUN, CR, glucose CT, ECG, Doppler Neurological exam: normal


Evaluate the event: Investigations Blood work: normal Fasting glucose and lipids ordered ECG=NSR Doppler booked next week CT head= normal


What is the urgency of managing Mr. Feeling?

Urgent What does this mean for the timing of

his tests? 7days


Lab requisition for: LFT, CK, FBS, Lipid Profile

Results: Total Cholesterol=5.2, TG=2.97,

HDL= .90, LDL= 3.7 Fasting Blood Glucose=6.5mmol/L CK & LFT=Normal


It’s not emergent! Are we done?

Yes No

What are Mr. Les Feeling’s Risk Factors?

Hypertension High cholesterol Smoking Diabetes Heart Disease (Atrial

Fibrillation) Obesity Physical Inactivity Excess alcohol intake

√ PreHTN

√

Modify Stroke Risk Factors: Smoking

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

Health care providers need to know how to support patients and families become better at self management

Local Resources for smoking cessation?


•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

Warning Signs of Stroke, (HSFC, 2006)

Putting it all together: System Resources

Local Systems for rapid evaluation and triage of TIA and minor stroke patients?

Summary

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

http://www.canadianstrokestrategy.ca/

Canadian Best Practice Recommendations for Stroke Care, updated 2008

www.canadianstrokestrategy.ca

preventing strokes one at a time putting it all together 2009

Documents