38 - Chronic stroke prevention

Question 1

• *SECONDARY Stroke Prevention**
• *AntiPlatelet Agents**

Answer 1

COX-I
Aspirin 81 > 325 qd

ADP Inhibitors

• *Ticlopidine 250mg BID w/food**
• *Clopidogrel 75mg qd**

PDE inhibitor + adenosine amplifier
Aggrenox
ASA 25mg / ERD 200mg BID

Question 2

Secondary Stroke Prevention
CLOPIDOGREL

Answer 2

PRODRUG
Thienopyridine

Requires Loading dose:

• *300mg - 2 hours**
• *7mg - 2 days**

Question 3

Secondary Stroke Prevention
AGGRENOX

ERD 200mg + ASA 25mg
BID

Answer 3

do NOT chew/crush/open capsule

SIDE EFFECTS:

• *HEADACHE 40%**
• *GI Pain / Diarrhea**
• *Better than Each agent ALONE**
• DOES NOT SAVE LIVES*

Question 4

When would we use the combination of:

ASA + Clopidogrel?

Answer 4

MINOR STROKE** or **TIA
CHANCE 2013: NIHSS score < 3 or High Risk TIA ABCD2 Score > 4

Start BOTH within 24 hours of TIA/Stroke
VVV
continue for ONLY 21 DAYS
↓Stroke ↓MI/CV/Stroke Death

Question 5

When would ANTIPLATELETS be preferred
> AntiCoagulants?

Answer 5

NON-CARDIOEMBOLIC STOKES

Question 6

• *Primary Stroke Prevention**
• *RISK FACTORS**

Answer 6

Control:
HTN / Diabetes / Hyperlipidemia

TREAT:
AFIB

Diet / Exercise

SMOKING CESSATION

Question 7

Secondary Stroke Prevention
RISK FACTORS

Answer 7

ALL PRIMARY
plus

CEA for carotid stenosis

AC for
Thromboembolic or hypercoagulable disease

Antiplatelet therapy

Question 8

• *NON-MODIFIABLE**
• *STROKE RISK FACTORS**

Answer 8

AGE > 55

FAMILY HISTORY

RACE:
AA > hispanic/asian > caucasian

Gender M > F

Prior:
Stroke / TIA / MI

Question 9

• *MODIFIABLE**
• *Stroke Risk Factors**

Answer 9

High BP / DM / AFIB

SMOKING

Poor Diet / Physical Inactivity / HYPERLIPIDemia

Heart Disease / Sickle Cell

Carotid/Peripheral Artery Disease

Question 10

Modifiable Risk Factor
HYPERTENSION

Answer 10

Lowering BP can:
↓Stroke Risk by 30-40%

Treatment Recommendations:
< 130/80
uncertain benefit in pts W/O HTN
May initiate treatment >24-48 hours after acute stroke

Diuretics + ACE inhibitors

Question 11

Modifiable Risk Factor
DIABETES

Answer 11

↑Risk of Recurrent stroke by 60%
present in 25-45% of ALL stroke patients

All Stroke pts. screened for DM:
Glucose >126 / HgbA1c _>_6.5%

***_NO single agent/class preferred_***
just want to be **CONTROLLED**

Question 12

Modifiable Risk Factor
HYPERLIPIDEMIA

Answer 12

no evidence linking the
CHOLESTEROL LEVELS or LIPID LEVELSto STROKE
BUT:
SPARCL Trial showed in:
recent stroke/TIA + LDL 100-190 + NO HISTORY OF CAD
↓Stroke Recurrence w/ ATORVASTATIN
↓Stroke / TIA

Question 13

ROLE of STATINS
In
Treatment / Prevention of Stroke

Answer 13

SPARCL TRIAL
Recent Stroke/TIA // LDL 100-190 // no h/o CAD
AHA/ASA recommends:
Intensive Statins for patients with:
Ischemic Stroke / TIA** of **Atherosclerotic Origin
AND
LDL > 100 but still recommended for LDL < 100

Question 14

Modifiable Risk Factor
SMOKING

Answer 14

INCLUDES SECOND HAND SMOKE

• *2x Stroke Risk**
• risk decreases RIGHT AFTER quitting*
• *dissapears after 5 YEARS**

Question 15

AHA/ASA Guidelines for:
Stroke Prevention in NON-Valvular AFib

Answer 15

• *AC** may start within 14 days AFTER stroke
• unless HIGH RISK for hemorrhage*

For patients UNABLE to take AC therapy
ASPIRIN ALONE > ASA + clopidogrel

Anticoagulant + Antiplatelet
ONLY recommended with CLINICALLY APPARENT CAD:
ACS or Cardiac stent placement