AIS and ACS Flashcards
What is FAST for stroke?
Face drooping
Arm weakness
Speech/slurring
Time to call ambulance
What labs suggests a MI?
- Troponin levels +++
- ST elevation
What are the 2 types of stroke and explain them?
Ischaemic stroke: blocked artery, when blood clot blocks the blood flow in an artery within brain, brain tissues die
Haemorrhagic stroke: ruptured artery -> intracranial haemorrhage, a blood vessel bursts within the brain. The bleeding compress other tissues and cause another infarction/tissue death (stop blood flow in another part)
Which type of stroke is more common?
Ischaemic stroke
What is TIA?
Sudden symptom onset for stroke but is temporary and goes away on its own. It is usually a pre-cursor to stroke.
Criteria of ABCD2
Age:
>=60y/o: 1
BP elevation when first assessed after TIA:
SBP >=140 or diastolic >=90: 1
Clinical features:
- Unilateral weakness: 2
- Isolated speed disturbance: 1
Duration of TIA smx:
- >=60mins: 2
- 10-59mins: 1
Diabetes: 1
What is NIHSS?
Determines if is minor stroke
What is ABCD2 score for?
Determine TIA risk
When is r-TPA eligible?
If AIS present within 3-4.5hrs
If pt is eligible for r-TPA, what should be given?
Start SAPT after 24hrs, within 48hrs
What NIHSS score suggests minor stroke?
0-3
What ABCD2 score suggests high risk TIA?
> =4
If pt is not eligible for rTPA, what should be given?
Minor stroke or high risk TIA: DAPT asap for 21d
Not minor stroke or high risk TIA: SAPT asap
What labs are done to evaluate stroke mechanism?
MRI: determine which vessel is affected
24h Holter: ambulatory ver of ECG
TTE: check heart func and if clot is present in heart
US carotids: evaluate carotid vessels
Lipid panel, TFT, HbA1c
If the stroke mechanism is cardioembolic, what should be done?
Stop antiplatelet as it suggests underlying AF so start OAC
If the stroke mechanism is non-cardioembolic, what to consider next?
If severe major ICAS (70-99%): add clopidogrel to aspirin x 90d. After that, lifelong SAPT
No severe major ICAS (70-99%): lifelong SAPT
What antiplatelet is not commonly used for SPAF?
Dipyridamole
What is the dose of aspirin?
Load 300mg (unless alr on aspirin) f/b 100mg OM lifelong
What is the dose of clopidogrel?
Load 300mg (onset within 6hr) or 600mg (onset within 2hr) f/b 75mg OM
Which CYP enzyme coverts clopidogrel to its active metabolite?
CYP2C19
How does CYP2C19 LoF affect clopidogrel?
Reduce clopidogrel active metabolite so increases risk of MACCE (major advere CV and cerebrovascular events)
What is the dose for dipyridamole IR?
25-150mg TDS
What is the dose for ticagrelor?
Load 180mg f/b 90mg BD up to 12m then 60mg BD (for extended therapy)
Dipyridamole SE
Flushing, dizziness, abdominal distress
Ticagrelor SE
Dyspnea, bleeding, bradycardia
Clopidogrel or ticagrelor preferred for ACS?
Ticagrelor as not subject to CYP2C19 polymorphism
Bleeding risk is higher than clopidogrel.
For CCS, clopidogrel is preferred
Ticagrelor or clopidogrel shorter t1/2?
Ticagrelor as it inhibits P2Y12 ADP receptor REVERSIBLY.
Clopidogrel is IReversibly.
What should be given after PCI procedure and why?
DAPT to prevent In-Stent Thrombosis (IST) or In-Stent Restenosis (ISR)
What should be given before PCI procedure?
UFH bolus
What other medications should be started for AIS?
High intensity statin if no CI:
Atorva 40-80mg QD
Rosuva 20-40mg QD
Is aspirin recommended for primary prevention of ASCVD?
No, unless atherosclerosis then SAPT
Which CYP2C19 alleles suggests LoF
*2 , *3 alleles
