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Therapeutics II Exam 3 > Cerebrovascular Dz > Flashcards

Cerebrovascular Dz Flashcards

1
Q

How is an ischemic CVA caused?

A

Reduction of blood supply to different areas of the brain due to obstruction of blood vessel

Obstruction can be d/t:

  • Atherosclerosis
  • Vessel injury
  • Plaque rupture
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2
Q

What are the 2 types of ischemic CVA? Definition?

A

Thrombotic–local vessel obstruction

Embolic–clot travels from somewhere else to the brain & obstruct a cerebro-vessel

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3
Q

Definition of Transient Ischemic Attack (TIA)?

A

Pre-CVA

  • brief episode of neurological dysfunction caused by focal brain or retinal ischemia w/ clinical sx lasting <1hr
  • w/o residual neurological dysfunction
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4
Q

Definition Ischemic CVA

A

Cerebrovascular infarct
IRREVERSIBLE damage occurs
w/ residual neurological defect

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5
Q

Risk Factors for Ischemic CVA

A
  • HTN (uncontrolled)
  • uncontrolled DM
  • Hyperlipidemia
  • Carotid Stenosis
  • High homocysteine
  • Hx non-cardioembolic stroke
  • Smoking
  • A-fib
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6
Q

Which of the following is a risk factor specific for EMBOLIC stroke?

a. Hyperlipidemia
b. Carotid Stenosis
c. A-fib
d. HTN

A

A-fib!

Risk factor for cardio-EMBOLIC stroke only

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7
Q

Presentation of Ischemic CVA

A
  • may vary depending on parts of brain involved
  • hemiparesis
  • face asymmetry
  • gaze deviation
  • dysphasia/aphasia
  • dysarthria
  • limb incoordination
  • ataxia (+/- vertigo)
  • one sided sensory sx
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8
Q

Which of the following is NOT a sx of ischemic CVA?

a. dysarthria
b. loss of vision
c. ataxia
d. hemiparesis

A

B. loss of vision

pt may have gaze deviation

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9
Q

What therapeutic class drugs are appropriate 1st choice therapy for a Non-Cardioembolic stroke (not from a-fib)?

a. NSAID
b. antiplatelet
c. anticoagulant
d. thrombolytic

A

B. Antiplatelet therapy

Aspirin 50-325mg/day**
Aggrenox (ASA +dipyridamole) BID
Clopidogrel (Plavix) 75mg/day
Ticagrelor 90mg/day

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10
Q

When would you give ticagrelor in a pt with a non-cardioembolic stroke?

A

If they have an aspirin allergy

Not inferior to aspirin, can be used as alternative option–can cause more bleeding

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11
Q

Which antiplatelet drug would you to start a pt on with noncardioembolic stroke that isn’t being treated with a thrombolytic?

A

ASPIRIN

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12
Q

What therapeutic class of drugs are appropriate therapy for cardio-embolic stroke (from a-fib)?

A

Anticoagulants

Warfarin (INR 2-3)
Dabigatran (150mg BID)
Rivaroxaban (20mg daily)
Apixaban (5mg BID)
Edoxaban (60mg daily)
Aspirin (81mg)
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13
Q

What pathway of the clotting cascade do anticoagulant affect?

A

Intrinsic pathway

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14
Q

What is CHA2DS2-VASC used for?

A

Determines risk of a cardioembolic stroke for pt w/ a-fib ONLY

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15
Q

What does CHA2DS2-VASC stand for?

A 
Congestive HF
Hypertension
Age >75yo / 65-74yo
Diabetes
Stroke
Vascular Dz (MI, PAD)
Female
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16
Q

Which 2 risk factors from CHA2DS2-VASC counts for 2points

A

Age >75yo

Stroke

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17
Q

If a pt has no risk factors for thromboemoblism, what drug therapy should they be on?

A

Aspirin

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18
Q

If a pt has 1 risk factor for thromboembolism which drugs could they be on?

A 
Warfarin
Dabigatran
Apixaban
Rivarxaban
Edoxaban
Aspirin
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19
Q

If a pt has 2 or more risk factors for thromboembolism, which drugs could they be on?

A 
Warfarin
Dabigatran
Apixaban
Rivarxaban
Edoxaban
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20
Q

Whether the pt had a thrombotic or embolic stroke, what other class of drugs should the pt be on?

A

STATIN

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21
Q

What statin should the pt be on and what dose?

A

Atorvastatin 80mg once a day

REGARDLESS of cholesterol profile

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22
Q

Aspirin (Dose/ADR)

A

50-325mg

GI bleed, stomach upset

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23
Q

Dipyridamole (Dose/ADR)

A

ASA 25mg + Dipyridamole 200mg (aggrenox)

BLEEDING

24
Q

Clopidogrel (Dose/ADR)

A

75mg/day

THROMBOCYTOPENIA, bleeding

25
Q

Ticagrelor (Dose/ADR)

A

90mg BID

BRADYCARDIA, bleeding

26
Q

Warfarin (Dose/monitor)

A

Dose to INR 2-3 indefinitely

INR, consistent vit K intake, DDI

27
Q

Direct Anti-Xa inhibitors Monitor

A

Bleeding

Renal function

28
Q

Statins (monitor/ADR)

A

LFT

Muscle pain

29
Q

What are the direct oral anticoagulants (DOA)?

A

Dabigatran
Rivaroxaban
Apixaban
Edoxaban

30
Q

Which of the DOA are dosed BID?

A

Dabigatran

Apixaban

31
Q

Which DOA are MORE EFFECTIVE than warfarin?

A

Dabigatran

Apixaban

32
Q

Which DOA is a direct thrombin inhibitor?

A

Dabigatran

33
Q

Which of the following drugs are eligible for a pt w/ cardioembolic stroke & CKD?

a. dabigatran
b. apixaban
c. warfarin
d. rivaroxaban

A

Warfarin

34
Q

What is the initial approach for a pt coming in with a CVA

A
  • IV fluid
  • eval for eligibility for thrombolytic therapy
  • plan on initiating/re-initiating antiplatelet, antithrombotic therapy
  • conservative HTN mgmt
  • Mgmt underlying etiologies for stroke
  • other supportive care
35
Q

What does thrombolytic therapy do?

A

Dissolve clots

36
Q

What are pt at high risk for if on thrombolytic therapy?

A

BLEEDING

37
Q

What is time frame allows for admin of thrombolytic therapy after a stroke?

a. 2.0-3.5hrs
b. 3.0-4.5hrs
c. 3.5-5.0hrs
d. any time

A

B. 3.0-4.5 hrs after stroke

given over 1hr

38
Q

Once a thrombolytic has been administered, what is the following steps of their mgmt?

A
  • IVF NS at 75-100mL/hr
  • No blood thinners for 24hrs (heparin, warfarin, ASA, clopidogrel or dipyridamole)
  • get brain CT/MRI at 24hrs
39
Q

If pt wasn’t eligible for thrombolytic, how should they be managed?

A
  • IVF NS at 75-100mL/hr
  • Aspirin 325mg w/i 1st 24hrs of hospital admission
  • Anticoagulants (heparin/warfarin) in cardioembolic stroke AFTER 24hrs & pt is STABLE
  • Repeat brain CT/MRI 24-48hrs after stroke or prn
40
Q

If pt is given tpA at 2pm, can they take their aspirin at 10am the next day?

A

NO. they can’t restart any blood thinner within 24hrs after admin of tpA

41
Q

Pt started experiencing dysarthria, hemiparesis, and face asymmetry, at 4pm and arrived at the ER at 10pm. No a-fib, They’re on aspirin 81mg, labetolol 10mg and simvastatin 15mg. How would manage this pt?

A

Pt isn’t eligible for tpA bc they arrived over >4.5hrs after the stroke occurred.

  • Give them higher dose aspirin (325mg) within 24hrs of admission
  • give them intensive statin therapy (atorvastatin 80mg)
42
Q

Can pt be on anticoagulants for DVT/PE prophylaxis within 24hr of stroke?

A

YES

  • bleeding risk is small bc dose is tiny
  • used to prevent DVT as complication of stroke bc pt will be bed bound; NOT used to tx the stroke

Low dose heparin (5000units sc BID or TID)
LMWH (Enoxaparin 30 or 40mg QD)
Fonadaparinux (2.5mg SC QD)

43
Q

Complications Post Acute Ischemic Stroke

A
  • cerebral hemorrhage
  • cerebral edema
  • DVT/PE
  • Seizure
44
Q

What BP lvl is the cut off for thrombolytic therapy?

A

Systolic 220

Diastolic 140

45
Q

What can be given to pt w/ BP >220/140

A

Labetalol or Nicardipine

Can add Nitroprusside if uncontrolled

46
Q

What % reduction of BP are you aiming for?

A

10-15% reduction

47
Q

Is BP 210/140 eligible for thrombolytic therapy?

A

Yes! just need to lower it to be <185/110

w/ antihypertensive therapy (BB or CCB)

48
Q

How would you manage a pt w/ BP 185/110

A
  • Check BP q15min for 2hr, then q30min for 6hrs, then q1hr for 16hrs
  • Labetalol (may repeat or give nitropaste) or
  • Nicardipine drip
  • if uncontrolled, add Nitroprusside
  • Aim for 10-15% reduction of BP
49
Q

IV Heparin, monitor?

A

aPTT 1.5-2.5x baseline

platelets

50
Q

LMWH, monitor?

A

Platelets

51
Q

Labetolol, monitor?

A

BP

52
Q

Nicardipine, monitor?

A

BP

53
Q

Nitroprusside, monitor?

A

BP
Cyanide toxicity
Renal fucntion

54
Q

Nitroglycerin, monitor?

A

BP
HA
sign of tachyphylaxis (when used for >2-3 days continuously)

55
Q

Which BP lowering drug should you monitor for cyanide toxicity?

A. Labetolol
B. Nicardipine
C. Nitroprusside
D. Nitroglycerine

A

C. Nitroprusside

also monitor BP and renal function!

Therapeutics II Exam 3 (2 decks)

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