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Clinical Therapeutics 2 > CVA > Flashcards

CVA Flashcards

1
Q

what are 2 types of a stroke?

A

ischemic and hemorrhagic

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2
Q

define ischemic CVA

A

reduction of blood supply to different areas of the brain d/t obstruction of blood vessels and causing ischemic injury

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3
Q

define hemorrhagic CVA

A

broken vessel, decreased blood to brain

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4
Q

what are the 2 types of ischemic CVA? define the 2 types

A

(1) Thrombosis (local vessel obstruction)

2) Embolism (clot travels from somewhere else and obstructs cerebra-vessel

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5
Q

what is the #1 cause of obstruction leading to ischemic CVA?

A

atherosclerosis (ex. carotid atherosclerosis)

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6
Q

what are causes of obstruction leading to ischemic CVA?

A

atherosclerosis (#1)

vessel injury, plaque rupture

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7
Q

ischemic embolus stroke can occur from what vessels?

A

aortic arch, cardiac (a-fib), carotid

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8
Q

what is a TIA?

A

Transient ischemic attack (a pre-CVA) - mini stroke

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9
Q

what is the traditional definition of a TIA?

A

Sudden, focal, neurological deficit of presumed cerebrovascular origin lasting < 24 hours

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10
Q

what is the revised definition of a TIA?

A

A brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical sx’s typically lasting < 1 hr and without evidence of acute infarct

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11
Q

when does pt with TIA need medical attention?

A

if don’t see any improvement at all w/in 1st hr or sx’s worsen (sx’s typically last < 1 hr)

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12
Q

what occurs damage occurs in an ischemic CVA?

A

cerebrovascular infarct

residual neurological dysfunction

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13
Q

risk factors for TIA and stroke

A
  • HTN (uncontrolled for years)
  • DM (uncontrolled)
  • Hyperlipidemia
  • Carotid Stenosis
  • High homocysteine
  • Hx of non-cardioembolic stroke
  • Smoking
  • ATRIAL FIBRILLATION
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14
Q

what is the only risk factor for TIA and stroke that is a risk factor for EMBOLIC STROKE?

A

A-fib

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15
Q

what is high homocysteine due to? what does it lead to? how do you manage it?

A

folic acid deficiency (manage with folic acid supplements)

leads to inflammation of blood vessels -> vessel injury -> deposit of plaques

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16
Q

signs and sx’s of stroke?

A
  • Hemiparesis
  • Face asymmetry
  • Gaze deviation
  • Dysphasia/aphasia (slurred speech)
  • Dysarthria
  • Limb incoordination
  • Ataxia (+/- vertigo)
  • One sided sensory sx’s
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17
Q

what is the goal of pharmacotherapeutics for prevention of RECURRENT TIA or stroke?

A

Control risk factors to prevent recurrent TIA or stroke

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18
Q

what is the #1 tx for non-cardioembolic stroke (thrombotic stroke)?

A

Aspirin (50-325mg/day) monotherapy

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19
Q

if pt with non-cardioembolic stroke (thrombotic stroke) is already on ASA or has had a lot of TIA episodes, then what is the tx?

A

switch to another med

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20
Q

what are the other tx’s (besides ASA) for non-cardioembolic stroke (thrombotic stroke)?

A

ASA 25mg + dipyridamole 200mg (Aggrenox) BID

Clopidogrel 75 mg/day

Ticagrelor 90mg 2x/day

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21
Q

what is dipyridamole?

A

anti-platelet med that works thru adenosine receptor

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22
Q

what is/the MOA of Clopidogrel?

A

P2Y12 inhibitor

-P2Y12 is a receptor on platelets, so Clopidogrel binds to it and prevents platelet aggravation

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23
Q

what do you NOT combine Clopidogrel with for tx of stroke?

A

ASA

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24
Q

when would you consider giving Ticagrelor to pt with non-embolic (thrombotic) stroke?

A

in pt with ASA allergy

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25
Q

thrombotic strokes respond best to what type of therapy?

A

anti-platelet

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26
Q

what meds do NOT work for cardioembolic stroke (from fib)?

A

anti-platelets

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27
Q

what are the meds for tx of Cardioembolic stroke?

A
  • Warfarin dose to INR 2-3 indefinitely
  • Dabigatran 150mg 2x/daily (DOA)
  • Rivaroxaban 20mg daily (DOA)
  • Apixaban 5mg 2x/daily (DOA)
  • Edoxaban 60mg daily (DOA)
  • ASA 81mg
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28
Q

what med is RECOMMENDED for pts with TIA and ischemic stroke in addition to the meds for tx (anti-platelets, DOA)?

A

atorvastatin (80mg qd) -> INTENSIVE STATIN THERAPY

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29
Q

what’s the CHA2DS2-VASc score?

A

it’s for determining risk of thromboembolism

do this for pts with Afib and to determine the tx that would be best for them

helps you decide which meds to use depending on the score

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30
Q

what’s the CHA2DS2-VASc stand for?

A 
C: Congestive heart failure
H: Hypertension
A: age > 75 years, 65-74 years
D: Diabetes
S2: stroke
Vascular disease (MI, PAD)
Female Sex
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31
Q

how many points do you get for Congestive heart failure in CHA2DS-VASc score?

A

1 point

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32
Q

how many points do you get for Hypertension in CHA2DS-VASc score?

A

1 point

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33
Q

how many points do you get for Age >/= 75 years in CHA2DS-VASc score?

A

2 points

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34
Q

how many points do you get for Age 65-74 years in CHA2DS-VASc score?

A

1 point

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35
Q

how many points do you get for Diabetes in CHA2DS-VASc score?

A

1 point

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36
Q

how many points do you get for Stroke in CHA2DS-VASc score?

A

2 points

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37
Q

how many points do you get for Vascular disease (MI, PAD) in CHA2DS-VASc score?

A

1 point

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38
Q

how many points do you get for Female sex in CHA2DS-VASc score?

A

1 point

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39
Q

what is the tx if pt has had a stroke TIA or ≥ 2 other RFs AND a CHA2DS2-VASc score of ≥2?

A
  • Warfarin
  • Dabigatran
  • Rivaroxaban
  • Apixaban
  • Edoxaban

PTS at HIGH RISK, so need real anticoag

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40
Q

what is the tx if pt has 1 RF for stroke or TIA and CHA2DS2-VASc score of 1?

A
  • Warfarin
  • Dabigatran
  • Rivaroxaban
  • Apixaban
  • Edoxaban
  • Aspirin
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41
Q

what is the tx if pt has 0 RF for stroke or TIA and CHA2DS2-VASc score of 0?

A

Aspirin

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42
Q

what’s the difference b/w Warfarin and DOA’s in terms of missing a dose?

A

Warfarin is long-acting, so if miss dose, don’t have to worry about clot

DOA’s are short-acting, so if miss dose, can have clot occurrence

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43
Q

if pts forget to take their DOA’s what do you do?

A

switch them to Warfarin

44
Q

what is the MOA of Dabigatran?

A

Direct thrombin inhibitor

45
Q

what are the Direct Anti-Xa inhibitors?

A

Rivaroxaban, Apixaban, Edoxaban

46
Q

what’s the difference b/w Warfarin and DOAs in terms of monitoring?

A

No monitoring for DOA’s

47
Q

what’s the difference b/w Warfarin and DOAs in terms of DDIs?

A

Warfarin interacts with a lot of drugs and also interacts w/ diet b/c it inhibits vit K (any food high in vet K will decr Warfarin’s effect)

DOAs don’t have as many DDIs

48
Q

what do you worry about DOAs with?

A

renal fxn -> need to dose adjust

49
Q

renal dose adjustment of Dabigatran?

A

1/2 when CrCl < 30ml/min

50
Q

renal dose adjustment of Rivaroxaban?

A

CrCl 15-50 ml/min: 15mg qd

51
Q

renal dose adjustment of Apixaban?

A

2.5mg BID in patients with 2 of the following:

≥80 y/o, weight ≤60kg, SCr ≥1.5

52
Q

renal dose adjustment of Edoxaban?

A

CrCl 15-50 ml/min: 30mg qd (or body weight ≤ 60kg)

AVOID in CrCl >95 ml/min

53
Q

at what CrCl do you AVOID the use of Edoxaban?

A

AVOID in CrCl >95 ml/min

54
Q

which 2 Oral anticoagulants are more effective than warfarin?

A

Dabigatran and Apixaban

55
Q

what 2 DOAs are similar in efficacy to warfarin?

A

Rivaroxaban and Edoxaban

56
Q

what’s the difference b/w life-threatening bleeding of DOA’s and Warfarin?

A

Life-threatening bleeding of DOA’s is LESS than Warfarin (e.g., severe GI bleed, intracranial hemorrhage)

57
Q

why do people take Warfarin these days?

A

People still take Warfarin these days b/c:

  • DOA’s can’t be used with CKD
  • Warfarin can be used for ANY coagulation disorder vs. DOA’s can only be used for DVT, PE, Afib
58
Q

what other RF’s need to be managed when preventing stroke/TIA or recurrent stroke/TIA?

A
  • HTN: ACEI, diuretics
  • Diabetes
  • Smoking cessation
  • Carotid endardectomy for pt with significant stenotic lesion (> 60%) in low surgical risk patients
  • Surgical intervention to take the clot out, can put stent in carotid artery
  • Management of high homocysteine (? Folic acid)
59
Q

monitor ASA for?

A

stomach upset, GI bleed

b/c anti platelet need to be aware of bleeding

60
Q

monitor Dipyridamole for what?

A

bleeding

61
Q

monitor Clopidogrel for what?

A

thrombocytopenia, bleeding

62
Q

monitor Ticagrelor for what?

A

bleeding, bradycardia

63
Q

monitor Warfarin for what?

A

INR, consistent vit K intake, drug interactions

64
Q

monitor DOA’s for what?

A

bleeding, renal fxn

65
Q

monitor statins for what and how often?

A

LFTs (q6 months or 1x/year), muscle pain

66
Q

what is very important in CVA (real stroke)?

A

the timing that the CVA started b/c of timing for tx’s

-want to find out as closely as possible when the event started to occur

67
Q

what is the goal for treatment of a CURRENT TIA or stroke?

A

to minimize neurological damage -> ACT FAST

68
Q

what is the approach to tx of a CURRENT TIA or stroke?

A
  • IVF
  • Evaluate for eligibility for thrombolytic therapy (rt-PA)
  • Plan on initiating/re-initiating anti platelet, antithrombotic therapy after clot is removed by rt-PA
  • Conservative HTN tx
  • Manage underlying etiologies for stroke
  • Other supportive care
69
Q

what meds Lyse/Dissolve clots?

A

rt-PAs

70
Q

what meds just prevent clot from growing bigger or from it reoccurring?

A

ASA, antithrombotic agents (Warfarin, DOA’s)

71
Q

why do you want to take pts HTN down conservatively during stroke?

A

b/c sudden drop of BP during stroke can lead to severe cerebral hypoperfusion and make stroke worse!!!

72
Q

when should thrombolytic therapy (rt-PA) be administered to eligible pts w/CURRENT stroke?

A

w/in 3.0-4.5 hours after stroke (after this time, there is IRREVERSIBLE damage done)

73
Q

what is NOT recommended at the time of giving rt-PA?

A

other thrombolytic agents b/c already at high risk for bleed d/t rt-PA given

74
Q

when is intra-arterial thrombolysis an option for major stroke?

A

Intra-arterial thrombolysis is an option for major stroke if administered within 6 hours of onset at an experienced stroke center

-But more important to start rt-PA early, than to think about transporting them

75
Q

what is the full tx for pts treated with thrombolytics (rt-PA)?

A

IV fluids NS at 75-100 mL/hr

No heparin, warfarin, ASA, Clopidogrel or dipyridamole for 24hrs, then start the antithrombotic as ordered

rt-PA -> one dose infused over 1hr

Brain Ct or MRI after rt-PA therapy (at 24hrs)

76
Q

why do Brain CT or MRI after rt-PA therapy (at 24hrs) for pt treated with rt-PA?

A

to make sure stroke hasn’t turned hemorrhagic (DON’T WANT PT BLEEDING INTO THEIR BRAIN)

77
Q

what is the full tx for pts NOT treated with thrombolytics (rt-PA)?

A

IV fluids NS at 75-100 mL/hr

Antiplatelet (ASA) should be ordered w/in first 24hrs of hospital admission

Anticoagulants (heparin, warfarin, or DOA) are NOT recommended until after 24hrs in cardioembolic stroke and patient is stable

Repeat brain CT scan or MRI may be ordered 24-48hrs after stroke or prn

78
Q

when should Brain CT or MRI be done in pt treated with rt-PA?

A

at 24hrs (after rt-PA therapy)

79
Q

when can heparin, warfarin, ASA, Clopidogrel or dipyridamole be started on pt treated with rt-PA

A

after 24hrs

80
Q

when should ASA be ordered in pts NOT treated with thrombolytics?

A

w/in first 24hours of hospital admission

81
Q

when can anticoagulants (heparin, warfarin, or DOA) be started in pt NOT treated with thrombolytics?

A

after 24hrs in cardioembolic stroke and pt is stable

82
Q

when is oral ASA (initial dose of 325mg) recommended for most stroke patients?

A

w/in 24-48 hrs

83
Q

what is the initial dose of ASA for stroke patients?

A

325mg

84
Q

when is ASA NOT recommended for stroke pts?

A

w/in 24hrs of IV rt-PA

85
Q

what meds can all stroke pts initiate has ppx?

A

anticoagulants for DVT/PE ppx

86
Q

what are the anticoagulants for DVT/PE ppx that all stroke pts can have?

A
  • Low dose heparin (5000 units sc bid or tid)
  • LMWH (e.g. Enoxaparin 30 or 40mg qd)
  • Fondaparinux (e.g. 2.5 mg sc qd)
87
Q

why use nticoagulants for DVT/PE ppx in all stroke patients?

A

(1) TINY dose so bleeding risk is very small

(2) stroke pts will be bed bound for awhile, so want to prevent them from developing DVT

88
Q

what BPs are NOT ELIGIBLE for rt-PA therapy?

A 
Systolic >220mmHg
or
Diastolic >140mmHg
or
Both
89
Q

what BPs ARE ELIGIBLE for rt-PA therapy?

A

Systolic >185mmHg
Or
Diastolic >110mmHg

90
Q

what is the tx for BPs that are NOT ELIGIBLE for rt-PA therapy?

A

Labetalol 10-20mg IV over 1-2 min may repeat

Or
Double every 10 min (maximum dose: 300mg)

Or

Nicardipine 5mg/h IV infusion as initial dose; titrate to desired effect by increasing 2.5 mg/h every 5 min to maximum of 15mg/hr
-Aim for a 10-15% reduction of BP

If uncontrolled, can add Nitroprusside 0.5 µg/kg per min IV infusion as initial dose with continuous blood pressure monitoring
-Aim for a 10-15% reduction of BP (don’t need to reduce to normal

91
Q

what is the tx for BPs ELIGIBLE for rt-PA therapy?

A

Check BP every 15min for 2hrs, then every 30 min for 6hrs, and then every hour for 16hrs

Labetalol 10-20mg IV over 1-2min

  • May repeat x1 or nitropaste 1-2 in or Nicardipine drip, 5mg/hr, titrate up by 0.25 mg/hr at 5-15 min intervals;
  • maximum dose: 15mg/hr, if BP is not reduced and maintained at desired levels (systolic 185mmHg and diastolic 110mmHg), do not administer rt-PA

If uncontrolled, can add Nitroprusside 0.5 µg/kg per min IV infusion as initial dose with continuous BP monitoring
-Aim for 10-15% reduction of BP

92
Q

if pt is eligible for rt-PA and BP >185/110, then do what?

A

treat BP first before TPA (BP >220/140 not eligible)

93
Q

after treat BP of >185/110, then do what?

A

start ASA 24hrs after rt-PA

94
Q

if pt is eligible for rt-PA and BP <185/110, then do what? after first tx?

A

start TPA

-after 24hrs of TPA, start ASA

95
Q

if pt not eligible for TPA, then do what?

A

ASA 325mg daily

no anticoagulants in first 24hrs (may consider anticoagulant 24hrs later)

96
Q

what are complications post-acute ischemic stroke?

A

***Cerebral hemorrhage -> big stroke and affects big area -> much easier to turn into hemorrhagic stroke

***Cerebral edema

  • DVT/PE
  • Seizure

***Complications d/t neurologic deficits (depend on area of damage in the brain)

97
Q

what 2 complications post-acute ischemic stroke are surgical requirements?

A

Cerebral hemorrhage

Cerebral edema

98
Q

what should you monitor for after tx of CURRENT stroke?

A

resolving of stroke sx’s

signs/sx’s of intracranial hemorrhage

99
Q

what is the FIRST sx of intracranial hemorrhage?

A

AMS

100
Q

what do imaging do pts need IMMEDIATELY after stroke and why?

A

NEED CT/MRI IMMEDIATELY AFTER STROKE TO MAKE SURE Intracranial hemorrhage isn’t occurring

101
Q

monitor heparin after stroke for what?

A

bleeding

aPTT 1.5-2.5x baseline, platelets

102
Q

monitor LMWH after stroke for what?

A

platelets

103
Q

monitor labetolol for what?

A

HR, BP (decreases them)

104
Q

monitor Nicardipine for what?

A

BP

105
Q

monitor Nitroprusside for what?

A

BP, cynaide toxicity, renal fxn

106
Q

monitor Nitroglycerin for what?

A

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

Clinical Therapeutics 2 (11 decks)

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