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Medicine II > CVA primary care > Flashcards

CVA primary care Flashcards

1
Q

PE of pt with CVA

A

Neurological examination notable for expressive aphasia and mild weakness on Rt side of face and arm. CV examination: S4 gallop and dorsalis pedis pulses diminished bilaterally. ECG shows NSR. CBC and BMP show glucose normal. Spouse wants to know what else to do.

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2
Q

ABCD2 score

A

Score (Age, BP, uinlateral weakness, duration 10-59 min

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3
Q

two types of stroke

A

Ischemic (occlusive) vs hemorrhagic

ischemic is seen with occlusions
80% of stroke are ischemic  
8/10 chance of ischemia 
seen with 
a fibb

(permanent brain infarction) –>accounts for 80% of all CVA.
o 3 main subtypes: thrombosis (49%), embolism (31%), systemic hypoperfusion

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4
Q

hemorrhagic strokes are caused by

A

usually derived from arterioles or small arteries –> causes bleeding directly into the brain, forming a localized hematoma which spreads along white matter pathways. Hematoma gradually enlarges

o Causes: HTN, trauma, bleeding diatheses: unusual susceptibility to bleed, amyloid angiopathy, illicit drug use (i.e. amphetamines, cocaine), vascular malformations
o Accounts for 20% of all CVA

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5
Q

why do we see thrombis

A

when ever an artery forks it is turbulent

susceptible to more damange

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6
Q

TIA

A

ischemia (transient ischemic attack TIA): transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, WITHOUT acute infarction

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7
Q

intrinsic pathophysiology of CVA

A

i.e. atherosclerosis, lipohyalinosis, inflammation, amyloid deposition, arterial dissection, developmental malformation, aneurysmal dilation, venous thrombosis

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8
Q

remote origin of cva

A

) The process may originate REMOTELY, as occurs when an embolus from the heart or extracranial circulation lodges in an intracranial vessel

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9
Q

describe inadequacy that leads to CVA

A

The process may result from INADEQUATE (CBF) cerebral blood flow 2˚ ↓ perfusion pressure or ↑ blood viscosity

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10
Q

statins don’t do anything about

A

that fats you ingest

they only effect the biosynthesis of cholesterol in the liver

you will get a better effect with lifestyle modfications

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11
Q

when does the liver biosynthesize cholesterol

A

at night
take statins at night

doesn’t have a great half life need to take at night when the liver is productive

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12
Q

what did the SPRACL trial find about the effects of CVA with statins

A
  • ” Reduced CVA risk 3.4-2.7%
    atorvastatin: reduces risk of recurrent stroke & major event over 5 years

Some concern about more hemorrhagic strokes in treatment group (55 vs 33)

but benefits outweight the risks

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13
Q

looking at lipid reductions with medications

what do you see with atorvastatin

A

35-39% reductions with 10 mg

40mg (53%)

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14
Q

10 mmHg reduction in SBP decreases risk by ___

regardless of whether or not you are HTN

A

10 mmHg reduction in SBP decreases risk by 1/3

but we are worried about people over 60 have perfusion of coronary arteries (occurs in diastole so make sure diastole is NOT TOO LOW)

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15
Q

volume tx for the management of HTN

A

: Diuretics/ACEI

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16
Q

tx that target the tone for the treatment of HTN

A

CCB

17
Q

modifiable risk factors for the prevention of CVA

A

o HTN, atherosclerosis, dyslipidemia

AND

o Smoking, DM, sickle cell, carotid stenosis, atrial fibrillation: irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure, or other heart-related complications

18
Q

MCC of stroke

A

Elderly - thrombotic & embolic strokes 2˚ atherosclerosis MC

19
Q

how do we manage HTN in post CVA pts

A

lower BP w/ 2 classes of agents

(↓ volume: ACE inhibitors & diuretics. ↓ Vascular tone: CCB)

20
Q

how to we manage lipids in post CVA pts

A

o Lipids - treat dyslipidemia (LDL = ~ 130-159)

21
Q

how do we promote anticoagulation

A

o Platelets - prevent blood clots w/ anticoagulants (ASA, ASA + ERDP, clopidogrel)

22
Q

why do we use 81mg of ASA

A

Risk reduction equivalent at low & high doses = 50-100mg/day sufficient–> lower dose preferred, try to minimize the risk of GIB

23
Q

daily ASA tx reduces

A

” ↓ CVA risk 22% (improves cardiac risk too)

24
Q

how does ASA inhibit coagulation

A

Also Inhibits prostaglandin synthesis

Inhibits cyclooxygenase, prevents thromboxane A2 formation, platelet activation & aggregation

25
Q

what should we do for our old pt who was on baby ASA and had a CVA

A

Aspirin + XR Dypyrimidole (ASA-ERDP)

save this for ASA failure

Possible vasodilator - inhibits platelet enzymes "	Trials (ESPS-2 & ESPRIT) demonstrated improved risk over aspirin alone w/o bleeding risk  "	But: BID dosing & less well tolerated (BID reduces compliance)

o SE: HA –> causes 3x d/c rate than aspirin alone
o Expensive
“ Reserved for “ASA failures”

26
Q

PLAVIX what is it

would you use this in a pt that had a CVA with

A

Inhibits ADP-dependent platelet aggregation

Improved stroke risk relative to ASA in pts with PVD

BUT No significant risk reduction in pts with previous ischemic stroke (MATCH Trial)

AND

Combination increases bleeding

27
Q

surgery for CVA

A

if occlusion of carotid ?

endarterectomy can be effective

28
Q

what is the decreased risk for pts with 70-99% stenosis of carotid endarterectomy

what about in pts with moderate stenosis (50-69%)

A

Fatal ipsilateral stroke or post-operative death decreased from 26% to 9% for those with severe symptomatic stenosis (70-99%occlusion)

with moderate stenosis (50-69%) had benefit to 5 years over medical therapy

29
Q

what is the risk of post operative stroke

A

30d post-operative stroke risk = 6-7%

have to get to the point where the risk of the surgery is outweighed by the benefit

if you’re over 60% occlusion

26 –> 9

probably will take the risk

30
Q

what are the different types of ischemic stroke causes

A

cardioembolic?

carotid occlusion?

31
Q

coumidin?

A

if he has a fibb

32
Q

would we treat out pt with a statin following a stroke?

A

With TIA or ischemic stroke and high lipid levels (independent of LDL), high intensity statin therapy recommended (SPARCL Trial)

we still want to see his lipid profile though

33
Q

what are we managing after ischemic stroke?

A

ANTICOAGULATION
STATIN
BP

34
Q

do we always treat pts with HTN medication following ischemic stroke?

A

really depends
even if they are not hypertensive it can be helpful

BUT we really want to make sure their heart is perfusing
looking a diastolic

35
Q

MAP calculation

A

MAP = SBP + 2 (DBP)

3

36
Q

if this pt is DM and hypertensive post stroke and your managing stroke risk?

if AA

A

ACE and metformin for blood sugar control

CCB

37
Q

MCC of cardioembolic stroke

A

nonvalvular afib is the number one reason for a cardioembolic stroke

38
Q

what diagnostic studies would you want for a pt post CVA

A

EKG and echo to evaluate for afibb

labs

Medicine II (21 decks)

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