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Therapeutics > EXam 4 lecture 5 > Flashcards

EXam 4 lecture 5 Flashcards

1
Q

What is a stroke?

A

An acute focal injury due to lack of blood/oxygen to the CNS causing neurological deficits

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2
Q

What ar ethe two types of strokes

A

Ischemic(85%) and hemorrhagic (15%)

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3
Q

Define ischemic stroke? Different types of ischemic stroke?

A

An infarction of brain tissue resulting from compromised blood flow.

Atherosclerotic ischemic stroke
Cardioembolic ischemic stroke

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4
Q

Define Hemorrhagic stroke

A

Bleeding in brain due to rupture of cerebral artery

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5
Q

risk factors for stroke

A

Non modifiable-age, race, low birth weight, sickle cell, HF, gender

Modifiable- Diabetes, HLD, HTN, CV disease (A fib, valvular disease)

Lifestyle- drug/lcohol use, obesity, ciggarette smoking

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6
Q

presentation of stroke

A

F- Face drooping
A- arm weakness
S- speech dificulty (dysphasia)
T- time to call hospital

Vision changes
Headache

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7
Q

What are imaging used in stroke? Vital signs?

A

Head CT or MRI

Blood pressure and O2 sat are important

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8
Q

Labs seen for stroke patients

A

BG
BMP
CBC
INR, aPTT

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9
Q

What is the use of EKG in stoke patients

A

We are trying to look for A- Fib.

If we have an ischemic stroke with A-Fib, we will consider that it is cardioembolic

if ischemic stroke with normal sinus rhythm, usually atherosclerotic

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10
Q

goals of tx of acute stroke

A

Limit extent of neurologic injury and long term disability
Decrease mortality
Prevent future strokes (secondary stroke prevention)

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11
Q

What are the three different types of strokes

A

cardioembolic and atherosclerotic (both ischemic)
Hemorrhagic

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12
Q

WHy is glycemic control important in strokes

A

Hypoglycemia- could mimick stroke, treat with carbohydrates

Hyperglycemia- Elevated BG (>180) has resulted in worse outcomes. Treat with SQ insulin to maintain BG below 180

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13
Q

What are srguments for and against reducing BP in stroke patients

A

Arguments for reduction-
minimize long term neurologic deficits
Decrease risk of cerebral edema and hemorrhagic transformation
Prevention of early recurrent stroke

Argument aginst reduction-
Dropping BP too quickly can limit brain perfusion, leading to worsening ischemia and neurologic function.

BP control after stroke requires balance

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14
Q

How often to we check BP in stroke? BP goals?

A

Check BP Q15 min x 2H, then q30 MIN X 6 H, THE N q 1 h for 16 H

BP goal within first 48 hours- higher than normal BP goals to allow permissive hypertension
No tPA<220/110
tPA administered- <180/105

AFter 48 hrs, goals are back to outpatient goal

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15
Q

acute HTN treatment for stroke pts

A

Always parenteral.
Labetalol, nicradipine, sodium nitroprusside

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16
Q

HTN management after 48 H

A

Start PO medications ( or restart home antihypertensives)

17
Q

What are tPA

A

Tissue plasminogen activator (tPA). It is a thrombolytic

Alteplase and tenecteplase

They disolve clots

18
Q

based on MOA of tPA, which type of stroke would you use an tPA? Does it have impact on mortality?

A

ischemic stroke (both of them)

No impact on mortality, but can improve neurologic function

19
Q

What are the inclusion criteria for tPA

A

Must meet all inclusion and have none of the exclusion criteria

Inclusion
- diagnosis of ischemic stroke as confirmed by imagine (NOT for hemorrhagic)
- symotom onset < 4.5 hrs
Age > 18 yrs

20
Q

What are exclusion criteria for tPA

A
  • evidence of internal bleed
    -H/o of intracranial hemorrhage
    -previous stroke or head trauma in past 3 months
  • GI or genitourinary hemorrhage in last 21 days
  • Major surgery in past 14 days
    -MI in past 3 months
  • PLatelets < 100,000
  • current anticoag use with INR > 1.7 or aPTT > 45 secs
    (Can use tPA if on warfarin only with INR < 1.7 or if on heparin with aPTT< 45 seconds)
    (if new oral anticoag, tPA is contraindicated)
    BP> 185/110
    BG < 50
21
Q

What is the dose of alteplase? Max dose? How is it given?

A

0.9 mg/kg

max- 90 mg

10% given as bolus over 1 minute
90% infused over 60 minutes

22
Q

Tenecteplase dose? max dose?

A

0.25 mg/kg IV

Max- 25 mg

23
Q

side effects of tPA agents

A

bleeding
(potentially causing a hemorrhagic stroke)
Keep BP< 180/105 to reduce risk of hemorrhagic stroke

Avoid all antiplatelets and anticoags for 24 hrs

Cerebral edema

24
Q

what are antiplatelet options for acute ischemic stroke management

A

Aspirin monotherapy
Aspirin + clopidogrel
Ticagrelor
Aspirin + Ticagrelor

25
Q

MOA of aspirin? What is it indicated for? Monitring?

A
  • irreversible inhibitor of COX enzyme, reducing the formation of thromboxane A2, thus reducing platelet aggregation.
  • 1st line for acute management of ischemic stroke (160-325 mg daily)

Monitoring- Bleeding, stroke

26
Q

Who gets aspirin for stroke? CI?

A

All ischemic stroke patients unless contraindicated.

Contraindicate din active bleeding and high bleeding risk

27
Q

When to give aspirin if tPA administered? What if no tPA administered?

A

> 24 hrs if tPA administered, immediately if no tPA

28
Q

MOA of clopidogrel? Monitoring? When is it used?

A

Clopidogrel is a P2Y12 inhibitor which inhibits platelet aggregation through blockade of ADP receptor

Monitoring- bleeding, stroke

Used in combo with aspirin as second line recommendation for minor stroke

29
Q

MOA of ticagrelor? When is it used?

A

Also a P2Y12 inhibitor (like clopidogrel) Which inhibits platelets through ADP blockade.

2nd line, Only used in minor strokes

30
Q

What do we do if a patient came in on a therapeutic anticoagulant for an acute ischemic stroke

A

Discontinue anticoagulant and transition to aspirin.

31
Q

When should we restart anticoagulant for an acute ischemic patient that had an indication (cardioembolic ischemic stroke etc..)

A

2-14 days after stroke.

32
Q

What does CHADSVASc score stand for

A

C- Congestive HF
H- HTN
A- age >65
D- Diabetes
S- Stroke (2 points)
V- Vascular disease
A- Age > 75
S- sex (female

33
Q

BG goal for atherosclerotic and cardioembolic ischemic stroke

A

<180

34
Q

BP goals for atherosclerotic and cardioembolic ischemic stroke

A

No tPA< 220/110
prior to tPA< 185/110
After tPA< 180/105

35
Q

Are anticoagulants indicated in cardioembolic ischemic stroke? Atherosclerotic stroke?

A

Not indicated in anticoagulants
Wait 2 days for use in cardioembolic stroke

36
Q

Are antiplatelets used in cardioembolic? Atherosclerotic?

A

Yes for both.

High dose aspirin (wait 24 hrs if tPA given)

ANtiplatelets only until covert to anticoagulants

37
Q

Can we use tPA with atherosclerotic stroke? Cardioembolic stroke?

A

Yes for both. Same exclusion/inclusion criteria

If prior A fib, may be on oral anti coagulant so contraindicated

Therapeutics (36 decks)

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