Exam 4 lecture 6 Flashcards
Does ischemic stroke have worse prognosis or hemorrhagic stroke?
Hemorrhagic
Distinguishing symptom of hemorrhagic stroke
Severe headache
acute hemorrhagic stroke management
-Supportive care
-glycemic control
-Reversing causative medications
-surgery
-antihypertensives
-prevention of cerebral vasospasm
-anticonvulsant
reversing causative medications for
warfarin, Heparin, DOACs (dabigatran, other DOACs), ANtiplatelets
Warfarin- vitamin K
Heparin products- protamine
DOAC
Dabigatran- idarucizumab
Other DOACs- recombinant coagulation factor Xa
ANtiplatelets: No antidote
When to use antihypertensives in acute hemorrhagic stroke? WHat are the goal BPs?
SBP>180
Goal BP first 24 hrs < 180/110
Goal BP in hospital after 24 hours is < 160/90
After 48 hrs, transition to outpatient goal BP
What are patients at risk for after a subarachnoid hemorrhagic stroke
Vasospasms
highest risk 4-21 days after subarachnoid hemorrhagic stroke
Worsens complications after stroke
What drug has been shown to minimize complications from cerebral vasospasm?
Nimodipine
Is there a risk of seizure after hemorrhagic stroke?
Yes, there is a risk of hemorrhagic stroke
How should we avoid seizures caused by hemorrhagic stroke
Prophylactic anticonvulsants are NOT recommended due to lack of benefit.
Anticonvulsants only used if patient has a documented seizure history
What to use for Ischemic stroke patients to prevent secondary strokes
Antiplatelet vs anticoagulants
atherosclerotic- antiplatelet
cardioembolic- anticoagulants
goal of antiplatelet drugs? Duration
(Aspirin)
goal- prevent future strokes through inhibition of platelet activation/aggregation
duration- indefinite until bleeding risk/complications
What is the 1st line tx for secondary stroke prevention in atherosclerotic stroke? dose? Monitoring?
first 2-4 weeks Aspirin (162-325)
after 2-4 weeks of high dose aspirin do < or equal to 162 mg/day indefinitely
bleeding, nausea
Can also use dipyridamole/Aspirin
MOA of dipyridamole/Aspirin? Place in therapy? How is it used?
MOA- inhibits adenosine phosphodiesterase , preventing platelet aggregation
Also first line therapy for secondary stroke prevention in atherosclerotic ischemic stroke.
Not used acutely . Start after using 2-4 weeks high dose aspirin after stroke
side effects of dipyridamole/aspirin
Headache
GI bleed
WHat is a second line option for secondary stroke prevention in non embolic ischemic stroke for aspirin intolerant
Clopidogrel
mostly used in combination with apsirin
What is the place in therapy for clopidogrel + aspirind
Secondary stroke prevention for atherosclerotic ischemic stroke, first line for minor strokes. Second line for moderate-severe strokes
WHat are antiplatelets we do not use for secondary prevention
Ticagrelor + aspirin and prasgurel
FIrst line options for secoondary prevention of strokes
Aspirin
Dipyridamole/aspirin
Clopidogrel + aspirin
2nd line options for secondary prevention of strokes
Clopidogrel
What type of stroke patients are anticoags reserved for
Cardioembolic stroke patients caused by A fib (EXAM), valvular heart disease or severe HF
When to initiate anticoag
2-14 days after stroke
Immediately after stroke use aspirin instead of anticoag as lower bleeding risk
once anticoag starts, dx aspirin
What are anticoags to be used for cardioembolic stroke
DOACs
Apixaban
dabigatran
edoxaban
rivaroxaban
Warfarin
What anticoags to use if patient has mitral valve/LV thrombus
Warfarin/rivaroxaban
What are antiplatelets and anticoags used for?
only used in ischemic strokes (not hemorrhagic) to prevent occlusion of brain vasculature to minimize risk of future strokes
What to use for cardioembolic stroke (A FIB) for secondary stroke prevention
Anticoag
What to use for atherosclerotic/thrombotic stroke
Antiplatelet
ACyte and chronix tx of atherosclerotic stroke
Acyte- high dose aspirin 2-4 weeks
Chronic- low dose aspirin indefinitely
Acute and chronic treatment of cardioembolic stroke
acute- High dose aspirin ? 2 days
CHronic- DOAC, warfarin indefinitely
(if mechanical valve- warfarin/riva indefinitely
long term BP goals for stroke pt
130/80
First line antihypertensive for Black, CKD, CAD, Diabetes, HFrEF, AFIB
Black- CCB, thiazide
CKD- ACEI, ARB
CAD- BB + ACEI (or ARB)
Diabetes- ACEI, ARB
HFrEF- Neprilysin inhibitor/ARB, ACEI or ARB + BB + aldosterone antagonist
A fib- BB or non-DHP CCB
What drugs and doses should be initiated for dyslipidemia after an atherosclerotic ischemic stroke? Cardioembolic stroke? Hemorrhagic stroke? Goals?
after atherosclerotic- atrovastatin 80 mg PO
rosuvastatin 20-40 mg PO dailt
DO not use statin if cardioembolic stroke or hemorrhagic stroke
LDL goal< 70
What drugs should be used if statin monotherapy is not working
ezetimebe (1st)
PCSK9 (2nd)
How common is depression after stroke? tx?
25-50%, worsens recovery and linked to increased mortality
Antidepressants have been shown to improve neurological functioning after stroke
SSRIs avoid paroxetine due to cholinergic effects)
What are rehabilitations needed after stroke
Speech therapy (swallowing, speaking)
Occupational therapy
Physical therapy
How do we prevent future hemorrhagic strokes
HTN and co morbidity management
LSM
Does nimodipine decrease risl fpr future stroke
No, only decreases risk for spasms
BG goals in stroke? BP goals?
<180
for ischemic stroke BP
No tpa- <220/110
prior to tpa < 185/110
after tPa: <180/105
For hemorrhagic stroke
<180/110 for 1st 24 hrs
<160/90 >24 hrs
can we use tPA in hemorrhagic stroke?
Contraindicated
