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Therapeutics > Exam 4 lecture 6 > Flashcards

Exam 4 lecture 6 Flashcards

1
Q

Does ischemic stroke have worse prognosis or hemorrhagic stroke?

A

Hemorrhagic

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2
Q

Distinguishing symptom of hemorrhagic stroke

A

Severe headache

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3
Q

acute hemorrhagic stroke management

A

-Supportive care
-glycemic control
-Reversing causative medications
-surgery
-antihypertensives
-prevention of cerebral vasospasm
-anticonvulsant

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4
Q

reversing causative medications for
warfarin, Heparin, DOACs (dabigatran, other DOACs), ANtiplatelets

A

Warfarin- vitamin K
Heparin products- protamine
DOAC
Dabigatran- idarucizumab
Other DOACs- recombinant coagulation factor Xa
ANtiplatelets: No antidote

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5
Q

When to use antihypertensives in acute hemorrhagic stroke? WHat are the goal BPs?

A

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

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6
Q

What are patients at risk for after a subarachnoid hemorrhagic stroke

A

Vasospasms

highest risk 4-21 days after subarachnoid hemorrhagic stroke

Worsens complications after stroke

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7
Q

What drug has been shown to minimize complications from cerebral vasospasm?

A

Nimodipine

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8
Q

Is there a risk of seizure after hemorrhagic stroke?

A

Yes, there is a risk of hemorrhagic stroke

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9
Q

How should we avoid seizures caused by hemorrhagic stroke

A

Prophylactic anticonvulsants are NOT recommended due to lack of benefit.

Anticonvulsants only used if patient has a documented seizure history

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10
Q

What to use for Ischemic stroke patients to prevent secondary strokes

A

Antiplatelet vs anticoagulants

atherosclerotic- antiplatelet
cardioembolic- anticoagulants

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11
Q

goal of antiplatelet drugs? Duration

A

(Aspirin)
goal- prevent future strokes through inhibition of platelet activation/aggregation

duration- indefinite until bleeding risk/complications

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12
Q

What is the 1st line tx for secondary stroke prevention in atherosclerotic stroke? dose? Monitoring?

A

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

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13
Q

MOA of dipyridamole/Aspirin? Place in therapy? How is it used?

A

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

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14
Q

side effects of dipyridamole/aspirin

A

Headache
GI bleed

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15
Q

WHat is a second line option for secondary stroke prevention in non embolic ischemic stroke for aspirin intolerant

A

Clopidogrel

mostly used in combination with apsirin

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16
Q

What is the place in therapy for clopidogrel + aspirind

A

Secondary stroke prevention for atherosclerotic ischemic stroke, first line for minor strokes. Second line for moderate-severe strokes

17
Q

WHat are antiplatelets we do not use for secondary prevention

A

Ticagrelor + aspirin and prasgurel

18
Q

FIrst line options for secoondary prevention of strokes

A

Aspirin
Dipyridamole/aspirin
Clopidogrel + aspirin

19
Q

2nd line options for secondary prevention of strokes

A

Clopidogrel

20
Q

What type of stroke patients are anticoags reserved for

A

Cardioembolic stroke patients caused by A fib (EXAM), valvular heart disease or severe HF

21
Q

When to initiate anticoag

A

2-14 days after stroke

Immediately after stroke use aspirin instead of anticoag as lower bleeding risk

once anticoag starts, dx aspirin

22
Q

What are anticoags to be used for cardioembolic stroke

A

DOACs

Apixaban
dabigatran
edoxaban
rivaroxaban
Warfarin

23
Q

What anticoags to use if patient has mitral valve/LV thrombus

A

Warfarin/rivaroxaban

24
Q

What are antiplatelets and anticoags used for?

A

only used in ischemic strokes (not hemorrhagic) to prevent occlusion of brain vasculature to minimize risk of future strokes

25
Q

What to use for cardioembolic stroke (A FIB) for secondary stroke prevention

A

Anticoag

26
Q

What to use for atherosclerotic/thrombotic stroke

A

Antiplatelet

27
Q

ACyte and chronix tx of atherosclerotic stroke

A

Acyte- high dose aspirin 2-4 weeks

Chronic- low dose aspirin indefinitely

28
Q

Acute and chronic treatment of cardioembolic stroke

A

acute- High dose aspirin ? 2 days
CHronic- DOAC, warfarin indefinitely
(if mechanical valve- warfarin/riva indefinitely

29
Q

long term BP goals for stroke pt

A

130/80

30
Q

First line antihypertensive for Black, CKD, CAD, Diabetes, HFrEF, AFIB

A

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

31
Q

What drugs and doses should be initiated for dyslipidemia after an atherosclerotic ischemic stroke? Cardioembolic stroke? Hemorrhagic stroke? Goals?

A

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

32
Q

What drugs should be used if statin monotherapy is not working

A

ezetimebe (1st)
PCSK9 (2nd)

33
Q

How common is depression after stroke? tx?

A

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)

34
Q

What are rehabilitations needed after stroke

A

Speech therapy (swallowing, speaking)
Occupational therapy
Physical therapy

35
Q

How do we prevent future hemorrhagic strokes

A

HTN and co morbidity management
LSM

36
Q

Does nimodipine decrease risl fpr future stroke

A

No, only decreases risk for spasms

37
Q

BG goals in stroke? BP goals?

A

<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

38
Q

can we use tPA in hemorrhagic stroke?

A

Contraindicated

39
Q
A

Therapeutics (38 decks)

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