Lopaz-Stroke prevention Flashcards
Stroke is the (blank) leading cause of death in the US
4th
76% of strokes are (blanK) events and subsequent events are common
first
What is a TIA?
transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia w/o acute infarction
Most TIAs last (blank) minutes, If the symptoms last hour, more likely than no there will be (Blank)
15
infarcted tissue
Stroke can be in the (blank) or (blank) or (blank)
brain, spinal cord, retina
A (Blank) infarction produces no symptoms
silent
What is the best tx for stroke?
What are the 2 categories for stroke risk factors?
dont have one
-non modifiable and modifiable
What are the non-modifiable stroke risk factors?
- age
- low birth weight
- ethnicity (black, some hispanics)
If you have a (blank) with ischemic stroke then you risk of stroke increases significatioy.
first degree relative
If you have a hx of ischemic stroke before the age of (blank) this is a bad sign and you will get another most likey
65
(blank) aneurysms are a risk for stroke
intracranial aneurysms
- 8% individuals w AD polycystic kidney disease
- 7% individuals w cervical fibromuscular dysplasia
What is the most important risk factor for stroke?
Hypertension
What is a stroke?
brain, spinal cord or retinal cell death attributable to ischemia, based on pathological, imaging and/or clinical evidence of permanent injury
silent infarctions produce no symptoms*
If you are black or hispanic what are you more likely to get and what will the result be?
more likely to get a stroke and die from it
Family history increases the risk of stroke by (blank) percent
30%
What type of aneurysm is associated with getting strokes? What individuals get these types of aneurysms?
Intracranial aneurysm
- 8% individuals w AD polycystic kidney disease
- 7% individuals w cervical fibromuscular dysplasia
WHo should you do screenings on for stoke?
-people with more than 2 first degree releatives with Subarachnoid hemorrhages or intracranial aneurysms
OR
-in patients w/ AD polycytic kidney disease and SAH or more than 1 relative w/ AD polycystic kidney disease and intracranial aneurysm
What are modifieable risk factors?
Physical inactivity Dyslipidemia HTN DM Diet Obesity
Physically active people have (blank) percent lower mortality than the least active
25-30%
What will physical activity do that helps prevent stroke?
- reduces plasma fibrinogen
- reduces platelet activity
- elevates t-PA activity
- elevates HDL
How much physical activity should adults do to prevent stroke?
40 min 3-4 days a week of moderate to vigorous intense aerobic physical activity
Tx with (blank) reduces the risk of stroke in patients w or at high risk for athersclerosis. SOOO plaque characteristics may improve w. (blank)
statins
statins
Each 1% reduction in total cholestero is associated w/ (blank) percent reduction in the risk of stroke
0.8%
SHould we worry that statins will increse the risk of intracerebral hemorrhage?
NO
What is the primary prevention of ischemic stroke in patients with high 10-year risk for CV events?
Is niacin helpful? is Fibric acid?
lifestyle changes and statins
not established
not established
What race is especially sensitive to the BP-raising effect of high salt intake, low potassium level, and suboptimal diet?
blacks
There is a strong diverse releationship between servings of (blank) and subsequent stroke
fruits and vegies
Increased intake of (blank), primarily from citrus fruits, has been associated with reduced risk of ischemic strokes
flavonoids
Higher intake of (blank) has been associated with a higher risk of stroke. Reduced intake of this ion and increased intake of this ion is indicated for a lower risk of stroke.
red meat
sodium, potassium
What is the best kind of diet?
high content of fruits,vegies,nutes
low fat dairy
reduced sat fats
(DASH style diet, Mediterranean diet)
The higher the (blank) is, the greater the risk of stoke. This is the MOST important RISK FACTOR for stroke
BP
Individuals who are normotensive at 55y of age have a (blank) lifetime risk for developing HTN
90%
More than 2/3rds of people over the age of (blank) have HTN
65
Bp control can be achieved in most individuals, but most patients require therapy (Blank) drug
more than one
What is the most important, modifiable risk factor for stroke?
HTN
(blank) treatment is the most effective strategy to prevent both ischemic and hemorrhagic stroke
HTN treatment
What is the target treatment of blood pressure?
less than 140/90 mm Hg
Where is the greater prevalence of obesity in the us? What is the linkage between obesity and stroke?
greater than 60 year olds and adolescents
More obese, more likely to get stroke
What races have the highest rates of obesity?
blacks, mexian-americans and all hispanics
lowest rates in whites
Having what disease more than doubles the risk for stroke?
What percent of adult Americans have this?
diabetes mellitus
8.2%
(blank) percent of patients w/ DM will die of stroke.
20%
(blank) reduces platelet sensitivity to aspirin
hyperglycemia
What should you give your patients with diabetes?
statins (to lower risk of first stroke)
cigarette smoking (blank) the risk of stroke. And (blank) fold increased the risk for subarachnoid hemorrhage
doubes
2-4
There are synergisitic effects between the use of (blank) and smoking on the risk of stroke
Oral contraceptives (OCs)
Is exposure to environmental tobacco smoke (second-hand) a risk factor for heart disease?
yes
Is there a linear-dose response relationship between tobacco smoke and stroke?
no there is a smoke exposure threshold
Bans on cigarette smoking are associated with a reduction in the risk of (blank)
stroke
Smoking as little as a single cigarette increase (blank and blank) and decreases (blank)
- heart rate, mean BP
- arterial distensibility
Both active and passive cigarette smoking exposure is associated w the development of (Blank)
atherosclerosis
What is the most effective med for smoking cessation?
varenicicline
more cost effective than nicotine replacement therapy
There is a (blank) fold increase risk of ischemic stroke resulting from embolism from (blank).
THis accounts for (blank) percent of ALL ISCHEMIC strokes (even higher fraction in the very elderly)
4-5
A fib
10%
(blank) percent of all strokes are ischemic.
85%
The rest are hemorrhagic
What is the CHADS2 for?
A fib stroke risk
How is the CHADS2 formatted?
Scored 0-6 1 point each given for CHF HTN Age >75 DM 2 point for -prior stroke or TIA
0 points - low risk (0.5%-1.7%)
1 point- moderate risk (1.2%-2.2%)
greater than 1 point- high risk (1.9%-7.6%)
What is the CHADS2VASc?
modifies CHADS2 by adding an age category -1 point for age 65-74 -2 point for age greater than 75 And adding 1 point each for -vascular disease -female sex
What are considered “vascular diseases” in the CHAD2DS2VASc?
- peripheral artery disease
- MI
- Aortic plaque
On the CHA2DS2VASc, what percentage of patients get a 0,1,2,3,4?
0 - 0.84% 1 - 1.79% 2 – 3.67% 3 – 5.75% 4 – 8.18%
What is the HAS-BLED?
Estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care.
What is the format of HAS-BLED?
Score greater than 2 associated w major bleeding 1 point each for HTN Abnormal renal function Abnormal liver function Prior stroke Prior major bleeding/bleeding predisposition INR in therapeutic range 65 Use of anti-platelets or NSAIDs Excessive alcohol use `
How do you treat a fib?
What is the target INR?
What is the risk reduction of stroke after tx?
adjust-dose warfarin
INR 2-3
64%
Taking warfarin will reduce your chance of dying by (blank) percent
26%
(blank) reduces stroke severity and post-stroke mortality
Warfarin
(blank ) reduces stroke by 39% w aspirin
warfarin
A study was done comparing New Anticoagulants to warfarin, are they better or worse than warfarin?
BETTER! had a lower hazard ratio
What is this:
- oral direct thrombin inhibitor
- twice-daily dosing
- renal clearance 80%
Dabigatran
What is this
- Direct factor Xa inhibitor
- once daily
- renal clearance 33%
Rivaroxaban
What is this:
- Direct factor Xa inhibitor
- Twice-daily dosing
- Renal clearance 25%
Apixaban
What is this:
- Direct factor Xa inhibitor
- Once-daily dosing
- Renal clearance 35%
Edoxaban
What are the advantages of NOACs?
- fixed dose
- no blood monitoring
- fewer drug interaxns than warfarin
- lower risk of ICH
What are the disadvantages of NOACs?
- Lack of reversing agent
- Short half-life
T or F
Warfarin-related ICH mortality is very high despite the availability of reversing agents
T
What are some reversing agents for warfarin?
Aripazine
Andexanet
Idarucizumab
T or F
Aspiring offers modest protection against stroke
T
Should you give aspirin in conjunction with warfarin?
not for AF and stable Coronary Artery Disease
TO prevent vascular events, which is better, aspirin alone or aspirin in conjunction with plavix?
combo is superior to aspirin alone (but more bleedings)
TO prevent vascular events, which is better, plavix with aspirin or warfarin?
Wafarin is superior to combo
T or F
Cardioversion, rate control, rhythm control do not protect AF patients against stroke
T
If you have a CHA2DS2VASc greater than 1, is anticoagulation recommended?
YES
if you have a CHA2DS2VASc score 0-1, is anticoagulation recommended?
aspirin may be considered but is not necessary
(blank) is reasonable for patients with ST elevated MI and asymptomatic L ventricular mural thrombi
anticoagulant therapy
(blank) may be considered for patients w/ ST elevated MI and anterior apical akinesis/hypokinesis
anticoagulant therapy
HOw does warfarin or aspirin affect cardiac ejection fraction? Is warfarin or aspirin better at reducing ischemic stroke?
- reduces it by 35%
- reduces ischemic stroke EVEN BETTER THAN ASPIRIN
Are you more or less likely to bleed using warfarin rather than aspirin?
more likely
Valvular heart disease can cause strokes. YOu are more likley to get an embolism if you have (blank) disease or if you have a (blank) valve
rheumatic valve disease
prosthetic
When should you give anticoagulation to a patient with valvular heart disease?
- mitral stenosis + prior embolic event, even if sinus rhythm
- mitral stenosis w L atrial thrombus
When do you give aspirin in valvular heart disease?
mitral valve prolapse w TIA
When do you give aspirin in valvular heart disease?
- mitral regurgitation
- AF
- L atrial thrombus
What is the most common cardiac tumor?
What percentage of these tumors will embolize?
Myxoma
30-40%
(blank) percent of patients w/ fibroelastoma present w stroke/TIA
50%
In Aortic Atherosclerosis, plaques greater than (blank) mm are associated with increased risk of stroke
4
Is anticoagulation indicated in mitral stenosis?
yes
Even if sinus rhythm and if L atrial thrombus
What 2 things are indicated in all mitral valve replacements?
Warfarin and aspirin
What do you perform on all atrial myxomas?
surgical excision
What do you give for aortic or mitral bioprosthesis?
aspirin
What do you give for patients with heart failure?
either ASA or warfarin
What do you give for ST elongated MI?
warfarin
What do you give for asymptomatic L ventricular mural thrombus or anterior apical akinesis/dyskinesis?
Warfarin
What shouldn’t you give to patients with PFO for primary prevention of stroke?
Anti-thrombotic therapy or catheter-based closure
Should you screen for asymptomatic carotid artery stenosis? What should you give these patients?
no
daily statins and ASA
Should you give asymptomatic carotid artery stenosis patients surgery?
no!
Sickle cell disease is inherited how? what causes it? what is the major complication of this?
AR
altered Hb beta chain
stroke
WHen will a Sickle cell disease patient most like get a stroke?
in childhood,
prevalence of stroke by age 20 is 11%
Velocity greater than 200 cm/sec by transcranial doppler (TCD) is associated with stroke rates of (Blank) percent/ year
10%
Annual TCD are recommened for sickle cell patients between ages (blank-blank) years
2-16
In sickle cell disease, what is the only intervention proven to decrease stroke rates?
periodic red cell transfusion
target is reduction of Hb s <30%
What are these: Migraine Metabolic Syndrome Alcohol consumption Drug abuse Sleep-disordered breathing Hyperhomocystenemia Hypercoagulability Inflammation and infection Antiplatelet agents/aspirin
less well-documented risk factors for stroke
What is associated with stroke in young women less than 45 years old who are smokers, and use oral contraceptives?
migraine w aura
Increased frequency of migraines w/ auras is correlated with increased risk of (blank) and (blank)
stroke
ICH
How can you reduce the frequency of migrain auras in women who take OCs?
use different ones, estrogen only ones
Heavy alcohol use is a risk factor for all types of (blank).
stroke
There is a linear association between alcohol consumption and the risk of (blank)
intracranial hemorrhage
What drugs are associated with increased risk of stroke and why?
- all sympathomimetics, cannabis, heroin
- BP elevations, cerebral vasospasm, vasculitis, endothelial dysfunction, increased blood viscosity, platelet aggregation
(blank) percent of adults have sleep apnea.
Sleep apnea is an independent (blank)
How do you treat it?
4%
stroke risk factor
CPAP
Hyperhomocysteinemia is a risk for stroke, can you reduce this risk?
no, reduction in homocysteine does not decrease stroke risk
Acquired and hereditary hypercoagulable states (thrombilias) are associated w (blank)
venous thrombosis
The 2 most common genetic causes of thrombolia are (blank and blank). Are these commonly asociated with arterial ischemic stroke?
- Factor V leiden mutation
- G20210A prothrombin mutation
no, rarely
Is inflammation a risk factor for stroke?
yes, inflammation has pro-thrombotic effects
-patients w/ inflammatory conditions, such as RA or SLE should be considered at risk of stroke
T or F
There is risk but no benefit of asa for the prevention of a first stroke in the general population
T, dont use ASA for stroke prevention
Aspirin is useful for (blank) prevention but not for stroke prevention
MI
The use of (blank) for CV prophylaxis is reasonable for people with a 10 year risk greater than 10% (not specific for stroke)
aspirin
For primary stroke prevention, Aspirin might be considered in patients with (blank or blank)
DM or Chronic kidney disease (not severe kidney disease)
T or F
Aspirin is not useful for preventing a first stroke in low-risk individuals.
T
