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PHAR152 > Stroke > Flashcards

Stroke Flashcards

1
Q

What is a stroke?

A

sudden onset of FOCAL neurologic deficit resulting from the interruption of blood flow to an area in the brain

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2
Q

What are some symptoms of stroke?

A

hemiplegia
hemiparesthesia
blindness in one eye
speech disturbance
dizziness
weakness
headache
confusion

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3
Q

What is the acronym to remember the signs of stroke?

A

FAST
face drooping?
can you raise both arms?
is speech slurred?
time to call 911

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4
Q

What is the leading cause of disability?

A

stroke

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5
Q

Do people recover from stroke?

A

function may improve slowly over days-months

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6
Q

What is TIA?

A

transient ischemic stroke
focal neurologic deficit as a result of ischemia lasting less than 24hrs WITHOUT evidence of infarction on imaging studies

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7
Q

Is hemorrhage a likely cause of TIA?

A

no
hemorrhage stroke is unlikely to resolve itself within 24hrs

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8
Q

What are the chances of experiencing a stroke in the future if you had TIA?

A

7.5-17% within 3 months

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9
Q

If a person experienced TIA, how are they now considered?

A

now considered as secondary prevention

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10
Q

What are the types of stroke?

A

hemorrhagic (13%):
-higher death rate
-higher morbidity
-risk: aneurysm, HTN, medications (DAPT, OAC)
ischemic (87%):
-20% atherosclerosis
-30% cryptogenic
-20% cardioembolic
-25% lacunar
-5% other causes

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11
Q

What are conditions that can result in thrombus generation within or on the heart?

A

atrial fibrillation
mechanical heart valves

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12
Q

Describe cardioembolic stroke.

A

thrombi can break off and travel through aorta–>carotid artery–>small cerebral vessels

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13
Q

What are medications used to prevent cardioembolic stroke?

A

anticoagulants
-warfarin
-dabigatran
-rivaroxaban
-apixaban

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14
Q

What is the first decision that will be made in ER after someone has been diagnosed with stroke?

A

is the person eligible for thrombolytics?

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15
Q

What are the recommendations for the use of thrombolytics and stroke?

A

IV tPA is recommended provided that treatment is initiated within 3 hours of clearly defined symptom onset
therapy is also recommended between 3-4.5hrs of stroke except: >80yrs, OAC, severe stroke, history of stroke, diabetes
ASA usually delayed until 24hrs after tPA

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16
Q

What do plasminogen activators do?

A

convert plasminogen to plasmin
plasmin degrades fibrin into soluble products

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17
Q

What are examples of plasminogen activators?

A

alteplase (tPA)
-exact human sequence
-requires 1hr infusion time
tenecteplase
-longer acting fibrinolytic
-administered with one IV bolus dose
-recently shown “non-inferior” to tPA

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18
Q

What are the outcomes with the use of fibrinolytics in acute stroke?

A

if administered within 3-.4.5hrs will reduce risk for poor outcomes (disability, lack of recovery, neuronal damage)
if administered later, outcomes are not lower

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19
Q

Why is there explicit eligibility criteria for tPA?

A

due to the risk of bleeding

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20
Q

What is the eligibility for tPA?

A

clearly defined onset within past 3hrs
significant neurologic deficit

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21
Q

What are the contraindications to tPA?

A

rapidly improving
hemorrhage on CT
seizure at stroke onset
recent stroke or head injury (3 months)
recent GI/UTI bleed (3 weeks)
bp>185/110
low platelets
recent anticoagulation (2 days)
history of ICH

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22
Q

True or false: it is common to see tPA administered alongside an anticoagulant for stroke

A

false

23
Q

What are the recommendations if someone is not eligible for tPA?

A

antiplatelet therapy is initiated
anticoagulation would be used instead for cardioembolic stroke
if hemorrhage has been ruled out

24
Q

What are examples of antiplatelet agents?

A

COX inhibitors: ASA
ADP inhibitors: clopidogrel, prasugrel, ticagrelor
interference with cAMP: dipyridamole/ASA
GP IIb/IIIa antagonists

25
Q

True or false: GP IIb/IIIa antagonists have no role in stroke

A

true

26
Q

True or false: Aggrenox (dipyridamole/ASA) has a role in MI

A

false
studied in post-stroke

27
Q

What is the antiplatelet of first choice in most cases when a person is ineligible for tPA?

A

ASA

28
Q

Describe the pathway of arachidonic acid.

A

arachidonic acid can become COX-1 or COX-2
COX-1 produces thromboxane A2
COX-2 produces prostacyclin

29
Q

How does ASA compare to other NSAIDs?

A

ASA is irreversible
little effect on COX-2 at low doses

30
Q

How much does ASA reduce the risk in secondary prevention of stroke?

A

16%

31
Q

ASA is used in secondary prevention of stroke in all patients, except who?

A

certain patients with afib/cardioembolic risks
hemorrhagic stroke
other CIs

32
Q

What is the incidence of GI bleeds from ASA?

A

0.4% per year

33
Q

What will put an individual at a greater risk of GI bleed from ASA?

A

higher dose (can occur with low doses)
hemostatic defect (hemophilia/low platelets)
previous GI bleed
drugs (anticoagulants)
age >60
uncontrolled HTN
CKD

34
Q

True or false: ADP inhibitors do not cause GI bleeding, only NSAIDs do

A

false

35
Q

What are the effects of prostacyclin (PgI2)?

A

inhibit acid secretion
enhance mucosal blood flow
promote secretion of cytoprotective mucous

36
Q

What are the guidelines for antiplatelets in non-cardioembolic stroke (2ndry prevention)?

A

acceptable 1st line agents:
-aspirin 50-325mg OD
-Aggrenox BID
reasonable 2nd line therapy:
-clopidogrel 75mg OD
ASA+clopidogrel for first 21 days followed by ASA alone
-considered for 21 days in patients with minor stroke
-long term use is not recommended

37
Q

What is dipyridamole?

A

MOA is controversial (PDE inhibitor or adenosine inhibitor or promoter of PGI2)
poor absorption from regular dosage forms
Aggrenox has modified release formulation

38
Q

True or false: Aggrenox is possibly superior to ASA alone for secondary prevention of stroke

A

true
RRR 18% vs ASA

39
Q

How frequently is Aggrenox administered?

A

BID (200mg/25mg)

40
Q

Are ticagrelor or prasugrel recommended in stroke guidelines?

A

not currently recommended in stroke guidelines
evidence is emerging
not covered by Sask drug plan for stroke indication
much more costly than ASA 81mg OD

41
Q

Describe low-dose ASA in secondary prevention of stroke based on the following: efficacy, safety, DI, convenience, CI, cost

A

efficacy:
-moderate effectiveness from RCT (may be slightly less
effective than Aggrenox)
-also indicated for prevention of ACVD events
-NOT very effective for cardioembolic conditions
safety:
-nuisance bleeding/bruising (common but not dangerous)
-major bleeding (mostly CNS or GI)
-GI bleeding in 0.4% in healthy, risk increases with disease/age
-GI bleed/ulceration often not painful
-CNS bleeding typically 1/10 of major bleeding (less common
but more dangerous
-at low doses, does not exhibit renal/bp effects of NSAIDs
DI:
-other antiplatelets/anticoagulants/NSAIDs/SSRIs
-methotrexate lvls increase with ASA but not likely 81mg
convenience:
-OD dosing but half life is short
CI:
-prior bleed
-uncontrolled HTN
-bleeding risk (low platelets, bleeding conditions, age)
cost:
-cheapest antiplatelet available

42
Q

What is the role of DAPT in stroke?

A

used in:
-non disabling stroke
-high risk TIA
ASA+clopidogrel given within 24hrs and continued for 21 days
reduces 90d stroke risk from 7.8% to 5.2%

43
Q

What are stroke patients at risk for and why?

A

venous thromboembolism due to paralysis/immobility
all patients with reduced mobility are given preventative therapy (low dose heparin, LMWH, IPC/ES)

44
Q

What is the worst possible outcome of VTE?

A

pulmonary embolism

45
Q

What are the recommendations around blood pressure control and stroke?

A

acute phase (onset to 72 hours):
-only extreme bp values are treated (>220/120)
-if thrombolysis is considered and bp >185/110

46
Q

What are the current guidelines of treating blood pressure post-stroke?

A

strong consideration for treating everyone post-stroke regardless of bp
threshold bp>140/90
target <140/90
FIRST LINE: ACEI + TZD

47
Q

What is the medication regimen of a patient for secondary stroke prevention?

A

blood pressure: ACEI+TZD (goal<140/90)
antiplatelet therapy
statins
smoking cessation (RRR 33%) and lifestyle intervention

48
Q

Is antiplatelet therapy or anticoagulant therapy preferred for atherosclerotic stroke management?

A

antiplatelet therapy:
-showed lower risk of death or recurrent stroke at 2 yrs, major
bleed over 2 yrs, and any bleed over 2 yrs

49
Q

When would warfarin or anticoagulants be used for stroke?

A

cardioembolic stroke

50
Q

What is a common consequence of afib?

A

stroke
thus, almost all patients will receive stroke prevention even if they have never had a stroke

51
Q

What is the only group of patients that will receive primary prevention for stroke?

A

afib

52
Q

Describe the recommendations of primary prevention of stroke for afib.

A

CHADS-65–>OAC (have one of the following):
-CHF (heart failure)
-hypertension
-age 65
-diabetes
-prior stroke or TIA
none of the above:
-CAD or PAD–>antiplatelet
none of the above–>no antithrombotic

53
Q

True or false: we use primary prevention of stroke or heart with ASA in virtually all patients

A

false

54
Q

What is the regimen of secondary stroke prevention?

A

ABCKDE
antiplatelets
blood pressure (ACEI + thiazide)
cholesterol (statins)
diabetes
exercise/lifestyle/diet (RRR 33%)

PHAR152 (21 decks)

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