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PHRM 864: Therapeutics IV > Stroke > Flashcards

Stroke Flashcards

1
Q

What is the epidemiology of Stroke?

A
  • 800,000 Strokes yearly
  • 5th cause of death
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2
Q

What is the defintion of a Stroke?

A
  • An acute focal injury due to lack of blood/oxygen to the CNS causing Neurological deficits
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3
Q

What are the two types of stoke?

A
  • Ischemic
  • Hemorrhagic
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4
Q

What is the definition of Ischemic Stroke?

A
  • An infarction of brain tissue resulting fom compromised blood flow
  • Atherosclerotic: Increased plaque = Decreased Blood Flow
  • Cardioembolic: Embolism from Afib
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5
Q

What is the definition of Hemorrhagic Stroke?

A
  • Bleeding in the brain due to rupture of a cerebral artery - Aneurysm
  • Intracranial Hemorrhage
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6
Q

What are some of the risk factors for Stroke?

A
  • Non-Modifiable: Age, Family History, Females > Male, Race, Birth Weight, Sickle Cell
    Modifiable: CV Diseases, Diabetes, Hyperlipidemia, HTN, Alcohol, Obesity, Smoking
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7
Q

What is are some of the clinical presentations for Stroke?

A
  • Difficulty Speaking
  • Facial Droop
  • Weakness
  • Ataxia
  • Vision Changes
  • Headache [more common in Hemorrhagic]
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8
Q

What does FAST mean within Clinical Presentation in Stroke?

A
  • F: Facial Droop
  • A: Arm Weakness
  • S: Speech Difficulty
  • T: Time to call 911
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9
Q

What are some of the assessments used to help determine a stroke?

A
  • Imaging [Head CT or MRI}
  • Vitals [BP or Oxygen Sat}
  • Lab [BG, BMP, CBC, Hematologic Markers]
  • Test [ECG or Echo]
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10
Q

What is imporant to know about Imaging in Assessment with Stroke?

A
  • Head CT or MRI
  • A quick way to see what is happening within the brain
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11
Q

What is important to know about Tests [ECG] in Assessment within Stroke?

A
  • AFib = Cardioembolic
  • Noraml = Atherosclerotic
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12
Q

What are some of the Goals of Treatment for Acute Stroke?

A
  • Limit Neurological Injury
  • Decrease Mortality
  • Prevent Future strokes [After 1st stroke, increased risk of others]
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13
Q

What is the Acute Managment Overview for Stroke?

A
  • Supportive Care
  • Glycemic Control
  • Antihypertensives
  • Thrombolytics
  • Antiplatelets
  • Anticoagulation
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14
Q

What is important to know for Glycemic Control in Acute Managment of Stroke?

A
  • Hypoglycemia: causes neuro changes that “mimics” stroke –> GIVE CARBS
  • Hyperglycemia: BG > 180mg/mL has Increased Morbidity & mortality –> GIVE INSULIN until BG < 180mg/mL
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15
Q

What should you do if a patient is Hyperglycemic and in Acidosis within Stroke?

A
  • Insulin Drip
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16
Q

What is important to know about arguing FOR or AGAINST Acute Blood Pressure Management in Stroke?

A
  • FOR: Minimize neuro deficits, Decreased cerebral edema & hemorrhage, Prevention
  • AGAINST: decreased BP to quickly can limit the brain perfusion = worse ischemia & neuro function
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17
Q

What are some fo the blood pressure goals for Acute Management of Blood Pressure in Stroke

A
  • Check BP every hour
  • GOAL within 48h: NO tPA = <220/110 & WITH tPA = <180/105
  • After 48h: <140/90 or <130/80
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18
Q

What are some of the Acute Hypertension Treatment options for Acute Management of Blood Pressure in Stroke?

A
  • Labetalol, Nicardipine, Sodium Nitroprusside
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19
Q

What are the Thrombolytics that are used in Acute Ischemic Stroke Management?

A
  • Alteplase, Tenecteplase
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20
Q

Based on the mechanism of action for Thrombolytics, what type of Stroke would you use a Thrombolytic in?

A
  • Activates plasminogen which helps break apart the clot
  • Ischemic [both atherosclerotic and cardioembolic]
  • NOT in Hemorrhagic [increases bleed risk]
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21
Q

What is important about using Thrombolytics in Ischemic Stroke?

Types? What does it help?

A
  • BOTH TYPES - Athero and Cardio
  • NO impact on mortailty but could improve neuro function
  • ONLY IN PATIENTS THAT MEET CRITERIA
22
Q

What is the tPA Eligibility criteria for Stroke?

A
  • Inclusion: Ishchemic Stroke ONLY & symptom onset <4.5 hours
  • Exclusion: increased bleeding, BP > 185/110 & BG<50mg/dL
23
Q

What are the two tPA agents that are used ?

A
  • Alteplase 0.9 mg/kg IV [MAX 90 mg]
  • Tenecteplase 0.25 mg/kg IV [MAX 25mg]
24
Q

What are some side effects from tPA agents in Stroke?

A
  • Bleeding [increases hemorrhage risk] - KEEP BP < 180/105 & avoid ALL antiplatelet and Anticoag for 24h
  • Cerebral Edema
25
Q

What are the Antiplatelet options for Acute Ishemic Stroke Management?

A
  • Aspirin
  • Aspirin + Clopidogrel
  • Ticagrelor
  • Aspirin + Ticagrelor
26
Q

What is important to know about Aspirin in Acute Ischemic Stroke Management?

MOA? When?

A
  • MOA: Irreversible inhibitor of COX enzyme; reducing fromation of TXA2 = decreased platelet aggregation
  • FIRST LINE
  • 325 mg daily for 2-4 weeks
27
Q

Who gets aspirin for a stroke?

A
  • ALL ischemic stroke [both Embolic and Atherosclerotic]
  • Contraindications: Bleeding
  • > 24h if tPA given [NO tPA then immediately]
28
Q

What important to know about Aspirin + Clopidogrel in Acute Management of Stroke?

A
  • MOA: Clopidogrel = P2Y12 inhibitor that decreases platelet aggregation by blocking ADP
  • ONLY for minor strokes [NIHSS < 4]
  • Second Line
29
Q

What is important to know about Ticagrelor in Actue Management of Stroke?

A
  • P2Y12 inhibitor that decreases platelet aggregation by blocking ADP
  • ONLY for minor strokes [NIHSS < 5]
  • Second Line
  • Used when True aspirin allergy
30
Q

When should you use therapeutic Anticoag be used within Acute Management of Stroke?

A
  • LACKs research - no improvement of neuro & Increased Bleeding
  • USE ASPIRIN
31
Q

What do you do if the patient comes in on an anticoagulant?

A
  • D/C anticoag –> START aspirin
  • NO alteplase if on Anticoag
32
Q

If the Patient is Cardioembolic what should you do with anticoagulant?

A
  • Start > 2-14 days after stroke
33
Q

What is the Acute Management overview of Hemorrhagic Stroke/

A
  • Reversal Agents
  • Surgery
  • Prevention of Cerebral Vasospasm
  • Anticonvulsants
34
Q

What are some of the Reversing Causative Medications that could be used in Acute Management of Hemorrhagic Stroke?

A
  • Vitamin K = Warfarin
  • Protamie = Heparin
  • Idarucizumab = Dabigatran [DOAC]
  • Andexxa = Other DOAC
  • NOTHING = Antiplatelets
35
Q

What are some fo the surgical options for Acute Management for Hemorrhagic Stroke?

A
  • Craiotomy, Endoscopic Coiling, Endoscopic Evacuation
36
Q

When should Antihypertensives be used in Acute Hemorrhagic Stroke?

A
  • Prevent rebleeding by controlling BP
  • GOAL: first 24h = <180/110
  • GOAL: after 24h = <160/90
  • GOAL: after 48h = < 130/80 or <140/90
37
Q

What is the way that we are able to prevent Vasospasm in Acute Management of Hemorrhagic Stroke/

A
  • Vasospasms after Subarachnoid Hemorrhagic Stroke [4-21d after]
  • Nimodipine decreases vasospasms [60mg q4h x 21d]
38
Q

When should Anticonvulsants be used in the Acute Management of Hemorrhagic Stroke?

A
  • Increased risk of seizure after stroke
  • Prophylactic NOT recommended
  • Use ONLY is history of seizure
39
Q

What is the goal of Antiplatelets in Secondary Stroke Prevention?

A
  • Prevent future strokes by inhibition of platelets
  • INDEFINITE TREATMENT
40
Q

What is the goal of Aspirin in Secondary Stroke Prevention?

A
  • FIRST LINE
  • Start with 325mg then switch to 81mg
  • SE: Bleeding, Nausea
41
Q

What is the goal of Dipyridamole/Aspirin [Aggrenox] in Secondary Stroke Prevention?

A
  • MOA: Both inhibit the aggregation fo platelets
  • FIRST LINE
  • SE: Headache & GI Bleeds
42
Q

What is the goal of Clopidogrel in Secondary Stroke Prevention?

A
  • SECOND LINE - mainly used in Atherosclerois
  • SE: Bleeding
43
Q

What is the goal of Clopidogrel + Aspirin in Secondary Stroke Prevention?

A
  • For Minor Stroke [NIHSS < 3] = 1st line & Mod-Severe = 2nd Line
  • SE: Bleeding [increased in combo]
44
Q

What are some fo the Other Antiplatelets in Secondary Stroke Prevention?

A
  • Ticagrelor + Aspirin
  • Prasugrel
  • NOT RECOMMENDED in guideline as treatment
45
Q

When should anticoagulants be used in Secondary Stroke Prevention?

A
  • In Cardioembolic stroke caused by AFIB –> start > 2-14d after stroke
46
Q

What are some of the anticoagulants that are used in Secondary Stroke Prevention?

A
  • DOAC [Apixaban, Dabigatran, Edoxaban, Rivaroxaban]
  • Warfarin
  • MECH VALVE = Warfarin/Rivaroxaban
47
Q

What is the Hypertension Management goal for Secondary Stroke Prevention?

A
  • GOAL BP <130/80 for ALL stroke types
48
Q

What is the Hypertensive medications for Secondary Stroke Prevention?

A
  • Black: CCB, Thiazide
  • CKD: ACEi, ARBs
  • CAD: BB+ACEi [or ARBs]
  • DM: ACEi, ARBs
  • HFrEF: ARNI, ACEi, or ARBs + BB + Aldosterone Antagonist [+SGLT2]
  • AFib: BB or Non-DHP CCB
49
Q

When should Dyslipidemia be used in Secondary Stroke Prevention?

A
  • After atherosclerotic ischemic should be given a High Intensity Statin [Ator 40-80mg or Rosuv 20-40mg]
  • GOAL: LDL < 70
  • DO NOT use statin in Cardioembolic or Hemorrhagic
50
Q

What are some other Additional Risk Factors to reduce in Secondary Stroke Prevention?

A
  • Cessation of Illicit Drugs [Cocaine]
  • Decrease Alcohol
  • Diabetes Control [A1c < 7]
  • Physical Acitivity
  • Dieting
  • Weight Loss
  • Smoking Cessation
51
Q

When should Antidepressants be started in those that have had a stroke?

A
  • AFTER STROKE
  • SSRIs [Sertraline, Escitalopram, Citalopram]

PHRM 864: Therapeutics IV (28 decks)

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