Stroke

Question 1

What are the three types of strokes

Answer 1

HIT!!!
- Haemorrhagic stroke
-iscahemic
Transient iscahemic

Question 2

How would you treat a haemorrhagic stroke?

Answer 2

Manage blood pressure and avoid statins

Question 3

What are the two main points about the management of stroke?

Answer 3

• Stroke is associated with the risk of morbidity and mortality
  
  • Transfer patients urgently to hospital to determine the type of stroke and initiate treatment

Question 4

What are the symptoms?

Answer 4

• BE FAST!!!!!!!
  
  • BALANCE
  • EYES - Droopy
  • FACE- drops
  • ARMS - weak and floppy
  • SPEECH- slow and slurred
  • TIME - call 999 quick

Question 5

Iscahemic stroke management

Answer 5

• Initially start off on 300mg of ASPIRIN
  
  • Clopidogrel immediately if Aspirin is not tolerated
  • Following a confirmed diagnosis, patients should receive treatment for secondary prevention immediately

Question 6

How do we treat acute iscahemic stroke?

Answer 6

Initially, Aleplase - within 4.5 hours for 24 hours
- Aspirin 300mg/clopidogrel 75mg OD for 14 days

Question 7

How do we manage it long term? Not associated with AF?

Answer 7

Anti-platelets (non AF patients):
- Clopidogrel 75mg OD - recommended
- MR dipyridamole 200mg + Aspirin (if clopidogrel is contraindicated)
- MR dipyridamole alone (if clopidogrel and aspirin contraindicated)
- Aspirin alone if dipyridamole and clopidogrel are contraindicated

Question 8

Anti coagulants for stroke associated with AF?

Answer 8

• Warfarin - anticoagulant for AF patients

Question 9

Long term management

Answer 9

• Initiate a statin 48 hours after stroke
  
  • Monitor blood pressure, target <130/80 mmHg and treat hypertension
  • All pts advised on life style changes - modifying diet, weight, alcohol intake and smoking

Question 10

AntiPlatelet vs Anti Coagulant -

Answer 10

Anti platelet agents inhibit clot formation by preventing platelet activation and aggregation
Anti coagulants primarily inhibit the coagulation cascade and fibrin formation

Question 11

AntiPlatelet vs Anti Coagulant -

Answer 11

Anti platelet agents inhibit clot formation by preventing platelet activation and aggregation
Anti coagulants primarily inhibit the coagulation cascade and fibrin formation

Question 12

Acute coronary syndrome (which can be medically treated):

Answer 12

ASPIRIN(lifelong) + Ticagrelor(12 months). If ASPIRIN contraindicated, Clopidogrel (lifelong)

Question 13

Acute coronary syndrome (which can be medically treated):

Answer 13

ASPIRIN(lifelong) + Ticagrelor(12 months). If ASPIRIN contraindicated, Clopidogrel (lifelong)

Question 14

Percutaneous coronary intervention:

Answer 14

ASPIRIN(lifelong) and Prasurgrel or ticagrelor(12 months). If aspirin contraindicated,clopidogrel given lifelong

Question 15

TIA

Answer 15

Transient Iscahemic Attack : Clopidogrel(lifelong). OR aspirin life long and dipyridamole(lifelong)

Question 16

Dipyridamole

Answer 16

Dipyridamole is an anti -platelet used in combination with aspirin after an ischaemic stroke or transient ischaemic attack

Question 17

Dipyridamole MoA

Answer 17

• Inhibits phosphodiesterase,elevating platelet cAMP levels which in turn reduces intracellular calcium levels
  
  • Other actions include reducing cellular uptake of adenosine and inhibit on of thromboxane synthase

Question 18

Clopidogrel

Answer 18

An anti-platelet agent used in the management of cardiovascular disease. Previously used when aspirin was not tolerated or contraindicated but now can be used for acute coronary syndrome. Clopidogrel is also first line for patients following Ischaemic stroke and in patients with peripheral arterial disease

Clopidogrel is a thienopyridine - Prasugrel, ticagrelor, ticlopidine

Question 19

Clopidogrel - Interactions:

Answer 19

• Concurrent use of PPI may make clopidogrel less effective
  
  • Evidence still shows that omeprazole and esomeprazole still a cause for concern
  • Lansoprazole and other should be okay