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Pharm I > Stroke > Flashcards

Stroke Flashcards

1
Q

Stroke

A

Sudden onset of focal neuronal deficit lasting longer than 24 hours

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2
Q

What population is 2x as likely to have a stroke?

A

Blacks > whites

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3
Q

Two main types of stroke

A

Hemorrhagic

Ischemic

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4
Q

Ischemic stroke

A

87% of all strokes
Blood flow to the brain is blocked
-Local thrombus or embolic phenomena occluding cerebral arteries
-Atherosclerosis of cerebral vascular is primary cause

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5
Q

Cardiogenic embolism is presumed when the pt has…

A

Afib

Valvular heart disease

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6
Q

Risk factors of ischemic stroke

A

Nonmodifiable
Modifiable
Potentially modifiable

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7
Q

Nonmodifiable risk factors of ischemic stroke

A 
Risk doubles every 10 yrs after age 55
Men > women (more likely to die)
Low birth weight
AA, Asian-Pacific, Hispanics
FHx
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8
Q

Modifiable risk factors of ischemic stroke

A 
HTN
Smoking
Diabetes
Afib
High cholesterol
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9
Q

Hemorrhagic stroke

A

Much less common but more lethal
Herniation and death
50% of 30 day mortality attributed to abrupt increase in ICP

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10
Q

Two types of hemorrhagic strokes

A

Intracerebral hemorrhage

Subarachnoid hemorrhage

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11
Q

Intracerebral hemorrhage

A

Most common type of hemorrhagic stroke

Artery in the brain bursts, flooding the surrounding tissue with blood

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12
Q

Subarachnoid hemorrhage

A

Less common

Bleeding in the area between the brain and the thin tissues that cover it

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13
Q

Transient ischemic attack (TIA)

A

Short blockage-usually no more than five mins
Warning sign of a future stroke
Blood clots often cause TIAs
More than a third of ppl who have a TIA and don’t get tx have a major stroke within 1 yr

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14
Q

Clinical presentation of stroke

A 
Hx typically comes from a witness
Unilateral body weakness
Loss of speech and/or vision
Vertigo
HA
-Ischemic: mild
-Hemorrhagic- severe
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15
Q

CT scan in stroke

A

W/o contrast to r/o hemorrhage and determine size, location, vascular distribution of infarct
Neurological deficits determined with National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS)

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16
Q

MRI in stroke

A

Higher resolution
Reveals damage earlier than CT
Get CT first then f/u with MRI if needed

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17
Q

Modified Rankin Scale

A

0- No sx
1-No significant disability, despite sx; able to perform all usual duties and activities
2- Slight disability; unable to perform all previous activities but able to look after own affairs without assistance
3- Moderate disability; requires some help, but able to walk without assistance
4-Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
5- Severe disability; bedridden, incontinent, and requires constant nursing care and attention
6-Death

18
Q

Other diagnostic tests for stroke

A 
Carotid Doppler
-Carotid artery stenosis
ECG
-Afib
Transthoracic echocardiography
-Structural abnormalities
Transesophageal echocardiography
-Thrombus in the LA
Transcranial Doppler
-Intracranial stenosis
19
Q

BP management on alteplase

A

SBP < 180 and DBP < 105

20
Q

BP management no alteplase

A

Avoid aggressive BP lowering which can decrease cerebral blood flow and perfusion pressure

21
Q

TPA based on BP alone

A

TP <180/105

No TPA <220/120

22
Q

1st line agents for BP management

A

Nicardipine: rapidly titratable and baseline BP returns on discontinuation
Labetalol: low cost, beta-blockade beneficial in Afib pts
Nitroprusside: for diastolic management

23
Q

Labetalol or nicardipine BP numbers to treat

A

185-230/110-120

24
Q

BP numbers in order to treat with nitroprusside

A

Diastolic > 120

25
Q

Labetalol IV dosing

A

10 mg, followed by an infusion of 2-8 mg/min

26
Q

Nicardipine IV dosing

A

Infusion starting at 5mg/h up to 15 mg/h

27
Q

Nitroprusside IV dosing

A

Infusion starting at 0.5 mcg/kg/min, with continuous arterial blood pressure monitoring

28
Q

ASA parameters with tPA

A

No ASA for 24 hrs after tPA

29
Q

Inclusion criteria for tPA

A

Age 18 years or older
Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit
Time of symptom onset well establish to be <4.5 hrs before tx would begin

30
Q

Exclusion criteria for tPA

A

Hx of previous intracranial hemorrhage
Active internal bleeding
Platelet count <100,000/mm cubed
Pt has received heparin within 48 hrs, resulting in an elevated APTT
Recent anticoagulant use and elevated INR (>1.7) or pT (>15 seconds)
Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (aPTT, INR, platelet count, or appropriate Xa activity assays)
Significant head trauma or previous stroke within 3 mos
Arterial puncture at noncompressible site within 7 days
Intracranial neoplasm, arteriovenous malformation, or aneurysm
SBP >185 mm Hg or DBP >110 mm Hg
Blood glucose < 50 mg/dL (2.7 mmol/L)
CT demonstrates multilobar infarction (hypodensity .1/3 cerebral hemisphere)

31
Q

Acute tPA tx

A

Less than 3 hrs from onset

  1. 9 mg/kg over 1 hours
    - 10% given as bolus over 1 min
32
Q

Between 3 and 4.5 hrs exclusions tPA

A

Age >80
OA regardless of INR
Score >25 on Stroke scale
Hx of diabetes and stroke

33
Q

Contraindications of tPA

A 
Bleeding
Recent stroke
BP <185/110
Platelets <100,000
Anticoagulation therapy within 24 hrs
34
Q

Endovascular thrombectomy

A

Done with stent retriever within 6 hrs of tPA

35
Q

Treatment/prevention of stroke

A

Carotid endarterectomy should be performed in ischemic stroke pts with 70% to 99% stenosis of the carotid artery
Done in an experienced center
Pts younger than 70 yrs

36
Q

ASA in stroke

A

Irreversibly inhibiting cylooxygenase, which, in platelets, prevents conversion of arachidonic acid to thromboxane A2, which is a powerful vasoconstrictor and stimulator of platelet aggregation
Platelets remain impaired for their lifespan (5-7 days) after exposure to ASA
ASA also inhibits prostacyclin (PGI2) activity in the smooth muscle of vascular walls. PGI2 inhibits platelet aggregation, and the vascular endothelium can synthesize PGI2 such that the platelet antiaggregating effect is maintained.

37
Q

ASA dosage

A

325 mg within 48 hrs

Do not give within 24 hrs of tPA use

38
Q

Secondary prevention of stroke

A 
BP control <140/90
LDL <100
HgA1c <7
DASH diet
-2000 calorie-a-day diet
-Low in saturated and trans fats
-Rich in K, Ca, Mg, fiber, and protens
-Lower in sodium < 2300 mg
39
Q

Antiplatelet ASA

A

50-325 mg/daily
Ibuprofen taken with daily ASA dose inhibits the ASA from binding irreversibly to the cylooxygenase and can decrease its antiplatelet effect
ASA at least 2 hrs before ibuprofen or to wait at least 4 hrs after ibuprofen dose

40
Q

Another antiplatelet option

A

ER dipyridamole (ERDP) + ASA

  • ASA 25 mg + ERDP 200 mg BID
  • Take on empty stomach 1 hr before or 2 hrs after meals
  • -If stomach hurts, take with small snack or milk
  • Discontinuation due to HA 6x higher
41
Q

Clopidogrel

A

Antiplatelet tx- secondary prevention
75 mg daily
Antiplatelet effects diminished in pts with reduced-fxn CyP2C19 or in those receiving agents that inhibit hepatic metabolism
Contraindicated with proton pump inhibitor use

42
Q

Oral anticoagulants

A 
Warfarin
-INR 2.5
Dabigatran (Pradaxa)
-150 mg BID
Rivaroxaban (Xarelto)
-20 mg/daily
Apixaban (Eliquis)
-5 mg BID

Pharm I (10 decks)

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