Stroke and AF

Question 1

What are the two types of stroke?

Answer 1

1. Ischemic - due to clot in the supply to the brain, accounts for 85% of cases.
2. Hemorrhagic - bleed in the brain

Question 2

How can you tell the difference between the two types of stroke?

Answer 2

CT scan

Question 3

Name 5 modifiable risk factors for stroke

Answer 3

Diabetes
Hyperlipidemia
Smoking
Alcohol 
Hypertension 
AF
CHF

Question 4

What is the most important modifiable risk factor for stroke?

Answer 4

Hypertension

Question 5

How can we prevent stroke?

Answer 5

Identify a persons risk factors and modify them e.g. HTN ,smoking cessation, diabetes control

Question 6

How can we predict someones risk of stroke after a TIA?

Answer 6

ABCD score

Question 7

What does ABCD stand for in terms of stroke risk?

Answer 7

A - age > 60 years = 1 point
B - blood pressure >140/90 = 1 point
C - clinical features
unilatereal weakness = 2 points
Speech disturbances with no weakness = 1 point
D- duration of symptoms 
>60 mins = 2 points
10-59 mins = 1 point
<10 mins = 0 points 

D- diabetes = 1 point

Question 8

Why might dabigatran be unsuitable in stroke patients?

Answer 8

Large capsule so difficult to swallow.

Cannot go down and NGT or PEG

Question 9

How can we increase the detection of AF in patients?

Answer 9

Regular manual pulse checks for the over 65s, particularly those with co-morbidities such as hypertension, heart disease, diabetes or renal dsyfunction.

Question 10

How do we assess a person with AF risk of stroke?

Answer 10

CHA2DS2Vasc score

Question 11

What does CHADVASc stand for?

Answer 11

C-congestive heart failure
H- hypertension
A- age >75 years = 2 points
D- diabetes
S - stroke or TIA = 2 points
Vascular disease - 1 point
Age between 64 and 75 - 1 
Sex - female = 1

Question 12

What does HASBLED stand for?

Answer 12

H - hypertension uncontrolled over 160
A - abnormal kidney or liver function (1 point for each)
S - Stroke history
B - bleeding (history of bleeding or predisposition
L - labile INR
E - elderly ?65 years
D - drugs/alcohol (1 point if taking antiplatelet drugs) and 1 point if consuming more than 8 drinks a week

Question 13

When do we offer an patient with AF an anticoagulant?

Answer 13

If their CHADVasc score outweighs their HASBLED.

Anticoagulate if >2 points. (consider men with a score >1)

Question 14

If a patient is taking warfarin but wants to switch to a DOAC what do you do?

Answer 14

Stop warfarin, and start DOAC once INR is <2

Question 15

What DOAC might be the best option in elderly patients at risk of bleeding?

Answer 15

Apixaban - has the lowest bleed risk

Question 16

When does the dose of DOACS need to be reduced?

Answer 16

Body weight (<60kg), renal impairment

Question 17

Is aspirin suitable monotherapy for stroke prevention in AF?

Answer 17

NO - patient should stop aspirin and switch to DOAC or warfarin

Question 18

What is the first line treatment for rate control in AF?

Answer 18

Cardioselective BB (if not suitable rate-limiting CCB)

Question 19

When should digoxin be considered in AF?

Answer 19

Consider monotherapy for people only if they are sedentary and if there is no control with BB monotherapy

Question 20

What is the acute management of stroke?

Answer 20

300mg aspirin for 14 days (stop any other antiplatelets during this time e.g. clopidogrel)

Question 21

If a patient cannot swallow asprin what is a suitable alternative?

Answer 21

Rectal aspirin suppositories.

Question 22

What is the initial management of recent onset (<48 hours) AF?

Answer 22

Revert them to sinus rhythm using electrical direct current (DC) cardioversion.

Question 23

What are the symptoms of stroke?

Answer 23

Sudden numbness or weakness of face, arm or leg, especially on one side of the body
Sudden confusion, trouble speaking or understanding
Dizziness, loss of balance and co-ordination.

Question 24

What is the difference between a TIA and a stroke?

Answer 24

Stroke is defined as a clinical syndrome of focal disturbance that lasts more than 24 hours. A TIA has the same symptoms but resolves within 24 hours.

Question 25

Why might atenolol be preferred for a patient with just AF and no other co-morbidities?

Answer 25

Can be taken once daily

Question 26

What pharmacological agent can you give a diabetic with AF for rate control?

Answer 26

Cardioselective BB is preferred, however if patient frequently experiences hypoglycemia we would avoid.
Use a RL CCB instead.

Question 27

Why is diltizaem the preferred RL-CCB?

Answer 27

Has fewer interactions

Question 28

Which BB should not be given in AF under any circumstances?

Answer 28

Sotalol

Question 29

An ABCD score or 3 or under means what?

Answer 29

Patient is at low risk of stroke

Question 30

An ABCD score of >4 means what?

Answer 30

Patient is at high risk of stroke

Question 31

For the secondary prevention of stroke guidelines recommend a BP target of what?

Answer 31

130/80

Question 32

What ongoing antiplatelet should be offered following a stroke or TIA?

Answer 32

Clopidogrel 75mg

Question 33

When does Alteplase need to be given in patients with acute ischemic stroke?

Answer 33

Within 3 hours of onset.

Question 34

what do we need to check before giving a patient alteplase?

Answer 34

Blood pressure - needs to be below 185/110 before treatment can be given.

Question 35

If a patient has hypo or hyperglycemia, alteplase is CI, what can we do to manage this?

Answer 35

If high - give quick acting insulin sub cut

Question 36

What is an essential part of a stroke assessment and management?

Answer 36

SALT

Question 37

All patients in a hospital must be assessed for their risk of VTE. How is VTE risk managed in stroke patients?

Answer 37

LMWH should not be given to stroke patients.
Antiembolic stockings are also CI
Mechanical foot pumps may be beneficial, ensure the patient is hydrated and mobile if possible.