Stroke and AF Flashcards
What are the two types of stroke?
- Ischemic - due to clot in the supply to the brain, accounts for 85% of cases.
- Hemorrhagic - bleed in the brain
How can you tell the difference between the two types of stroke?
CT scan
Name 5 modifiable risk factors for stroke
Diabetes Hyperlipidemia Smoking Alcohol Hypertension AF CHF
What is the most important modifiable risk factor for stroke?
Hypertension
How can we prevent stroke?
Identify a persons risk factors and modify them e.g. HTN ,smoking cessation, diabetes control
How can we predict someones risk of stroke after a TIA?
ABCD score
What does ABCD stand for in terms of stroke risk?
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
Why might dabigatran be unsuitable in stroke patients?
Large capsule so difficult to swallow.
Cannot go down and NGT or PEG
How can we increase the detection of AF in patients?
Regular manual pulse checks for the over 65s, particularly those with co-morbidities such as hypertension, heart disease, diabetes or renal dsyfunction.
How do we assess a person with AF risk of stroke?
CHA2DS2Vasc score
What does CHADVASc stand for?
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
What does HASBLED stand for?
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
When do we offer an patient with AF an anticoagulant?
If their CHADVasc score outweighs their HASBLED.
Anticoagulate if >2 points. (consider men with a score >1)
If a patient is taking warfarin but wants to switch to a DOAC what do you do?
Stop warfarin, and start DOAC once INR is <2
What DOAC might be the best option in elderly patients at risk of bleeding?
Apixaban - has the lowest bleed risk
When does the dose of DOACS need to be reduced?
Body weight (<60kg), renal impairment
Is aspirin suitable monotherapy for stroke prevention in AF?
NO - patient should stop aspirin and switch to DOAC or warfarin
What is the first line treatment for rate control in AF?
Cardioselective BB (if not suitable rate-limiting CCB)
When should digoxin be considered in AF?
Consider monotherapy for people only if they are sedentary and if there is no control with BB monotherapy
What is the acute management of stroke?
300mg aspirin for 14 days (stop any other antiplatelets during this time e.g. clopidogrel)
If a patient cannot swallow asprin what is a suitable alternative?
Rectal aspirin suppositories.
What is the initial management of recent onset (<48 hours) AF?
Revert them to sinus rhythm using electrical direct current (DC) cardioversion.
What are the symptoms of stroke?
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.
What is the difference between a TIA and a stroke?
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.
Why might atenolol be preferred for a patient with just AF and no other co-morbidities?
Can be taken once daily
What pharmacological agent can you give a diabetic with AF for rate control?
Cardioselective BB is preferred, however if patient frequently experiences hypoglycemia we would avoid.
Use a RL CCB instead.
Why is diltizaem the preferred RL-CCB?
Has fewer interactions
Which BB should not be given in AF under any circumstances?
Sotalol
An ABCD score or 3 or under means what?
Patient is at low risk of stroke
An ABCD score of >4 means what?
Patient is at high risk of stroke
For the secondary prevention of stroke guidelines recommend a BP target of what?
130/80
What ongoing antiplatelet should be offered following a stroke or TIA?
Clopidogrel 75mg
When does Alteplase need to be given in patients with acute ischemic stroke?
Within 3 hours of onset.
what do we need to check before giving a patient alteplase?
Blood pressure - needs to be below 185/110 before treatment can be given.
If a patient has hypo or hyperglycemia, alteplase is CI, what can we do to manage this?
If high - give quick acting insulin sub cut
What is an essential part of a stroke assessment and management?
SALT
All patients in a hospital must be assessed for their risk of VTE. How is VTE risk managed in stroke patients?
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.
