Stroke and Atrial Fibrillation Flashcards
What is the definition of a stroke?
A syndrome of rapidly developing clinical signs of focal disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death. With no apparent cause other than of vascular origin.
What is the definition of a TIA?
Same as stroke but lasting less than 24 hours
In a TIA, the blood clot that is blocking the flow of blood in the brain breaks up on its own and the symptoms disappear after a short period of time.
TIAs generally don’t cause severe brain damage, but they are a warning sign of a future stroke and should be taken seriously. Even if symptoms disappear quickly, it is important to seek medical care immediately to prevent a future major stroke.
What are the main signs/symptoms of stroke?
Face - drooped on one side
Arms - unable to lift both arms
Speech - slurred or garbled
Others
- paralysis on one side of the body
- sudden loss of or blurred vision
- dizziness
- confusion
- difficulty understanding what other people are saying
- problems with balance and co-ordination
- difficultly swallowing
- a sudden and very severe headache
- loss of consciousness
What are the main lifestyle risk factors for stroke?
High body weight
Smoking
High alcohol intake
Diet
What are the main medical risk factors for stroke?
Hypertension
Atrial fibrillation
High cholesterol
Diabetes
Infection
Circulation problems
Carotid artery disease
What are the main uncontrollable risk factors for stroke?
Age over 55
Gender (females at higher risk)
Ethnicity (African americans at higher risk)
Family history
Previous stroke
Recent TIA
Fibromuscular Dyplasia (FMD) - blood vessels not as developed
Patient Foramen Ovale (PFO)
- hole in the heart
What is the ABCD^2 score?
Score to predict risk of stroke after TIA
Look at separate sheet!
What strategies are normally used for primary prevention of stroke?
Hypertension treatment
Smoking cessation
Cholesterol (Statin?)
Reduced alcohol intake
Diabetes control
Diet & Exercise
Warfarin for Atrial Fibrillation
What strategies are normally used for secondary prevention of stroke?
Aspirin 300mg OD for 14 days (24 hours post thrombolysis) then Clopidogrel 75mg OD
Hypertension treatment
Statins (consider for cholesterol >3.5mmol/l)
Carotid endarterectomy for patients with symptomatic carotid stenosis
Anticoagulant therapy for patients with Atrial Fibrillation
Smoking Cessation
Stroke is a serious complication of AF…
Stroke in AF is associated with a heavy burden of morbidity and mortality
AF stroke is usually more severe than other strokes
- more likely to experience disability and have a longer stay in hospital
- More likely to be discharged to a care home
The mortality rate for patients with AF is about double that in people with normal heart rhythm
CHADSVASc risk criteria
Risk of stroke in patients with AF
- Look at separate sheet
HASBLED score
Risk of bleeding in patients with AF
- See separate sheet
RCP guidelines for thromboprophylaxis in AF
CHA2DS2-VASC = 0: no treatment
Score 1 or more consider anticoagulation
Aspirin should NOT be used: ineffective
Assess risks versus benefits:
What are the main disadvantages of using Warfarin?
Narrow therapeutic window
Administrative burden to NHS
Inconvenience of INR testing
Dietary/drug interactions
What are the main advantages of using Warfarin?
Cheap
Familiar
Easily reversible
What monitoring do you need for NOACs?
Renal function
Liver function
BP
Prothrombin time
What advice should be given to patients who have had a TIA?
Driving
- Private Car - May not drive for 1 month
- PSV/HGV - May not drive and must report to DVLA
No contraindication for flying but airlines may be reluctant for 1 month
No restriction on occupation but may need to be assessed by occupational health
What is the acute treatment of stroke?
General medical care
- Hydration
- Management of dysphagia
- Oxygen therapy
- Blood pressure (B-block and Nimodipine have no benefit - do have benefit in ICH though)
- Venous thromboprophylaxis
Aspirin
- Started within 48 hours
Re-perfusion/Thrombolysis
Neuroprotection?
What should NOT be offered for stroke prevention in patients with AF?
Aspirin monotherapy
Need to give Warfarin or NOACs
Considerations for
anticoagulation in patients with AF and have had a stroke or TIA
- Should not be given after stroke or TIA until brain imaging has excluded haemorrhage
- After haemorrhage ruled out, treatment should begin immediately with a LMWH or NOAC
- Should not be commenced in patients with uncontrolled hypertension
What are the main symptoms of AF?
Light-headedness
Syncope
Fatigue
Palpitations
Dysnea
Chest Pain
Thrombo-embolism
Death
What should be monitored in patients with AF?
TFT FBC U&Es BG BP
Manual pulse check
- ECG if irregular
What is first line for patients with AF?
Rate control (Monotherapy) - B-blocker or RL-CCB
& Anticoagulation
What is second line for patients with AF?
Rate control (Dual therapy)
- B blocker
- Diltiazem
- Digoxin
What is third line for patients with AF?
Rhythm control strategy
- Pharmacological
(Bisprolol, Amiodarone, Flecainide or Sotolol etc)
- Electrical cardioversion
How do B-blockers control heart rate?
They slow conduction through the AV node
What happens if patients have previously been prescribed a standard B-blocker and they get new onset AF?
Consider an alternative agent
- Straight to rhythm control (Amiodarone or Sotalol)
What do you prescribe after a patient has had a TIA?
Start aspirin, clopidogrel and statin immediately
- Aspirin STAT 300mg loading dose (1 time only) and Clopidogrel 75mg OD permanently
How quickly do you refer a patient who has had a TIA to a specialist?
ABCD2 score less than 4 = within 7 days
ABCD2 score greater than or equal to 4 = within 24 hours
