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Pharmacotherapy II > Stroke Isaacs Exam 4 > Flashcards

Stroke Isaacs Exam 4 Flashcards

1
Q

What is a stroke?

A

Acute focal injury to the CNS causing neurological deficits from lack of O2

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2
Q

What are the two recognizable types of ischemic stroke?

A

Atherosclerosis and embolus

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3
Q

What is the cause of hemorrhagic stroke?

A

Bleeding from a rupture in the brain. Can be from hypertension or aneurysm

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4
Q

Name the five non-modifiable risk factors for developing a stroke.

A

Age, family history, male gender, low birth weight, and african american, hispanic, or asian race

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5
Q

Name the three modifiable lifestyle risk factors for developing a stroke.

A

Drug abuse (alcohol, cocaine), obesity/physical inactivity, and cigarette smoking

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6
Q

What are the four disease states that put someone at higher risk for stroke?

A

Diabetes, hypertension, hyperlipidemia, and cardiovascular diseases (afib, vascular disease)

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7
Q

Patients with atrial fibrillation should receive primary stroke prevention through rate/rhythm control and anticoagulation for patients with a CHA2DS2-VASc score of

A

2 or greater

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8
Q

For patients with valvular disease, what is used for primary stroke prevention?

A

Warfarin to goal INR of 2-3 or 2.5-3.5

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9
Q

An antiplatelet such as aspirin can be used as PRIMARY prevention in:

A

Women with high cardiovascular risk.

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10
Q

Name key signs of acute stroke?

A

Facial droop, arm weakness, slurred speech, ataxia, vision changes, headache (more common for hemorrhagic).

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11
Q

What are key diagnostic tools for use in acute stroke?

A

CT or MRI, BP, O2 sat, BG, BMP, CBC, INR, aPTT, ECG

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12
Q

What is the only thrombolytic approved for acute ischemic stroke?

A

Tissue plasminogen activator (t-PA), alteplase (Activase)

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13
Q

True or false: Use of alteplase for ischemic stroke may be the difference between life and death for a patient.

A

False – has no impact on mortality, only improves patient function after stroke.

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14
Q

What patient history criteria may make them ineligible for receiving alteplase?

A

Age under 18, history of intracranial hemorrhage, previous stroke/head trauma in past 3 mos, GI hemorrhage in past 3 weeks, major surgery last 14 days, MI in past 3 mos

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15
Q

What patient signs or symptoms would make them ineligible to receive alteplase?

A

BP >185/110, BG under 50, platelets under 100, INR under 1.7, or abnormal aPTT
Within 3 hours of symptom onset

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16
Q

Alteplase may be used up to 4.5 hours after symptom onset IF the patient is not:

A

> 80 years old, NIHSS >25, on any recent anticoagulants, or has a history of previous stroke with diabetes

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17
Q

How is alteplase dosed for acute ischemic stroke?

A

0.09 mg/kg IV bolus + 0.81 mg/kg IV infusion over 60 minutes

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18
Q

What are two potential side effects of alteplase?

A

Bleeding (keep BP

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19
Q

What blood pressure goal do we have for patients who receive tPA (for the first 24 hours)?

A

Less than 180/105

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20
Q

What is the blood pressure goal for acute ischemic stroke in patients who do not receive alteplase (for the first 24 hours)?

A

Less than 220/120

21
Q

How often should BP be checked during the first 24 hours after stroke?

A

q15mins for 2 hours, then q30mins for 6 hours, then q1h for 16 hours

22
Q

How is labetalol dosed to control blood pressure acutely in stroke?

A

Labetalol 10-20mg IV q10-20 min (MAX 300mg)

23
Q

How is nicardipine dosed to control BP acutely in stroke?

A

Nicardipine 5mg/hr IV titrated q5min to BP goal (MAX 15mg/hour)

24
Q

How is nitroglycerine dosed to control BP acutely in stroke?

A

5mg/hour IV tirtated 2.5mg/hr q5min (MAX 15mg/hr)

25
Q

What type of antihypertensive medications may be started AFTER 24 hours if BP still elevated?

A

PO drugs (if able to take) – may resume home therapies.

26
Q

Why is it vital to check blood glucose before considering tPA?

A

Hypoglycemia symptoms may mimic stroke and hyperglycemia worsens morbidity AND mortality. Hyperglycemia treated with insulin to maintain BG under 140mg/dL.

27
Q

What antiplatelets may be used in acute ischemic stroke management?

A

Aspirin with or without clopidogrel

28
Q

What ischemic stroke patients should get aspirin?

A

ALL – unless contraindicated. Give more than 24 hours after tPA if given, immediately if not.
Limited evidence for dual therapy with clopidogrel.

29
Q

True or false: Anticoagulants play a key role in the acute management of embolic stroke.

A

False – increased bleeding, no improvement in neurological function or prevention of early recurrent stroke.

30
Q

What stroke patients should receive VTE prophylaxis?

A

High risk hospitalized patients with no bleeding contraindications. High risk patients are those with immobilization, cancer, genetic clotting disorder, and VTE history.

31
Q

What agents may be used for VTE prophylaxis in stroke patients?

A

Lovenox (and other LMWH), UFH, mechanical prophylaxis

NO NOACs

32
Q

In hemorrhagic stroke, little can be done pharmacologically to treat acutely. What can be done?

A

Reversal of causative medications (if anticoagulants), BP control, prevention of vasospasm, anticonvulsants, and VTE prophylaxis

33
Q

What drug can be given to prevent vasospasm after subarachnoid hemorrhage? What dose?

A

Nimodipine 60mg PO/NG q4h for 21 days

34
Q

What patients should receive anticonvulsants after hemorrhagic stroke?

A

Only patients with a documented seizure

35
Q

When should hemorrhagic stroke patients receive DVT prophylaxis?

A

If imaging confirms hemorrhagic stroke has not expanded and patient at high risk for DVT, can start prophylaxis 1-4 days after hemorrhagic stroke with LMWH or UFH. Compression devices possible.

36
Q

What three drug classes are used for post-ischemic stroke management but not post-hemorrhagic stroke managment?

A

Antiplatelets, anticoagulants, and statins

37
Q

What is the goal blood pressure in patients with a history of stroke?

A

Less than 140/90 according to stroke guidelines

38
Q

What types of stroke need antiplatelet therapy after acute treatment?

A

Ischemic, non-embolic stroke

39
Q

How is aspirin dosed in secondary stroke prevention?

A

High dose aspirin for 2-4 weeks, then low dose aspirin chronically.

40
Q

When is clopidogrel 75mg PO daily used for secondary prevention?

A

In patients truly intolerant to aspirin–second line therapy

41
Q

What is the other first line therapy for secondary stroke prevention besides aspirin?

A

Dipyridamole 200mg + aspirin 25mg PO BID

*higher incidence of HA

42
Q

What other antiplatelets are studied in secondary stroke prevention?

A

None

43
Q

True or false: Antiplatelets are recommended in all patients with a history of ischemic, non-embolic stroke without contraindications or high bleeding risk.

A

True

44
Q

What patients should receive anticoagulants for secondary stroke prevention?

A

Patients with embolic stroke due to atrial fibrillation, valvular heart disease, or heart failure

45
Q

What statin intensity is always used in ischemic stroke patients?

A

High intensity, consider higher doses even.

46
Q

Why are antidepressants used prophylactically in stroke patients?

A

25-50% of patients experience depression after a stroke. They also improve neurological function.

47
Q

What antidepressants should be avoided in stroke patients?

A

Paroxetine (anticholinergic SE), TCAs (anticholinergic SE, arrhythmias)

48
Q

What antidepressants are recommended?

A

SSRIs including sertraline, fluoxetine, escitalopram, and citalopram

49
Q

How are the antidepressants generally dosed post-stroke?

A

Started low and titrated up. Effect may take 2-6 weeks.

Pharmacotherapy II (15 decks)

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