Stroke lectures Flashcards
What is the definition of a stroke?
A syndrome of rapidly developing clinical signs or 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 a TIA?
Stroke symptoms but lasting less than 24 hours.
Why is stroke treatment important?
- Third most common cause of death after Heart Disease and all Cancers.
- Stroke is the most common cause of severe disability.
- Stroke consumes 5% of the NHS budget and fills 7% of NHS beds.
What strategies are there for reducing the risk of strke in the general population?
- Regular BP checks.
- Smoking cessation.
- Lipid control.
What are the main modifable risk factors for stroke?
- Uncontrolled BG.
- Hyperlipidaemia
- Smoking
- Alcohol use
- Uncontrolled BP
Primary prevention of stroke consists mainly of what? [5]
- Hypertension management,
- Smoking cessation
- Cholesterol management
- Diabetes control
- AF control
HRT is associated with an increased risk of what type of stroke?
Ischaemic stroke, not haemorrhagic.
What is the ABCD score?
Predicts the risk of stroke after TIA. A: Age B: SBP >140 or DBP >90 C: Clinical features D: Duration/diabetes
What does secondary prevention of stroke and TIA consist of?
Antiplatelet therapy
Hypertension/blood pressure
Statins
Carotid endartarectomy for patients with symptomatic carotid stenosis.
Anticoagulant therapy for patients with cardio-embolic stroke especially AF.
Smoking cessation.
What impact does AF have on stroke risk?
HIGH RISK.
Due to irregular beat, blood can pool in the heart and clot.
Use of concurrent Aspirin __mg and Clopidogrel __mg leads to an __% reduction in the risk of early recurrent stroke.
Aspirin 75mg and Clopidogrel 75mg = 80% reduction.
Only both for 12 months, then aspirin for life.
Treatment with __mg ______statin ______ daily leads to a 2.2% reduction in 5-year absolute stroke risk.
80mg Atorvastatin first line once daily.
People with AF are _x more likely to have a stroke
AF = 5x more likely to have a stroke.
What is the CHA2DS2-VASc score used for?
Calculating stroke risk. Congestive heart failure = 1 point. Hypertension = 1 point. Age >75 yrs = 2 points Diabetes = 1 point. Stroke/TIA previously = 2 points. Vascular disease = 1 point. Age 65-74 years = 1 point. Sex = female = 1 point.
What is HAS-BLED used to calculate?
Bleed risk, Hypertension. Abnormal renal or liver function. Stroke. Bleeding. Labile INR. Elderly age (>65 years) Drugs or alcohol.
What are the disadvantages of Warfarin?
Narrow therapeutic window.
Administrative burden to the NHS.
Inconvenience of INR testing for patients.
Dietary/drug interactions.
What are the advantages to Warfarin use?
Cheap
Familiar to HCP.
Easily reversible.
WRT Warfarin, why does time in therapeutic range (TTR) matter?
Once the TTR falls below 70%, the efficacy of warfarin to prevent stroke falls dramatically.
What benefits do the new oral anticoagulants have vs warfarin? what are some examples?
No INR monitoring.
Direct thrombin inhibitor: Dabigatran.
Factor Xa inhibitors: Rivaroxaban, Apixaban, Edoxaban. All licenced for SPAF and recommended by NICE.
Need to monitor renal function: liver caution.
Why does dabigatran interact with: dronedarone, amiodarone, verapamil, ketoconazole, quinidine?
Dabigatran is potentiated by p-glycoprotein inhibitors such as these.
What is the MOA of dabigatran?
Direct thrombin inhibitor.
80% renal excretion so renal function needs to be checked,
What are the practical issues regarding the use of dabigatran?
Large capsule: can be difficult to swallow.
Cannot go in a dosette box due to degradation.
Cannot go down NG tube.
Benefit: only drug to currenty have a reversibility agent.
What is the MOA of rivaroxaban?
Direct factor Xa inhibitor.
What are the issues with Rivaroxaban use?
Lack of reversibility.
Metabolised by CYPs, potentiated by ketoconazole, HIV protease inhibitors.
What is the MOA of Apixaban?
DIrect and competitive Xa inhibitor.
What are the issues with Apixaban use?
Lack of reversibility.
Metabolised by CYPs, potentiated by ketoconazole, HIV protease inhibitors.
How is acute stroke managed on the stroke unit?
- Hydration
- Management of dysphagia
- Oxygen therapy
- Blood pressure control
- Venous thromboprophylaxis
Can aspirin monotherapy alone be used as stroke prevention in people with AF?
No
A CHADVASc score of what is low ris?
0 for men or 1 for women
A CHADVASc score of what would mean we should consider OAC?
For men: 1.
A CHADVASc score of what means we should offer OAC?
> 2
Patients with ischaemic stroke should not be offered anticoagulation until how long has passed from the outset? What should be used in the mean time?
Patients with disabling ischaemic stroke should be deferred until at least 14 days have passed from the onset; aspirin 300 mg daily should be used until this time
Anticoagulation should be commenced ________ following a TIA once brain imaging has ruled out ______. Agents that can be used include: _____, ______ or ______. These agents are all ______
Anticoagulation should be commenced immediately following a TIA, once brain imagine has rule out haemorrhage. Agents that can be used include: LMWH, direct thrombin inhibitors and factor Xa inhibitors. All rapidly acting.
What is first line treatment for rate and rhythm control in AF?
Monotherapy with either:
B-blocker or RL-CCB.
What is the second line treatment for rate and rhythm control in AF?
Dual therapy, any 2 of:
B blocker
Diltiazem
Digoxin
What is third line treatment for AF?
Pharmcological options + electrical cardioversion.
How do rate and rhythm control differ?
Rate:
Beta blockers (bisoprolol)
RL - CCB (Diltiazem or verapamil)
Digoxin
Rhythm: Elective DC conversion Bisoprolol Amiodarone Flecainide/sotolol Dronedarone?
Ischaemic strokes caused by __ tend to be more severe than other types of ischaemic stroke.
AF
Which gender with AF will have more severe strokes?
women > men.
This difference was not found in people without atrial fibrillation and was independent of age, previous functional status, vascular risk factors, and vascular co-morbidities.
