Stroke part 4

Question 1

Prasugrel is contraindicated in pts with a stroke!!

Question 2

Patients with ischemic stroke without known heart disease but who have LDL cholesterol over 100 mg/dL (2.59 mmol/L) should be givenatorvastatin 80 mg daily to reduce the risk of stroke recurrence

Question 3

Patients with ischemic stroke or TIA who have atherosclerotic cardiovascular disease (ASCVD) should be given lipid-lowering therapy with a high-intensity statin (and ezetimibe, if necessary) to reach a goal of LDL cholesterol of less than 70 mg/dL (1.81 mmol/L)

Question 4

In very high-risk patients (multiple major atherosclerotic cardiovascular events or one major atherosclerotic cardiovascular event and multiple high-risk conditions) who are taking maximally tolerated statins and ezetimibe with LDL cholesterol ≥70 mg/dL (1.81 mmol/L), a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor may be considered

Question 5

Hemorrhagic Stroke 101

management of hypertension and reversal of coagulopathy in anticoagulant-associated ICH should be considered
Clinical trials have demonstrated that acute lowering of SBP to a goal of 140 mm Hg is safe and may be effective at improving functional outcomes

Anticoagulation reversal with four-factor prothrombin complex concentrate

Question 6

Hypertension in patients with hemorrhagic stroke increases the risk of hematoma expansion

For patients with ICH presenting with an SBP above 220 mm Hg aggressive lowering of BP with continuous IV infusion medications is reasonable

Clinical trials have demonstrated that acute lowering of SBP to a goal of 140 mm Hg is safe and may be effective at improving functional outcomes

For patients with SAH due to aneurysm rupture, targeting an SBP less than 160 mm Hg is reasonable in the time period from symptom onset to aneurysm obliteration

Question 7

For
patients on warfarin with elevated INR, reversal with vitamin K, typically IV, in combination with a four-factor prothrombin complex concentrate is recommended
Fresh frozen plasma can be used in place of a prothrombin complex concentrate, if necessary, but is not preferred

Question 8

Antidotes
Warfarin
Vitamin K 10 mg IV x 1

4PCC IV
INR 2 to < 4
25 units/kg, max 2500 units

INR 4 to 6
35 units/kg, max 3,500 units

INR > 6
50 units/kg, max 5,000 units

DOAC
4PCC 50 units/kg IV

Question 9

HAS-BLED score >2 associated with clinically relevant and major bleeding.

Question 10

HAS-BLED
H=hypertension
A=Abnormal renal or liver function
S Prior Stroke
B=prior major bleeding or bleeding predispostion
L=Labile INRs(in therapeutic range <60% of time)
E=Elderly (age >65 years)
D=drugs of abuse or excessive alcohol use

Question 11

Don’t use a fibrinolytic in someone with a hemorrhagic stroke

Question 12

Four-factor prothrombin complex concentrate aka Kcentra