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IPFC 4 Final > Stroke Therapeutics > Flashcards

Stroke Therapeutics Flashcards

1
Q

What is included in the general supportive care for stroke (5)

A

Pyrexia – treat high temperature
O2 – if low
Rehab – as soon as patient is stable
NPO – if LOC and swallow test
Family and community support for social reintegration

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2
Q

How to prevent DVT in stroke patients

A
  • Early mobilization
  • Adequate hydration
  • Intermittent pneumatic compression strocking within first 24hr
  • Use UFH or LWMH prophylactic doses with ischemic stroke who cannot move one or both lower limbs
    **STOP if OAC is ordered
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3
Q

What is the inclusion criteria for thrombolytics
All need to be present (6)

A
  • Ischemic stroke
  • NHISS score 4+ (means stroke is disabling)
  • Prior status (see if they were already disabled before)
  • Life expectancy of 3+ months
  • Age 18+
  • ONSET OF STROKE <4.5 hours
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4
Q

T/F Age under 18 is a contraindication for thrombolytics in stroke patients

A

False

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5
Q

What are absolute contraindications to thrombolytics

A

Active hemorrhage
Any condition that can increase risk of major bleeding

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6
Q

What is the altepase dosing?

A

0.9mg/kg over 1 hour
then 10% of the dose given as bolus over 1 min

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7
Q

What is the target BP (SBP & DBP) for administering altepase?
What do you do if it is higher?

A

Target is SBP <180 or DBP <105

If higher
- administer IV labetolol (10-20mg), nicardipine (5), clevidipine, hydralazine, enalapril

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8
Q

How often do you monitor for BP and nuero assessments during altepase administration

A

First 2 hours: q15 min
Next 6 hours: q30 min
24 hours after: q1 hour until finished

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9
Q

What follow up monitoring/investigations do you have you to do 24 hours after altepase?

A

CT or MRI scan before starting OAC or antiplatelet

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10
Q

What are risks of administering altepase at high BP? (2)

A
  • Life-threatening ICH (suspected when patient has sudden deterioration of neurological status -> order CT scan STAT)
  • Orolingual/hemi-lingual angioedema (acute welling of tongue/lips/face): Occurs in 5% of tPA patients, very serious, requires continuous monitoring
    (Treatment: tPA to be stopped immediately -> IV corticosteroids, H2RAs, diphenhydramine)
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11
Q

What do the trials say for altepase efficacy when given in these hours:
Within 3 hours
Between 3-4.5 hours
Between 4.5-6.3 hours

A

Thrombolysis within 3 hours increased chances of being alive and more functional 3-6 months after ischemic stroke.

Thrombolysis within 4.5 hours still had benefit, but not as great.

Thrombolysis within 6.3 hours had no difference in outcomes.

These benefits are consistent even if <80 or >80.

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12
Q

T/F thrombolytics saves lives

A

False
- goal is to reduce effects on QOL after the stroke

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13
Q

What is the BP target for patients not eligible for thrombolysis?

A

BP target <220/120 mmhg

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14
Q

what factors MAY increase mortality from thrombolysis? (5)

A
  • Being older
  • a woman
  • non-Hispanic white race
  • A fib
  • higher NIHSS
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15
Q

Who should still get altepase if 4.5 hours has passed?
Who was excluded?
WAKE-UP trial
EXTEND trial

A

WAKE-UP
- >4.5 hours after onset of symptoms who had SPECIAL IMAGING to determine eligibility

EXTEND
- 4.5-9 hours after onset of symptoms who had ADVANCED IMAGING to determine eligibility

Excluded
- ICH
- Planned EVT
- NIHSS >25

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16
Q

What is the difference between tenecteplase and altepase?
Dose?
Efficacy
Safety

A

Main advantage of Tenecteplase: One single bolus dose (vs 1 hour infusion of Alteplase)

Non-inferior in efficacy and safety

Dose = 0.25mg/kg (max 25 mg dose)

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17
Q

For acute treatment of stroke who should get antiplatelet agents?
When?
Dose?

A

All patients with ischemic stroke or transient ischemic attack
- AFTER imaging (MRI/CT) EXLUDES intracranial hemorrhage
- within 24 hours of symptoms onset (ideally within 12)

Dose: 160mg
- no need to load if on it daily

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18
Q

T/F avoid ASA for patients receiving thrombolysis therapy in the first 24 hours

A

True

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19
Q

How do you administer ASA for patients with dysphagia? (2)

A

Enteral tube
Rectal suppository (325mg)

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20
Q

Who should get antiplatelet therapy in secondary prevention?
When?
Dose?

A

all patients with acute ischemic stroke/TIA unless they are on an anticoagulant

When
- AFTER imaging (MRI/CT) EXLUDES intracranial hemorrhage
- within 24 hours of symptoms onset (ideally within 12)

Dose:
- ASA 81mg
- Clopidogrel 75mg
- ASA/Dipyridamole (aggrenox) 25mg/200mg BID (not for patients with dysphagia)

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21
Q

What do the 7 trials say about efficacy for ASA in the acute phase?
Non-fatal stroke recurrence
Vascular death
All-cause mortality

A

Reduction in all:
Non-fatal stroke recurrence: Sig
Vascular death: non-Sig
All-cause mortality: non-Sig

Despite insignificance, the trend points towards benefit of ASA for all 3 outcomes

22
Q

What do the 21 trials say about efficacy for ASA in the secondary prevention?
Non-fatal stroke recurrence
Vascular death
All-cause mortality

A

Non-fatal stroke recurrence
Vascular death
All-cause mortality
- All signifcant

23
Q

Do benefits outweigh the harms of using ASA in ischemic stroke?
CAST and IST trial

A

CAST trial (160mg ASA vs placebo) + IST trial (300mg ASA vs UFH):
- significant reduction in recurrent ischemic stroke (ARR 0.7%)
- insignificant reduction in death without stroke
Safety:
- insignificant increase in hemorrhagic stroke

Bottom line: significant benefits + insignificant harms of ASA

24
Q

What is the dose range you can give for ASA according to the ATC trial

A

75-235mg daily

25
Q

What does the CAPRIE trial tell us in clopidogrel vs ASA?

A

No benefit of clopidogrel over ASA for stroke
- only benefit in PAD patients

Typically used if ASA intolerant or already on ASA prior to stroke

26
Q

What did the CHANCE trial and POINT trial tell us about loading dose of clopidogrel?

A

CHANCE
- use 300mg loading dose

POINT
- use 600mg loading dose

Use depending on risk vs benefit

27
Q

What does the ESPRIT trial tell us about Aggrenox vs ASA in:
Primary outcome (vascular death + stroke + MI + beeding)
Major bleeding
Dropout rate

A

Primary outcome (vascular death + stroke + MI + beeding)
- BETTER than ASA (significant)

Major bleeding
- similar (insignificant)

Dropout rate
- much higher in Aggrenox (34%)
- Lots of ADRs, majority are headaches, BID regimen

28
Q

Who should get DAPT? (3)

A
  1. High risk of TIA ABCD2 score 4+
  2. NIHSS score 0-3
  3. Not at high bleed risk
29
Q

What DAPT should they get?
For how long?

A

Clopidogrel 75mg (LD 300mg or 600mg) and ASA 81mg
21 days

30
Q

When should you give DAPT longer than 21 days?

A

Specific indication
- arterial stent
- symptomatic intracranial artery stenosis

31
Q

What is the other option for DAPT for 30 days?

A

Ticagrelor + ASA for 30 days

32
Q

What does the MATCH trial say about adding ASA in high risk patients with 1 risk factor already taking clopidogrel 75 daily

A

No difference in reducing [stroke + MI + CV death + rehospitalization] but DAPT (ASA + clopidogrel) caused more bleed

33
Q

What were the exclusion criteria for the CHANCE and POINT trial (5)

A

Excluded patients
- IV thrombolysis
- EVT
- ICH
- mod-severe strokes (4+ NIHSS)
- patients on anticoagulation for any reason

34
Q

What did the CHANCE and POINT trial comparecompare

A

CHANCE
- Day 1-21: 75mg (LD 300mg clopidogrel) + (75-300mg ASA)
- Day 22-90: Clopidogrel + placebo
VS
- ASA + placebo

POINT
- Day 1-90: Clopidogrel (LD 600) + ASA
VS
- ASA + placebo

35
Q

What were the results of the CHANCE and POINT trial
What days had most benefits

A

main benefit of DAPT occurs in first 21 days (with bleed risk increasing very slightly overall)
- most benefit in the first 7-10 days

36
Q

What did the THALES trial tell us about ticagrelor (90mg BID) 30 days + ASA compared to

A

Sig reduction in future stroke risk, however significant increase in bleed risk

37
Q

If patient has an indication for OAC, when do we restart it after?
Is this evidence based?
What do you bridge with in the meantime?

A

1-3-6-12 day rules

1: TIA, start after 1 day
3: Mild stroke (NIHSS <4)
6: Moderate stroke
12: Severe stroke

What do you bridge with in the meantime?
- ASA

38
Q

What did the ENCHANTED trial say for BP target before giving altepase
SBP 130-140 vs 180

A

SBP 130-140 vs 180
- no difference

39
Q

T/F SPRINT trial applies to stroke patients

A

False

40
Q

What is BP tagrget for
Subcortical stroke
Ischemic stroke/TIA

A

Subcortical stroke: <130
Ischemic stroke/TIA: 140/90

41
Q

What did the PROGRESS Trial say with perindopril vs perindopril + indapamide for reducing stroke + major vascular events

A

perindopril + indapamide was more effective

42
Q

What did the PROGRESS-POST HOC ANALYSIS say with perindopril vs perindopril + indapamide for reducing stroke + major vascular events

A

Stroke risk is based on SBP, does not matter what agent is used

43
Q

What is the target LDL for stroke patients?

A

LDL <1.8 mmol/L
- Treat-to-target LDL is used in stroke

44
Q

Who should not get a statin?

A

Post-intracerebral hemorrhage

45
Q

Which type of statin should be used for stroke patients.
What if LDL levels not met?

A

INTERMEDIATE intensity statin (no higher, to reduce risk of ADRs)

If LDL <1.8mmol/L is not met, ezetimibe, PCSK9 OR Icosapent can be ADDED on to statin

46
Q

What does the SPARCL trial say about who to not use Atorva 80 (high-intensity statin) (3)

A
  • Had hemorhagic stroke at baseline
  • Older men/women
  • High BP (SBP 160+ or DBP 100+)
47
Q

Which 2 diabetic agents have CV benefit

A

SGLT2is
GLP-1RAs

48
Q

Physical activity recommendation in stroke patients

A

Moderate-vig intensity for 10-20 min 2-4 times/week

if possible
- 40 min 4 times/week

49
Q

What is the foundation of intracerebral hemorrhage treatments (2)

A

Anticoagulant reversal
Blood pressure control

50
Q

What do you administer if warfarin was used in the last 1-2 hours

A

Charcoal

51
Q

Reversal agents
Warfarin (3)
dabigatran
Apixiban, edoxaban, rivaroxaban

A

Warfarin
- vit K, prothrombin, fresh-frozen plasma

dabigatran
- idarucizumab

Apixiban, edoxaban, rivaroxaban
- andexanet alfa

52
Q

What is BP target in hemorrhagic stroke?

A

First 6 hours <160
<130/80

IPFC 4 Final (6 decks)

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