Stroke Therapeutics Flashcards
What is included in the general supportive care for stroke (5)
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
How to prevent DVT in stroke patients
- 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
What is the inclusion criteria for thrombolytics
All need to be present (6)
- 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
T/F Age under 18 is a contraindication for thrombolytics in stroke patients
False
What are absolute contraindications to thrombolytics
Active hemorrhage
Any condition that can increase risk of major bleeding
What is the altepase dosing?
0.9mg/kg over 1 hour
then 10% of the dose given as bolus over 1 min
What is the target BP (SBP & DBP) for administering altepase?
What do you do if it is higher?
Target is SBP <180 or DBP <105
If higher
- administer IV labetolol (10-20mg), nicardipine (5), clevidipine, hydralazine, enalapril
How often do you monitor for BP and nuero assessments during altepase administration
First 2 hours: q15 min
Next 6 hours: q30 min
24 hours after: q1 hour until finished
What follow up monitoring/investigations do you have you to do 24 hours after altepase?
CT or MRI scan before starting OAC or antiplatelet
What are risks of administering altepase at high BP? (2)
- 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)
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
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.
T/F thrombolytics saves lives
False
- goal is to reduce effects on QOL after the stroke
What is the BP target for patients not eligible for thrombolysis?
BP target <220/120 mmhg
what factors MAY increase mortality from thrombolysis? (5)
- Being older
- a woman
- non-Hispanic white race
- A fib
- higher NIHSS
Who should still get altepase if 4.5 hours has passed?
Who was excluded?
WAKE-UP trial
EXTEND trial
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
What is the difference between tenecteplase and altepase?
Dose?
Efficacy
Safety
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)
For acute treatment of stroke who should get antiplatelet agents?
When?
Dose?
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
T/F avoid ASA for patients receiving thrombolysis therapy in the first 24 hours
True
How do you administer ASA for patients with dysphagia? (2)
Enteral tube
Rectal suppository (325mg)
Who should get antiplatelet therapy in secondary prevention?
When?
Dose?
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)
What do the 7 trials say about efficacy for ASA in the acute phase?
Non-fatal stroke recurrence
Vascular death
All-cause mortality
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
What do the 21 trials say about efficacy for ASA in the secondary prevention?
Non-fatal stroke recurrence
Vascular death
All-cause mortality
Non-fatal stroke recurrence
Vascular death
All-cause mortality
- All signifcant
Do benefits outweigh the harms of using ASA in ischemic stroke?
CAST and IST trial
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
What is the dose range you can give for ASA according to the ATC trial
75-235mg daily
