strokes and DOACS Flashcards
what are the 3 types of stroke?
transient ischaemic stroke
haemorrhagic stroke
ischaemic stroke
what are the symptoms of stroke?
FAST
face drop
arm weakness
slurred speech
time to dial 999
what medication must you avoid in stroke until haemorrhagic stroke has been excluded and why?
avoid antiplatelets bc pt could bleed out and die
how should transient ischaemic stroke be treated? [2 options]
1- aspirin 300mg asap with a PPI
2- clopidogrel [unlicensed] if intolerant to aspirin
what is the initial management of ischaemic stroke?
what if the patient has had a stroke for longer than 4.5 hours?
- initial treatment is alteplase within 4.5 hours of symptom onset for 24 hours [if intracranial haemorrhage is excluded]
- if pt has stroke for longer than 4.5 hours then give aspirin 300mg
- after wards you give aspirin 300mg [or clopidogrel 75mg] once daily for 14 days
what is the long term management of ischaemic and TIA stroke NOT associated with atrial fibrillation?
recommended: clopidogrel 75mg once daily
if clopidogrel unsuitable: MR dipyridamole 200mg twice daily WITH aspirin 75mg once daily
if clopidogrel and dipyridamole unsuitable: aspirin 75mg once daily alone
what is the long term management of stroke WITH atrial fibrillation?
warfarin and other anticoagulants
in addition to antiplatelet therapy, what is the long term management of ischaemic stroke and TIA?
hint: statins
what must you monitor?
what advice must you give patients?
high intensity statins [eg atorvastatin 20-80] 48 hours after a stroke.
monitor blood pressure target of less than 130/80
advice on lifestyle, diet, exercise, weight, alcohol
what is the initial management of intracerebral haemorrhage?
surgery
avoid all medication
what is the long term management of intracerebral haemorrhage stroke?
treat hypertension
avoid all meds
what drugs are in the drug class coumarins?
warfarin, phenindione, acenocoumarol
what is the onset of action of warfarin?
48-72 hours to get full anticoagulant effect - long time to work
what are the 4 different strengths of warfarin and their associated colours?
0.5mg = white 1mg = brown
3mg = blue 5mg = pink
what is an important interaction of warfarin?
miconazole daktarin oral gel.
switch to nystatin
what side effect is very common in patients on warfarin and what must you do if it occurs in a patient?
calciphylaxis - painful rash
refer to gp
what is the initial dose of warfarin for adults?
what is the maintenance dose of warfarin?
initial: 5-10mg daily on day 1, subsequent doses depend on prothrombin time
maintenance : 3-9mg daily at same time each day
what is the antidote for warfarin?
vitamin K [phytomenadione]
are coumarins safe in pregnancy? what can you use instead?
no
use heparins instead
what is inr and in which drug is it only measured in?
a measure of how long it takes the blood to clot
in warfarin only
what are the target warfarin INR values for recurrent DVT or PE and mechanical prosthetic heart valves?
What INR target value is satisfactory above and below this number?
- 5
0. 5
what is the target warfarin value for treatment of DVT and PE atrial fibrillation cardioversion dilated cardiomyopathy mitral stenosis or regurgitation myocardial infarction acute arterial embolism
2.5
what must you do if a patient is experiencing a major bleed on warfarin?
INR does not matter
stop warfarin
administer vitamin K phytomenadione by slow IV injection and/or dried prothrombin complex/fresh frozen plasma
what must you do if a patient has an INR greater than 8 with minor bleeding?
when can you restart warfarin?
stop warfarin
administer phytomenadione vit K. by slow iv injection. repeat dose of vitamin K if INR is still high after 24 hours
restart warfarin once INR smaller than 5
what must you do if a patient has an INR greater than 8 with NO bleeding?
when can you restart warfarin?
stop warfarin
IV phytomenadione by mouth orally. repeat dose of vitamin K if INR still high after 24 hour
restart warfarin if INR less than 5
