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Fall 2024 > Therapeutics Exam 4 (Stroke) > Flashcards

Therapeutics Exam 4 (Stroke) Flashcards

1
Q

what is a stroke?

A

An acute focal injury due to lack of blood/oxygen to the CNS that causes neurological deficits

-short or long term

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2
Q

What are the 2 main types of stroke?

A

Ischemic

Hemorrhagic

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3
Q

What is an ischemic stroke?

A

An infarction of brain tissue that results from compromised blood flow

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4
Q

What are the 2 types of ischemic stroke?

A

Atherosclerotic
Cardioembolic

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5
Q

What is a hemorrhagic stroke?

A

Bleeding in the brain due to rupture of a cerebral artery

*AKA intracranial hemorrhage (ICH)

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6
Q

What causes an atherosclerotic stroke?

A

Cholesterol plaque buildup

-a blood clot gets stuck between it and the wall and leads to a blocked artery

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7
Q

What causes a cardioembolic stroke?

A

*Primarily afib

-clot blocks blood flow to part of the brain

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8
Q

What causes hemorrhagic stroke?

A

Aneurysm in cerebral artery breaks open and causes bleeding around the brain

-the pressure of blood on the brain causes brain tissue death

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9
Q

What are the modifiable risk factors for stroke?

A

CV disease
Diabetes
Hyperlipidemia
Hypertension

Lifestyle:
-Illicit Drug/Alcohol Abuse
-Obesity/Physical Inactivity
-Cigarette Smoking

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10
Q

What is the clinical presentation of stroke?

A

Dysphagia (difficulty speaking)

Facial droop

Unilateral/Bilateral weakness

Ataxia (unable to coordinate muscle movement)

Vision changes

Headache

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11
Q

If a patient has an ischemic stroke and an ECG show afib or valvular abnormalities, what kind of stroke is it?

A

Cardioembolic

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12
Q

If a patient has an ischemic stroke and an ECG shows normal sinus rhythm, what kind of stroke is it?

A

Atherosclerotic

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13
Q

Why do we differentiate the two types of ischemic stroke?

A

They have the same initial management but different preventative therapy

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14
Q

How can hypoglycemia affect strokes?

A

-Can cause neurological changes that mimic a stroke

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15
Q

How can hyperglycemia affect strokes?

A

Elevated BG >180 has resulted in worse morbidity + mortality

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16
Q

How often do we check BP in stroke patients?

A

q 15 minutes for 2h

then q 30 minutes for 6h

then q 1 hour for 16h

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17
Q

What is the blood pressure goal for ischemic stroke?

A

No tPA: <220/110

tPA: <180/105

After 48 hours goal lowers to outpatient goal (160/90 then 130/80)

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18
Q

What are our treatment options for acute hypertension treatment?

A

Parenteral Agents

-Labetalol
-Nicardipine
-Sodium Nitroprusside

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19
Q

How do we manage hypertension after 48 hours?

A

Start PO medications if able to take

-restart home meds if applicable

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20
Q

What are the thrombolytics we can use for acute ischemic stroke?

A

tPA’s:

-Alteplase
-Tenecteplase

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21
Q

What strokes do we use thrombolytics for?

A

Ischemic
-atherosclerotic AND cardioembolic

DO NOT USE FOR HEMORRHAGIC

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22
Q

Why do we use thrombolytics in ischemic stroke?

A

-Improve functional capabilities
-DO NOT IMPACT MORTALITY
-Can improve neurologic function

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23
Q

What are the inclusion criteria to be able to use a thrombolytic?

A

-Ischemic stroke
-Symptom onset </= 4.5 hrs
-Adult

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24
Q

What are the exclusion criteria that prevent use of a thrombolytic?

A

BP > 185/110

BG < 50

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25
Q

How do we dose alteplase and what is the max dose?

A

0.9 mg/kg IV bolus

Max: 90mg

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26
Q

How do we dose tenecteplase and what is the max dose?

A

0.25 mg/kg IV bolus

Max: 25mg

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27
Q

What does BP need to be kept under while using tPA agents to reduce bleeding/hemorrhagic stroke risk?

A

<180/105

(note that this is different than the exclusion BP of >185/110)

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28
Q

If a patient experiences bleeding, how long do we hold antiplatelets and anticoags?

A

For 24 hours after

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29
Q

Antiplatelets are primarily used for what stroke?

A

Atherosclerotic

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30
Q

What are the antiplatelet options for acute ischemic stroke?

A

Aspirin Monotherapy
Aspirin + Clopidogrel
Ticagrelor
Aspirin + Ticagrelor

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30
Q

What antiplatelet is considered first-line for acute ischemic stroke?

A

Aspirin

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31
Q

How do we dose aspirin for acute ischemic stroke?

A

High dose (160-325mg daily) for 2-4 weeks

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32
Q

Who gets aspirin for stroke?

A

All ischemic stroke patients initially unless contraindicated

*Wait 24 hours if tPA administered
*Give immediately if no tPA

33
Q

How does tPA administration affect aspirin use in acute ischemic stroke patients?

A

Need to wait >/= 24 hours to administer aspirin if a tPA is given

*Otherwise we give patients aspirin immediately

34
Q

Who should receive aspirin + clopidogrel combination antiplatelet therapy?

A

Minor ischemic strokes only

*second line option

35
Q

Who should receive ticagrelor antiplatelet therapy?

A

Minor ischemic strokes only

*not superior to aspirin and combination showed no difference in disability with an increased bleeding risk

Second line but not used much, consider in true aspirin allergy!!!!

36
Q

What do we do if a patient came in on anticoagulation?

A

Discontinue it and transition to aspirin instead

**Do not use a tPA if on anticoagulation

37
Q

Which type of stroke do we want to use anticoagulation in and when?

A

Cardioembolic stroke

-start >/= 2-14 days after stroke
*typically start after 7 days

*discontinue aspirin when starting anticoagulation

38
Q

What is the distinguishing symptom of hemorrhagic stroke?

A

Headache

39
Q

Which type of stroke has a worse prognosis?

A

Hemorrhagic

40
Q

What type of hemorrhagic stroke do we use nimodipine for?

A

Subarachnoid Hemorrhage

41
Q

What medication might we use in acute management of hemorrhagic stroke that we do not use in ischemic stroke?

A

Anticonvulsants

42
Q

What medications can cause hemorrhagic stroke?

A

Warfarin
Heparin
DOACs
Antiplatelet

43
Q

What is the reversal agent for warfarin?

A

IV vitamin K

44
Q

What is the reversal agent for heparin?

A

Protamine

45
Q

What is the reversal agent for Dabigatran?

A

Idarucizumab (Praxabind)

46
Q

Besides Dabigatran, what is the reversal agent for the other DOACs?

A

Recombinant coagulation factor Xa (Andexxa)

47
Q

Which class of medications that can cause hemorrhagic stroke does not have an antidote?

A

Antiplatelets

48
Q

When do we treat BP in hemorrhagic stroke?

A

When SB > 180

49
Q

What is the BP goal for hemorrhagic stroke?

A

First 24 hrs: <180/110
After 24 hrs: <160/90
After 48 hrs: Transition to outpatient goal

50
Q

When is nimodipine used and why?

A

Subarachnoid Hemorrhagic Stroke

-to prevent cerebral vasospasm which can worsen ischemia

-give q4H for 21 days

51
Q

When should we consider giving stroke patients anticonvulsants?

A

Hemorrhagic stroke only and only if they have a documented seizure history

52
Q

What drugs do we use for secondary stroke prevention in ischemic stroke?

A

Atherosclerotic: Antiplatelets

Cardioembolic: Anticoagulants

53
Q

How long are atherosclerotic stroke patients on antiplatelets for for secondary prevention?

A

Indefinitely
-until they have complications

54
Q

What are the antiplatelets that can be used for secondary prevention in atherosclerotic stroke?

A

Aspirin *first-line
Dipyridamole + Aspirin
Clopidogrel
Clopidogrel + Aspirin

55
Q

What is the first-line antiplatelet choice for secondary stroke prevention in atherosclerotic stroke?

A

Aspirin -high dose for 2-4 weeks (162-325) then low dose (81) indefinitely

56
Q

What is the role of dipyridamole/aspirin combination therapy in secondary atherosclerotic stroke prevention?

A

First-line antiplatelet therapy to use after transition off high dose aspirin

-would not start this until after using 2-4 weeks of high dose aspirin
-has shown some increased benefit over monotherapy

57
Q

What is a major side effect of dipyridamole/aspirin use?

A

Headache

-can titrate up slowly to minimize risk

58
Q

What is the role of clopidogrel in secondary atherosclerotic stroke prevention?

A

Second-Line treatment
*use in aspirin intolerant patients

59
Q

What is the role of clopidogrel + aspirin combination therapy in secondary atherosclerotic stroke prevention?

A

Second-line therapy

**First-line for minor strokes (NIHSS</=3)

*note that aspirin is used at a low dose when in combination, you would transfer to aspirin monotherapy after 21-90 days

60
Q

What antiplatelet therapy should not be used in secondary prevention of atherosclerotic stroke?

A

Ticagrelor + Aspirin

Prasugrel

61
Q

Overall: what are the first-line antiplatelet treatment options for secondary prevention of atherosclerotic stroke?

A

Aspirin

Dipyridamole + Aspirin

Clopidogrel + Aspirin (only minor strokes with NIHSS </= 3)

62
Q

Overall: what are the second-line antiplatelet treatment options for secondary prevention of atherosclerotic stroke?

A

Clopidogrel monotherapy

63
Q

Overall: what drug is contraindicated in antiplatelet secondary prevention of atherosclerotic stroke?

A

Prasugrel

64
Q

When do we use anticoagulants in secondary stroke prevention?

A

Cardioembolic stroke caused by afib, valvular disease, or HF

65
Q

How long after a stroke should anticoagulant secondary prevention be initiated?

A

> /= 2-14 days
(7 on average)

-want to use aspirin immediately after stroke and then d/c and switch to anticoagulant

66
Q

What drugs can we use as anticoagulant secondary stroke prevention?

A

All DOACs
Warfarin

67
Q

What stroke patients must receive Warfarin or Rivaroxaban for anticoagulant secondary prevention?

A

Mechanical Mitral Valve or LV Thrombus

68
Q

How long do we use anticoagulants in cardioembolic stroke patients?

A

Indefinitely

69
Q

What is the long-term BP goal for all stroke patients?

A

<130/80

70
Q

What is first-line antihypertensive therapy in African American patients?

A

CCB or Thiazide

71
Q

What is first-line therapy antihypertensive therapy in CAD?

A

BB + ACE/ARB

72
Q

What is first-line antihypertensive therapy in HFrEF?

A

ARNi + BB + Aldosterone Antagonist

73
Q

What is first-line antihypertensive therapy in Afib patients?

A

BB or Non-DHP CCB

74
Q

What is first-line antihypertensive therapy in Diabetes and CKD patients?

A

ACEi/ARB

75
Q

What additional long-term therapy should all patients who had an atherosclerotic ischemic stroke be started on?

A

High-intensity statin

Atorvastatin 80mg
Rosuvastatin 20-40mg

76
Q

What is the LDL goal in atherosclerotic stroke patients?

A

<70

77
Q

What additional drug should most stroke patients of any type receive?

A

Antidepressants

78
Q

What antidepressants can be used for stroke management?

A

SSRIs: sertraline, fluoxetine, escitalopram, citalopram

79
Q

What antidepressants should be avoided in stroke treatment?

A

Paroxetine
Tricyclic antidepressants

Fall 2024 (16 decks)

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