Therapeutics Exam 4 (Stroke) Flashcards
what is a stroke?
An acute focal injury due to lack of blood/oxygen to the CNS that causes neurological deficits
-short or long term
What are the 2 main types of stroke?
Ischemic
Hemorrhagic
What is an ischemic stroke?
An infarction of brain tissue that results from compromised blood flow
What are the 2 types of ischemic stroke?
Atherosclerotic
Cardioembolic
What is a hemorrhagic stroke?
Bleeding in the brain due to rupture of a cerebral artery
*AKA intracranial hemorrhage (ICH)
What causes an atherosclerotic stroke?
Cholesterol plaque buildup
-a blood clot gets stuck between it and the wall and leads to a blocked artery
What causes a cardioembolic stroke?
*Primarily afib
-clot blocks blood flow to part of the brain
What causes hemorrhagic stroke?
Aneurysm in cerebral artery breaks open and causes bleeding around the brain
-the pressure of blood on the brain causes brain tissue death
What are the modifiable risk factors for stroke?
CV disease
Diabetes
Hyperlipidemia
Hypertension
Lifestyle:
-Illicit Drug/Alcohol Abuse
-Obesity/Physical Inactivity
-Cigarette Smoking
What is the clinical presentation of stroke?
Dysphagia (difficulty speaking)
Facial droop
Unilateral/Bilateral weakness
Ataxia (unable to coordinate muscle movement)
Vision changes
Headache
If a patient has an ischemic stroke and an ECG show afib or valvular abnormalities, what kind of stroke is it?
Cardioembolic
If a patient has an ischemic stroke and an ECG shows normal sinus rhythm, what kind of stroke is it?
Atherosclerotic
Why do we differentiate the two types of ischemic stroke?
They have the same initial management but different preventative therapy
How can hypoglycemia affect strokes?
-Can cause neurological changes that mimic a stroke
How can hyperglycemia affect strokes?
Elevated BG >180 has resulted in worse morbidity + mortality
How often do we check BP in stroke patients?
q 15 minutes for 2h
then q 30 minutes for 6h
then q 1 hour for 16h
What is the blood pressure goal for ischemic stroke?
No tPA: <220/110
tPA: <180/105
After 48 hours goal lowers to outpatient goal (160/90 then 130/80)
What are our treatment options for acute hypertension treatment?
Parenteral Agents
-Labetalol
-Nicardipine
-Sodium Nitroprusside
How do we manage hypertension after 48 hours?
Start PO medications if able to take
-restart home meds if applicable
What are the thrombolytics we can use for acute ischemic stroke?
tPA’s:
-Alteplase
-Tenecteplase
What strokes do we use thrombolytics for?
Ischemic
-atherosclerotic AND cardioembolic
DO NOT USE FOR HEMORRHAGIC
Why do we use thrombolytics in ischemic stroke?
-Improve functional capabilities
-DO NOT IMPACT MORTALITY
-Can improve neurologic function
What are the inclusion criteria to be able to use a thrombolytic?
-Ischemic stroke
-Symptom onset </= 4.5 hrs
-Adult
What are the exclusion criteria that prevent use of a thrombolytic?
BP > 185/110
BG < 50
How do we dose alteplase and what is the max dose?
0.9 mg/kg IV bolus
Max: 90mg
How do we dose tenecteplase and what is the max dose?
0.25 mg/kg IV bolus
Max: 25mg
What does BP need to be kept under while using tPA agents to reduce bleeding/hemorrhagic stroke risk?
<180/105
(note that this is different than the exclusion BP of >185/110)
If a patient experiences bleeding, how long do we hold antiplatelets and anticoags?
For 24 hours after
Antiplatelets are primarily used for what stroke?
Atherosclerotic
What are the antiplatelet options for acute ischemic stroke?
Aspirin Monotherapy
Aspirin + Clopidogrel
Ticagrelor
Aspirin + Ticagrelor
What antiplatelet is considered first-line for acute ischemic stroke?
Aspirin
How do we dose aspirin for acute ischemic stroke?
High dose (160-325mg daily) for 2-4 weeks
Who gets aspirin for stroke?
All ischemic stroke patients initially unless contraindicated
*Wait 24 hours if tPA administered
*Give immediately if no tPA
How does tPA administration affect aspirin use in acute ischemic stroke patients?
Need to wait >/= 24 hours to administer aspirin if a tPA is given
*Otherwise we give patients aspirin immediately
Who should receive aspirin + clopidogrel combination antiplatelet therapy?
Minor ischemic strokes only
*second line option
Who should receive ticagrelor antiplatelet therapy?
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!!!!
What do we do if a patient came in on anticoagulation?
Discontinue it and transition to aspirin instead
**Do not use a tPA if on anticoagulation
Which type of stroke do we want to use anticoagulation in and when?
Cardioembolic stroke
-start >/= 2-14 days after stroke
*typically start after 7 days
*discontinue aspirin when starting anticoagulation
What is the distinguishing symptom of hemorrhagic stroke?
Headache
Which type of stroke has a worse prognosis?
Hemorrhagic
What type of hemorrhagic stroke do we use nimodipine for?
Subarachnoid Hemorrhage
What medication might we use in acute management of hemorrhagic stroke that we do not use in ischemic stroke?
Anticonvulsants
What medications can cause hemorrhagic stroke?
Warfarin
Heparin
DOACs
Antiplatelet
What is the reversal agent for warfarin?
IV vitamin K
What is the reversal agent for heparin?
Protamine
What is the reversal agent for Dabigatran?
Idarucizumab (Praxabind)
Besides Dabigatran, what is the reversal agent for the other DOACs?
Recombinant coagulation factor Xa (Andexxa)
Which class of medications that can cause hemorrhagic stroke does not have an antidote?
Antiplatelets
When do we treat BP in hemorrhagic stroke?
When SB > 180
What is the BP goal for hemorrhagic stroke?
First 24 hrs: <180/110
After 24 hrs: <160/90
After 48 hrs: Transition to outpatient goal
When is nimodipine used and why?
Subarachnoid Hemorrhagic Stroke
-to prevent cerebral vasospasm which can worsen ischemia
-give q4H for 21 days
When should we consider giving stroke patients anticonvulsants?
Hemorrhagic stroke only and only if they have a documented seizure history
What drugs do we use for secondary stroke prevention in ischemic stroke?
Atherosclerotic: Antiplatelets
Cardioembolic: Anticoagulants
How long are atherosclerotic stroke patients on antiplatelets for for secondary prevention?
Indefinitely
-until they have complications
What are the antiplatelets that can be used for secondary prevention in atherosclerotic stroke?
Aspirin *first-line
Dipyridamole + Aspirin
Clopidogrel
Clopidogrel + Aspirin
What is the first-line antiplatelet choice for secondary stroke prevention in atherosclerotic stroke?
Aspirin -high dose for 2-4 weeks (162-325) then low dose (81) indefinitely
What is the role of dipyridamole/aspirin combination therapy in secondary atherosclerotic stroke prevention?
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
What is a major side effect of dipyridamole/aspirin use?
Headache
-can titrate up slowly to minimize risk
What is the role of clopidogrel in secondary atherosclerotic stroke prevention?
Second-Line treatment
*use in aspirin intolerant patients
What is the role of clopidogrel + aspirin combination therapy in secondary atherosclerotic stroke prevention?
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
What antiplatelet therapy should not be used in secondary prevention of atherosclerotic stroke?
Ticagrelor + Aspirin
Prasugrel
Overall: what are the first-line antiplatelet treatment options for secondary prevention of atherosclerotic stroke?
Aspirin
Dipyridamole + Aspirin
Clopidogrel + Aspirin (only minor strokes with NIHSS </= 3)
Overall: what are the second-line antiplatelet treatment options for secondary prevention of atherosclerotic stroke?
Clopidogrel monotherapy
Overall: what drug is contraindicated in antiplatelet secondary prevention of atherosclerotic stroke?
Prasugrel
When do we use anticoagulants in secondary stroke prevention?
Cardioembolic stroke caused by afib, valvular disease, or HF
How long after a stroke should anticoagulant secondary prevention be initiated?
> /= 2-14 days
(7 on average)
-want to use aspirin immediately after stroke and then d/c and switch to anticoagulant
What drugs can we use as anticoagulant secondary stroke prevention?
All DOACs
Warfarin
What stroke patients must receive Warfarin or Rivaroxaban for anticoagulant secondary prevention?
Mechanical Mitral Valve or LV Thrombus
How long do we use anticoagulants in cardioembolic stroke patients?
Indefinitely
What is the long-term BP goal for all stroke patients?
<130/80
What is first-line antihypertensive therapy in African American patients?
CCB or Thiazide
What is first-line therapy antihypertensive therapy in CAD?
BB + ACE/ARB
What is first-line antihypertensive therapy in HFrEF?
ARNi + BB + Aldosterone Antagonist
What is first-line antihypertensive therapy in Afib patients?
BB or Non-DHP CCB
What is first-line antihypertensive therapy in Diabetes and CKD patients?
ACEi/ARB
What additional long-term therapy should all patients who had an atherosclerotic ischemic stroke be started on?
High-intensity statin
Atorvastatin 80mg
Rosuvastatin 20-40mg
What is the LDL goal in atherosclerotic stroke patients?
<70
What additional drug should most stroke patients of any type receive?
Antidepressants
What antidepressants can be used for stroke management?
SSRIs: sertraline, fluoxetine, escitalopram, citalopram
What antidepressants should be avoided in stroke treatment?
Paroxetine
Tricyclic antidepressants
