Therapeutics - Stroke Prevention and Treatment Flashcards
stroke vs TIA
TIA is a deficit that lasts less than 24 hrs with complete resolution of symptoms. typically lasts less than an hour
a lot of patients with a TIA will eventually have a stroke
we don’t ignore TIA, just like we don’t ignore ischemia!
a ___ diet can help to limit stroke
mediterranean (fruits and veggies, whole grains, fish)
most strokes are ischemic or hemorrhagic
ischemic
as mentioned, most strokes are ischemic
name 2 general causes
cerebrovascular disease (disease in vessels)
cardiogenic embolism due to things like afib, valvular heart disease, or infective endocarditis
TIA clinical presentation
temporary blindness, slurred speech, dizziness, 1 side weakness
stroke symptoms
depends on location
aphasia, dysphagia – choking concern, hemiparesis or plegia
what is the ABCD2 score
explain the categories
estimating the risk of stroke after a patient gets a TIA
0-3 is low risk
4-5 is moderate risk
6-7 is high risk
if the stroke was suspected to be of a cardiogenic source, what is used to diagnose
echocardiogram
what tests are done to rule out a hemorrhagic stroke?
why do we want to rule out that it’s not hemorrhagic?
CAT scan or MRI
bc before we give thrombolytics we have to make sure that the patient isn’t bleeding
why is malnutrition a consequence to stroke
bc of the dysphagia - trouble swallowing
pt may need a feeding tube
what is aphasia
language disorder
consequence of stroke
a consequence of stroke is transient HTN
explain why this may actually be desirable
may want to keep the BP a lil high at first to keep the perfusion
role of antiplatelet therapy in prevention
NOT USED FOR PRIMARY PREVENTION
most studies are on secondary
differentiate between primary and secondary prevention for stroke
primary - patient never had an event. all we want to focus on is lifestyle modification, control BP and weight
secondary - patient already had a TIA or another event. want to prevent another
true or false
in patients with CVD, anticoagulation is NOT routinely used for prevention
true
true or false
a patient is over 60 years old with no risk factors for stroke. it WOULD NOT BE beneficial for them to take aspirin daily
true
DO NOT GIVE ASPIRIN!!
if they have risk factors, it’s a different story
patients who have a history of non-cardioembolic stroke or TIA
(non cardioembolic indicates NOT DUE TO AFIB)
what can they be given for prevention
this is considered SECONDARY prevention - so we give antiplatelets
low dose aspirin daily
or
clopidogrel 75mg QD
or
aspirin/ER dyprimidamole 25/100 BID
or
cilostazol 100mg BID (not in US)
The 2 preferred ones are clopidogrel or aspirin/dipyidamole
for secondary prevention from non-cardioembolic cause, what do we use if the patient is allergic to aspirin
use clopidogrel
true or false
increasing aspirin dose to 325mg provides more benefit for secondary prevention
FALSE - no benefit over 81mg
just increased bleeding risk
after a stroke, does DAPT show any benefit?
start aspirin + clopidogrel within 24 hours of a minor ischemic stroke or TIA and continue for 21 days
if had a recent stroke or TIA due to SEVERE stenosis, clopidogrel + aspirin for 90 days, then single agent after that
pt had NONCARDIOGENIC (not afib) ischemic stroke
do we use dual or single antiplatelet therapy?
if EARLY ischemic and NIHSS is 3 or less, DUAL for 0-90 days, then single after that
if NOT early, or if NIHSS is more than 3, single antiplaaltet
patient had non-cardiogenic TIA
dual or single antiplateleet
if high risk - dual for 0-90 days, then single after that
if nit high risk - just do single
aspirin toxicity
GI - take with food
when we use dipyridamole with aspirin, which form do we use
ER! NO IR
true or false
aggrenox cannot be given via feeding tube
true
has ER dipyridamole which cant be crushed
aggrenox (aspirin + ER dipyridamole) should be avoided in patient with ___
CAD
___ should be used for patients allergic to aspirin
clopidogrel
can clopidogrel be given via feeding tube
YES - can be crushed
2 SE of clopidogrel
GI ulcer, rash
**clopidogrel is a ___ and must be ____
what is the concern
prodrug and must be metabolized!!!!
concern in CYP2C19 polymorphism
AND PPIs except protonix inhibit CYP2C19, so decreased efficacy of clopidogrel
PPIs (except pantoprazole) + clopidogrel
decreased efficacy of clopidogrel bc inhibit CYP2C19 which activates the drug
ticagrelor uses
short term use in pts who had minor ischemic stroke or TIA to reduce the risk of another stroke (SECONDARY PREVENTION)
180mg loading, then 90mg BID for 30 days with aspirin
what scoring is used to see if anticoagulants should be used in cardiogenic disease states
CHA2DS2-VASc
in the CHA2DS2-VASc scoring for anticoagulation, when is a patient considered high risk
if score over 2 for males and over 3 for females
BUT also have to assess bleeding risk with HAS-BLED before we start any anticoagulation
on the HAS-BLED scoring for bleeding risk, what value is considered high risk for bleeding
over 3
CHA2DS2-VASC2 score is
___ for male
__ for female
we suggest NO TREATMENT
0 for male
1 for female
CHA2DS2-VASc score –
the patient has 1 NONSEX risk factor
what do we consider and what do we suggest
consider stroke prevention
possibly suggest oral anticoagulation
better than no treatment and better than antiplatelets (inc DAPT)
if CHA2DS2 score is over than 2 in males and over 3 in females
what do we do
recommend oral anticoagulation !!
when we recommmend oral anticoagulation, ___ is preferred over -___
DOAC preferred over warfarin
though DOAC is preferred over warfarin for anticoagulation, if we are using wafarin what is goal TTR and what is goal INR
goal TTR is over 70%
goal INR is 2-3
true or false
if a patient gets a high risk CHA2DS2-Vasc score and they are already on warfarin, we need to switch them to a DOAC
FALSE
while doac preferred, if they’re already on warfarin they can stay on
just make sure meating TTR and INR goals
3 specific anticoagulants that are recommended if the patient has a HIGH RISK OF BLEEDING or has prior warfarin-associated bleeding
apixaban
edoxaban
dabigatran 110mg
if a patient is on warfarin, is it recommended to home-monitor their INR
yes - fingerstick
is warfarin recommended in older adults
no - on beers criteria for drugs to avoid
not contrindicated, but not recommended
if an older patient is on warfarin, aim for INR of 2
true or false
dabigatran etexilate is a prodrug
true
if a patient has VALVULAR disease, ___ is used
wafarin
use of dabigatran
prevention of stroke and systemic embolism in patients with NONVALVULAR AFIB
(if valvular - use warfarin)
is dabigatran used in older adults
use with extreme caution in over 80 years
on beers “use with caution
true or false
dabigatran does not need dose adjustment for renal insufficiency
FALSE - it does
15-30 dose changes from 150mg BID to 75mg BID
avoided at all in under 30 or 15
what drug is used for the reversal of dabigatran
idarucizumab (praxbind)
normal dose of xarelto in afib for stroke prevention
are dose adjustments needed?
20mg QD
in crcl 15-50, decrease to 15mg daily
avoid in under 15mL/min
DOACS boxed warning
they are shorter acting agents. increased risk of stroke if you stop suddenly
which DOAC has the highest risk of GI and major bleeding compared to the other DOACS?
what is an advantage of it?
xarelto
has QD dosing tho!
as mentioned, DOACS have a boxed warning of increased risk of stroke if you stop suddenly
if you need to stop, what is recommendation
cover with something else like heparin or lovenox
use of xarelto
prevnetion of stroke and systemic embolism in pts with NONVALVULAR a fib
true or false
apixaban cannot be used in hemodialysis patients
false - it can
interesting “do not use” edoxaban
dont use if CrCl is over 95!
will just eliminate too quickly
reversal agent for xarelto and eliquis
andexxa (andexanet alpha)
DOACS need to be dose adjusted for ____
renal impairment
dosing concern DOACS
there are diff doses for different indications - make sure the dose is correct
true or false
DOACS are safer than warfarin, particularly in older adults
true
true or false
antiplatelets can be used in afib
FALSE - do not use antiplatelets in afib
BP concern for the acute treatment of ISCHEMIC STROKE
want to maintian the BP - dont let it drop. need to maintain perfusion to the ischemic part of the brain
as mentioned, in general for ischemic stroke, we want to maintain the BP
what is an exception to this
if giving a thrombolytic, get the BP below 185/110
in the acute treatment of ischemic stroke, ____ should be witheld until dysphagia evaluation
oral feedings
2 thrombolytics for early acute ischemic stroke
alteplase and tenecteplase
thrombolytics like alteplase and tenecteplase can only be used if….
hemorrhagic stroke has been ruled out by a CT scan or MI
ideally, thrombolytics should be given within _____ of symptom onset
4.5 hours (or 3 hours - controversial)
if pt is not a candidate for thrombolytics what is given instead
Aspirin 325mg within 24-48 hrs of stroke onset
dapt is only given if
CVD (and meet other requirements)
DO NOT GIVE IN AFIB! ANTIPLATELETS HAVE NO ROLE IN AFIB
pt has hemorrhagic stroke
if CT scan shows increased intracrainal pressure or shifting, what do we give
IV mannitol
warfarin counseling
limit kale and brocolli (can have a lil just dont overdue)
electric razor, soft toothbrush
no herbal supplements
