Therapeutics Ii Exam 3 Stroke

Front 1

Modifiable risk factors for stroke:

Back 1

HTN
Cardiac Dx
TIA
HPL

Front 2

Two types of stroke & their incidences?

Back 2

Ischemic- 88%
Hemorrhagic - 12%

Front 3

Define stroke

Back 3

Abrubt onset neurologic deficit &
lasts at least 24 hours &
vascular origin

Front 4

Another name for ischemic stroke?

Back 4

Cerebral infarction

Front 5

The mortality rates for Ischemic stroke vs. Hemorraghic stroke?

Back 5

Ischemic mortality= 12%
Hemorrhagic mortality = 38%

Front 6

The 3 types of hemorrhagic stroke?

Back 6

Subarachnoid: Due to Trauma, aneurysm, or AVmalform rupture

Intracerebral: blood vessel ruptures w/in brain parenchyma resulting in hematoma

Subdural: refers to collections of blood below the dura-> often due to trauma

Front 7

What is a TIA?

Back 7

transient episode of neuro deficit w/ rapid onset & resolution w/in 24 hours (us 1 hr)

Front 8

How long do most TIAs persist?

Back 8

<30 minutes

Front 9

What % of TIA pts end up experiencing A cerebral infarction?

Back 9

33%

Front 10

What % of pts if untreated have stroke w/in 5 years?

Back 10

35%

Front 11

What is primary tx goal for TIAs?

Back 11

Prevent stroke

Front 12

How is TIA treated

Back 12

Similar to stroke!

Front 13

What are the 5 main causes of ischemic stroke?

Back 13

1. Atherosclerotic/ CV disease
2. Penetrating Artery Disease
3. Cardiogenic Embolism: AFib, Valve Dx, Vent Thrombosis, Many others
4. Cryptogenic Stroke
5. Other, Unusual Causes: Prothrombotic states, Dissections, Arteritis, Migraines, vasospasm, Drug abuse, & more

Front 14

Risk factors for strokes per Kanaan:
Modifiable?
Nonmodifiable?

Back 14

Modifiable:
HTN
Cardiac dx
Smoking/illicit DU, EtoH
Hypercholesterolemia
Obesity/Physical inactivity
Carotid stenosis

Nonmodifiable:
Age (risk doubles ea decade after 55)
Gender (>male, but mortality worse for females)
Ethnicity (AAs, APIs, Hispanics)
Heredity

Front 15

Which Cardiac disease poses the highest risk for stroke? What is the incidence?

Back 15

Afib, 5-20% of incidence of stroke

Front 16

Which risk factor is the most important?

Back 16

HTN

Front 17

Stroke is also increased by which 5 multiple risk factors (re Framingham profile)?

Back 17

1. increased systolic
2. increased cholesterol
3. glucose intolerance
4. smoking
5. left ventricular hypertrophy

Front 18

TIA will preced an ischemic stroke in ?% of cases?

Back 18

60%

Front 19

When do the majority of strokes occur? %?

Back 19

At rest (sleeping or rising) - 60%

Front 20

Signs of stroke:

Back 20

Vertigo/double vision: posterior circulation involvement
Aphasia: Anterior Circ involved
Aphasia, Rt hemiparesis & visual field deficit, dysarthria: diff w/ calcs, read, write-->left dominant hemisphere

Front 21

What are the 7 diagnostic tests used re stroke cases?
What will each show?

Back 21

CT scan: dark area(hypointesity)=infarction; White everywhere-> hemorrhagic stroke; may take 24 hrs to reveal, used to r/o hemorrhagic stroke
MRI: shows areas of ischemia
Carotid doppler: shows if high degrees of stenosis in carotid arteried
ECG: shows if AFib present
TTE: transthoracic echo shows if valve or motion wall abnormalities are source of brain emboli
TEE: transesoph echo shows if thrombus is in left atrium
TCD: transcranial doppler: shows if intracranial sclerosis is present

Front 22

What are the 3 goals of stroke therapy?

Back 22

1. Reduce ongoing jeuro injury & decrease mortality & long term disability
2. Prevent complications 2ndary to immobility and neurologic dysfnxn
3. Prevent stroke recurrence

Front 23

General Approach To Stroke Tx:

Back 23

a. Stable cardiac/resp
b. Determine stroke type via CT scan
c. Pts w/ high BP should NOT be txd UNLESS: BP>220/120, aortic dissection, acute MI, pulm edema, or HTN encephalopathy
d. Supportive care: e'lytes (hyponatr), glycemic control, DVT prophylaxis

Front 24

General Approach To Stroke Tx:

Back 24

a. Stable cardiac/resp
b. Determine stroke type via CT scan
c. Pts w/ high BP should NOT be txd UNLESS: BP>220/120, aortic dissection, acute MI, pulm edema, or HTN encephalopathy
d. Supportive care: e'lytes (hyponatr), glycemic control, DVT prophylaxis

Front 25

Which 3 meds can be given (alone) for management of BP (>220/120) with stroke?
Which of these NOT ideal in pts w/ renal dysfxn?

Back 25

Labetolol
Nicordipine
Nitroprusside


Nitroprusside

Front 26

General Pharmacological ACUTE tx for stroke (doesn't include post-stroke meds)?

Back 26

a. Thrombolytic (us tPA)
b. Antiplatelet (us ASA) if can't use tPA (otherwise would give 24-48 hrs after conclusion of tPA)

Front 27

Non-pharm tx for stroke?

Back 27

a. For acute ishcemic stroke, ltd to:
Craniectomy when a large infarct present to release pressure
Surgical decompression can save life if signif swelling present
b. Early rehab

Front 28

What is the timeframe for administration of thrombolytic?
What s/b ruled out prior to administering lytic?

Back 28

S/b given w.in 3 hours of onset of sx for reperfusion therapy.
Always R/O hemorrhagic stroke

Front 29

Preferred thrombolytic therapy in stroke tx?
Dose schedule?
Max dose?

Back 29

Alteplase (tPA)
0.9 mg/kg over 60 min w/ 10% of dose give as an initial bolus over 1 min
Max dose of 90 mg

Front 30

When Alteplase (thrombolytic) given for ischemic stroke tx, how do beneifits outweigh risk?

Back 30

Beneficial effects outweigh the 10x increase in risk of intracerebral hemorrhage

Front 31

What must be withheld for at least 24 hours after thrombolytic therapy?

Back 31

ALL antiplatelet & anticoagulant therapy m/b withheld for at least 34 hours post thrombolytic (Alteplase) therapy

Front 32

What trial supports the use of Alteplase in stroke pts?

Back 32

NINDS rtPA Stroke Trial

Front 33

Why might a stroke pt NOT be a candidate for a thrombolytic?

Back 33

If >3 hours past sx onset
??other reasons?

Front 34

If a pt is NOT a candidate for thrombolytic, what type of pharm therapy should be used?

Back 34

Antiplatelet s/b used if pt not a candidate for thrombolytic therapy

Front 35

If a pt is not a candidate for thromboltics, and as such is given ASA, when should it be given in order to decrease M&M?

Back 35

**ASA w/in 48 hrs of sx shown to decrease M&M by IST study (300mg), and CAST study (160mg)
So, dose 162-325mg/day

Front 36

HOW is UFH/LMWH used in stroke tx?

Back 36

Trials do NOT SUPPORT use for management of ischemic stroke, however, can be used for VTE prophylaxis

Front 37

What are the doses of BPmanagement meds used for stroke tx?

Back 37

Labetolol:
If got tPA & BP180-230/105-120 or
If NO tPA & BP>220/121-140
(10-20mg, doubled q10min to max of 300mg) or2-8mg/min infus
Nicordipine:
If got tPA & BP 180-230/105-120, or
if NO tPA & BP>220/121-140:
5mg/hr infus, max 15mg/hr
Nitroprusside:
If DBP>140 w/ or w/o tPA
0.5mcg/kg/min IV infus for

Front 38

What is the 2ndary prevention tx for stroke pts?

Back 38

In non-cardiioembolic stroke pts, antiplatelet therapy s/b started
In cardioembolic pts, warfarin therapy s/b initiated w/ INR goal of 203. BP s/b controlled but not during the acute phase (1st 7 days)

Front 39

What drugs can be used for 2ndary prevention of stroke?

Back 39

1. Antiplatelets
2. Anticoagulants
3. BP-lowering agents
4. Statins

Front 40

**For 2ndary prevention of stroke, what did the studies show re meds?

Back 40

CAPRIE: (in pts w/ MI, stroke, PVD): Plavix 75mg better than ASA325mg, both similar bleeding incidences

ESPS-2: supports use of ERdipyridamole & ASA combo (200/25mg) po BID

MATCH: Patients (with prior stroke or TIA) plus additional risk factors were allocated to clopidogrel 75mg or clopidogrel 75 mg + ASA 325 mg. There was no significant benefit of combination therapy and increased bleeding risk was observed. Use of clopidogrel+ASA supported in stroke ptsw/ acute ACS

Front 41

What are the anticoags that can be used for 2ndry prev of stroke & their roles?

Back 41

Warfarin:
Most effective tx for pts w/ AFib
INR goal is 2-3 w/ target of 2.5

UFH : For DVT prophylaxis

Enoxiparin: For DVT prophylaxis

Fondaparinux: For DVT prophylaxis

Front 42

What BP lowering has shown a benefit in 2ndry prevention of stroke?

Back 42

Average reduction as low as 10/5mm Hg

Front 43

What did the PROGRESS study show?

Back 43

PROGRESS study supports the use of an ACEI (ramipril) + diuretic (thiazide) in pts w/ strokes/TIA for BP control.

Front 44

What did the LIFE study show?

Back 44

LIFE study supports the use of ARBs in pts that are intolerant to ACEI

Front 45

What role do statins play in the 2ndary prevention of stroke?

Back 45

"Heart Protection Study" supports the use of statins in high risk pts even w/ LDL <116mg/dL

LDL goal is <100mg/dL or <70mg/dL depending on pt; <70 preferred for ACS pts

Front 46

Tx of Hemorrhagic Stroke?

Back 46

If subarachnoid hemorrhage 2ndary to ruptured aneurysm,=surgical to clip/ablate vasc abnorm reduces mortality.

If primary intracerebral hemorrhage, insertion of EVD & monitoring of ICP

If subarachnoid hemorrhage: Nimodipine: CCB at a dose of 60mgq4h fx21d to prevent delayed cerebral ischemia.

Front 47

Irregular rhythym + absent p-wave=

Back 47

AFib

Front 48

NTK Osmolality cal for NA & GLUC:

Back 48

When correcting Na, don't exceed (?). What is supp rate & max?

Front 49

What do S3 sounds indicate?
S4sounds?
How does this affect case?

Back 49

S3=CHF
S4=uncontrolled HTN
S4->single monst important risk factor for stroke

Front 50

What is dysarthria?

Back 50

Trouble speaking

Front 51

What causes ischemic strokes?

Back 51

Either:
local thrombus formation, or
Emboli that occlude a cerebral artery

Front 52

What % of embolic stroke arise from the heart?

Back 52

20%

Front 53

What is cardiogenic embolism?

Back 53

An embolism caused by blood stasis in heart which leads to clots which then dislodge & go to cerebral circulation!

Front 54

What is most of early mortality in hemorrhagic stroke caused by?

Back 54

The abrupt increase in ICP-> compression leads to secondary ischemia

Front 55

Inclusion criteria for Alteplase use in acute ischemic stroke?

Back 55

1. 18yrs +
2. Clinical dx of ischemic stroke causing a measurable neurological deficit
3. Time of sx onset well established to be <3 hours b4 treatment would begin.

Front 56

Exclusion criteria for Alteplase use in ischemic stroke?

Back 56

Any of below-> CI for Alteplase:
1. Evidence of intracranial hemorrhage on CT
2. Only minor or rapidly improving stroke sx
3. High clinical suspicion of subarachnoid hemorrage even w/ normal CT
4. Active internal bleeding w/in 21 days
5. Heparin w/in 48hrs & had elevated aPTT
6. Recent use of anticoag (warfarin) & PT>15seconds
7. Intracranial surgery, serious head trauma, or prev stroke w/in 3 mos
8. Major surgery or serious trauma w/in 14days
9. Lumbar puct w/in 7 days
Hx of intracranial hemorrage, av malform, or aneurysm
10. Seizure at onset of stroke
11. Recent MI
12. SBP>185 or DBP>110 at time of tx

Front 57

Antiplatelets used for secondary prevention of stroke:
Doses of each, when used?
Roles of each in therapy?

Back 57

ASA (162-325mg): 1st line
Clopidegrel(75mgpoQD)/Ticlodipine (150mgpoBID): For pts intolerant of ASA
Dipyridamole(75-400mg divided tid/qid): Not effective in preventing recurrent ischemic stroke in pts w/ TIA

Front 58

What does MRI of the head reveal?

Back 58

Ischemia

Front 59

What does a Carotid Doppler determine?

Back 59

if high degree of stenosis in carotid arteries (this helps to determine which meds to d/c pts on)

Front 60

What will an ECG determine?

Back 60

If Afib is present

Front 61

What does a transthoracic echo (TTE) determine?

Back 61

if valve or motion wall abnormalities are the source of emboli to the brain.

Front 62

What does a TEE (transesophageal echo) determine?

Back 62

If thrombus is present in the left atrium

Front 63

What does a transcranial Doppler determine?

Back 63

If intracranial sclerosis is present

Front 64

What agents are used for the complete management of stroke?
What stage is each used for?
Dose of each?

Back 64

tPA: acute: 0.9mg/kg IV over 1 hour; 10% given as bolus over 1 min; max 90mg
ASA: acute only if tPA is CI, otherwise for 2ndry prevention: 162-350mg w/in 24-48hrs after tpa completed
UFH/LMWH/Fondaparinux - for DVT prophylaxis only if pt has thrombus: UFH=5000U BID or q8h; LMWH=40mg q24h; Fond=2.5mg SQ q24h
Clopidegrel- for 2nd prevention: 75mgqd
ACEI: 2ndry prevention (us w/ HTN pts, in combo w/ a THIAZIDE)
Statin: 2ndry prevention
ARB: alternative to ACEI in 2ndry prevention

Front 65

If a patient has a stroke and was already on ASA, what is appropriate re the use of ASA/clopidogrel in the secondary prevention of stroke?

Back 65

If pt was already on ASA & has a stroke, it is appropriate to increase the ASA level or add clopidegrel.

Front 66

Physical activity recommendations for stroke pts- long term:

Back 66

Resistance training 2d/week
Aerobic activity 30-60min min 5d/wk

Front 67

Diet recommendations for stroke pts

Back 67

Sat fat <7% of calories
< 200mg dietary cholesterol
Omega-3: 1g/d
Sodium reduction
Alcohol moderation
Increase consumption of fresh fruit, vegetables, & low-fat daily products