Ischemic Stroke Prevention (L40)

a 52 y/o man comes to the ED with 5 hours of left arm weakness. An MD says he cannot receive alteplase since he is outside the window. Do you agree?

NO! (the optimal window is 4.5hrs i guess, but guidelines changed and now it can be given anytime 24 hours post onset)

Secondary Stoke Prevention: Aspirin dose ranges _____-325mg with lower doses having less _______________

81, side effects

Secondary Stoke Prevention: Aspirin dose ranges 81-325mg with lower doses having less SEs (like ________ irritation or ______________)

Gi, bleeding

Secondary Stoke Prevention: Aspirin dose ranges 81-325mg with lower doses having less SEs

Dosage forms: tablets (EC or chewable) and _____________

suppositories

Secondary Stoke Prevention: Clopidogrel is rapidly absorbed and extensively metabolized to ________ drug

active

Secondary Stoke Prevention: ______________ is a rapidly absorbed prodrug that is extensively metabolized to active drug in the liver

Clopidogrel

Secondary Stoke Prevention: Clopidogrel is a rapidly absorbed prodrug that is extensively metabolized to active drug in the __________

liver

Secondary Stoke Prevention: Clopidogrel is a rapidly absorbed prodrug that is extensively metabolized to active drug in the liver

the onset of action with the LD is about _________, while the maintenance dose is about 3 days

2 hours

according to the CAPRIE trial, which is better for MI, stroke, and vascular death outcomes: Aspirin vs. Clopidogrel

neither! (both will work)

Secondary Stoke Prevention: ERD/ASA stands for Extended-Release ___________ + Aspirin

Dipyridamole

Secondary Stoke Prevention: ERD/ASA stands for Extended-Release Dipyridamole + Aspirin

it is metabolized in the ________

liver

Secondary Stoke Prevention: ERD/ASA stands for Extended-Release Dipyridamole + Aspirin

it is metabolized in the liver

this drug dosage form cannot be _________ or _________

crushed or chewed

Secondary Stoke Prevention: ERD/ASA stands for Extended-Release Dipyridamole + Aspirin, which is metabolized in the liver

this drug dosage form cannot be crushed or chewed

this drug (of the 3 for secondary prevention) has the highest incidence of ____________

side effects (abdominal pain, diarrhea, and headache)

Secondary Stoke Prevention: ERD/ASA stands for Extended-Release Dipyridamole + Aspirin, which is metabolized in the liver

this drug dosage form cannot be crushed or chewed

this drug (of the 3 for secondary prevention) has the highest incidence of SEs (like ___________ (18%), ___________(13%), and __________ (40%))

abdominal pain, diarrhea, headache

according to the PRoFESS trial, ERD/ASA and Clopidogrel had similar outcomes when it came to stroke recurrence and stroke/MI/vascular death, but ___________ had more bleeding and had more discontinuations d/t SEs

ERD/ASA

according to the PRoFESS trial, ERD/ASA and Clopidogrel had similar outcomes when it came to stroke recurrence and stroke/MI/vascular death, but ERD/ASA had more __________ and had more discontinuations d/t ____________

bleeding, side effects

CHANCE trial included pts with NIHSS score <3 and/or ABCD2 score >4

it randomized ASA vs. ASA + Clopidogrel for 21 days → then d/c Clopidogrel and just do ASA

it found stroke and stroke/MI/CV death was reduced with _________ after 90 days

combination (ASA + Clopidogrel)

CHANCE trial included pts with NIHSS score <3 and/or ABCD2 score >4

it randomized ASA vs. ASA + Clopidogrel for 21 days → then d/c Clopidogrel and just do ASA

it found stroke & stroke/MI/CV death was reduced with combination (ASA + Clopidogrel) after 90 days

it found similar mortality and _________ with combo or with just ASA

bleeding

POINT trial included pts with ischemic stroke or high-risk TIA s/sx within 12 hours

it randomized ASA vs. ASA + Clopidogrel for 90 days

it found stroke & stroke/MI/CV death was reduced with _________ after 90 days

combination (ASA + Clopidogrel)

POINT trial included pts with ischemic stroke or high-risk TIA s/sx within 12 hours

it randomized ASA vs. ASA + Clopidogrel for 90 days

it found stroke & stroke/MI/CV death was reduced with combination (ASA + Clopidogrel) after 90 days

it found similar mortality between the two, however major __________ was worse in the combination group

hemorrhage

POINT trial included pts with ischemic stroke or high-risk TIA s/sx within 12 hours

it randomized ASA vs. ASA + Clopidogrel for 90 days

it found stroke & stroke/MI/CV death was reduced with combination (ASA + Clopidogrel) after 90 days

it found similar mortality between the two, however major hemorrhage was worse in the __________ group

combination

the ASA/AHA 2021 guidelines recommend ___________, OR __________, OR ____________ as initial antithrombic therapy for non-cardioembolic stroke

ASA, ERD/ASA, Clopidogrel (all are class I, level A recommendations)

the ASA/AHA 2021 guidelines recommend Aspirin, OR ERD/ASA, OR Clopidogrel as initial antithrombic therapy for non-cardioembolic stroke

_______________ may be beneficial in patients with minor stroke (NIHSS <3) or high-risk TIA (ABCD score >4) when started within 24 hours of onset and continued for 21-90 days → followed by ___________ treatment indefinitely

ASA + Clopidogrel, ASA alone (class I, level A recommendation)

the ASA/AHA 2021 guidelines recommend Aspirin, OR ERD/ASA, OR Clopidogrel as initial antithrombic therapy for non-cardioembolic stroke

ASA + Clopidogrel may be beneficial in patients with minor stroke (__________ score <3) or high-risk TIA (________ score >4) when started within 24 hours of onset and continued for 21-90 days → followed by ASA treatment indefinitely

NIHSS, ABCD2

the ASA/AHA 2021 guidelines recommend Aspirin, OR ERD/ASA, OR Clopidogrel as initial antithrombic therapy for non-cardioembolic stroke

ASA + Clopidogrel may be beneficial in patients with minor stroke (NIHSS score <3) or high-risk TIA (ABCD2 score >4) when started within _________ of onset and continued for __________ → followed by ASA treatment indefinitely

24 hours, 21-90 days

the ASA/AHA 2021 guidelines recommend Aspirin, OR ERD/ASA, OR Clopidogrel as initial antithrombic therapy for non-cardioembolic stroke

ASA + Clopidogrel may be beneficial in patients with minor stroke (NIHSS score _____) or high-risk TIA (ABCD2 score ______) when started within 24 hours of onset and continued for 21-90 days → followed by ASA treatment indefinitely

<3, >4

the ASA/AHA 2021 guidelines recommend Aspirin, OR ERD/ASA, OR Clopidogrel as initial antithrombic therapy for non-cardioembolic stroke

ASA + Clopidogrel may be beneficial in patients with minor stroke (NIHSS score <3) or high-risk TIA (ABCD2 score >4) when started within 24 hours of onset and continued for 21-90 days → followed by ASA treatment indefinitely

Antiplatelets are recommended over anticoagulants in patients with _____________ stroke

non-cardioembolic

risk factor modification is key to successful stroke prevention

Primary: control risk factors like ________, ________, and ________; diet/exercise; smoking cessation; treat A-fib

HTN, DM, HLD

risk factor modification is key to successful stroke prevention

Primary: control risk factors like HTN, DM, and HLD; diet/exercise; stopping __________; treating _____________

smoking, A-fib

risk factor modification is key to successful stroke prevention

Primary: control risk factors like HTN, DM, and HLD; diet/exercise; smoking cessation; treat A-fib

Secondary: alllll the primary things + anticoagulation for thromboembolic or hypercoagulable disease + __________ therapy

antiplatelet

True or False: A 21 y/o male non-smoker with NO HTN, HLD, or DM has zero risk of stroke

False (no one has a stroke risk of zero technically)

Non-modifiable stroke risk factors: age >______, family history, race (______ > Hispanics/Asians > Caucasians), gender (higher risk in ______), and prior stroke, TIA, or MI

55, AA, males

Modifiable stroke risk factors: HLD, smoking, physical inactivity, obesity, alcohol consumption, but _________ and _________ have the highest relative risk

HTN, A-fib

HTN is present in up to 70% of stroke patients

lowering BP can reduce stroke risk by 30-40% if patient is compliant

treatment recommendations: target BP <130/80mmHg, may initiate anti-hypertensives >_______ after acute stroke, and ________________ (drug class) are preferred for primary stroke prevention

48-72, CCBs

DM is present in 25-45% of all stroke patients & increases recurrent stroke risk by 60% if uncontrolled

all stroke patients are screened for DM with an HgbA1c goal of <_____%

7

DM is present in 25-45% of all stroke patients & increases recurrent stroke risk by 60% if uncontrolled

all stroke patients are screened for DM with an HgbA1c goal of <7%

inpatient glucose goals ________mg/dL (we should optimize their current regimen, or can initiate therapy based on their comorbidities)

140-180

HLD has NO clear evidence linking elevated cholesterol level and overall stroke risk

however, data supports recommendation of a ______-________ _________ for ALL patients

high-intensity statin

smoking doubles the risk of stroke, and risk starts to decrease after quitting and can disappear completely 5-years post-quitting

this risk includes _________ smoke

second-hand

Cardioembolic Stroke is a stroke that starts in the heart

most common etiology is from ____-________ ____________, then valvular heart disease/mechanical heart valve, then left ventricular mural thrombus

non-valvular atrial fibrillation

Cardioembolic Stroke is a stroke that starts in the heart

most common etiology is from non-valvular atrial fibrillation, then valvular heart disease/mechanical heart valve, then left ventricular mural thrombus

Stroke/TIA patients diagnosed with A-fib should automatically be considered for ______________

anticoagulation

Cardioembolic Stroke is a stroke that starts in the heart

Assessing stroke risk in Afib is done using the ______________ score

CHA2DS2-VASc

Cardioembolic Stroke is a stroke that starts in the heart

Assessing stroke risk in Afib is done using the CHA2DS2-VASc score

Stroke/TIA/thromboembolism is _______ points

2

Cardioembolic Stroke is a stroke that starts in the heart

Assessing stroke risk in Afib is done using the CHA2DS2-VASc score

Stroke/TIA/thromboembolism is 2 points; this automatically places patients into the ______-risk category (even if they have zero other risk factors!) for which _______ ___________ is recommended

high, oral anticoagulation

Cardioembolic Stroke is a stroke that starts in the heart

Assessing stroke risk in Afib is done using the CHA2DS2-VASc score

Stroke/TIA/thromboembolism is 2 points; this automatically places patients into the high-risk category for which oral anticoagulation is recommended

AHA/ASA 2021 guidelines for stroke prevention in non-valvular A-fib: what are the recommendations for prevention of first and recurrent stroke?

Warfarin or DOACs

Cardioembolic Stroke is a stroke that starts in the heart

AHA/ASA 2021 guidelines for stroke prevention in non-valvular A-fib: anticoagulation with Warfarin or DOACs can start within ___-___ _______ after a stroke, unless high risk for hemorrhage

2-14 days

Cardioembolic Stroke is a stroke that starts in the heart

AHA/ASA 2021 guidelines for stroke prevention in non-valvular A-fib: anticoagulation with Warfarin or DOACs can start within 2-14 days after a stroke, unless high risk for ___________

hemorrhage

Cardioembolic Stroke is a stroke that starts in the heart

AHA/ASA 2021 guidelines for stroke prevention in non-valvular A-fib: anticoagulation with Warfarin or DOACs can start within 2-14 days after a stroke, unless high risk for hemorrhage

for TIA, we can initiate __________ after the index event

immediately

Cardioembolic Stroke is a stroke that starts in the heart

AHA/ASA 2021 guidelines for stroke prevention in non-valvular A-fib: anticoagulation with Warfarin or DOACs (alone) can start within 2-14 days after a stroke, unless high risk for hemorrhage

Anticoagulation + Antiplatelet therapy is reasonable only for patients with clinically apparent ________

CAD (like ACS or a cardiac stent)