acute ischemic stroke

2 stroke subtypes

1. hemorrhagic

2. ischemic

ischemic stroke

• caused by a blockage in the cerebral artery —> athersclorosis, cardioembolism, etiology may be unknown

non modifable risk factors

• hx of TIA

• genes, sex, gender, race, etc

modifiable risk factors

• cigs

• HTN

• alc and drug use

• afib

• diabetes

• dyslipidemia

primary prevention screening 40-79 year old

evaluate risk for CVS q 1-5 years - use lifestyle and tx to decrease stroke risk

AF primary prevention screening

chadvasc score assessment to guide decision on oral anticoagulation to decrease stroke risk

18+ screening

periodic screening for modifiable behaviors that increase stroke risk and periodic screening for SDOH

BE FAST

B- balance

E- eyes

F-face droopy

A - arms

S - speech slurred

T- timing call 911!

TIA

• arterial ischemia without evidence of infarction

• its a warning or mini stroke

• neuro sx resolve within 24 hours spontaneously

• tx as a med emergency

goals of therapy

• minimize ongoing neuro injury

• prevent neuro dysfunction complications

• prevent recurring strokes

stroke scale

• 0 = no stroke symptoms

• 1 -4 = minor stroke

• 5-15 = moderate stroke

• 16-20 = moderate to severe stroke

• 41-42 = severe stroke

ALL patients with AIS suspect should receive

emergency head imaging before starting any specific treatment to rule out brain bleed

IV fibronlytics treatment

for pts within 4.5 hours onset of stroke

BP targets before starting IVT

<185/110

BP target after IVT

<=180/105

pharm options to decrease bP

• remember to not abruptly reduce it

• IV labetolol

• IV nicardepine

• IV hydralazine (bolus)

IVT relative contraindications

• DOAC exposure <48 hrs

• ischemic stroke < 3 months

• prior ICH

• recent major non CNS trauma (14d-3 months)

• STEMI within 3 mos

• active malignancy

• neurosurgery >= 14 days-3 months

IVT absolute CI

• extensive hypodensity on CT

• CT with hemorrhage

• mod-severe trauma brain injury <14 days

• intracranial/spinal injury within 3 months

• acute spinal cord injury within 3 months

• PLT<100

• INR>1.7

• aPTT >40s

• PT>15 s

IVT ADRs

• ICH

• bleeding

• arrhythmias

• hypersensitivity

IVT monitoring

• baseline - neuro exam, PT/INR, glucose

• duringa nd after starting

  • BP and neuro assessment

  • bleeding complications

  • S/sx of ICH

alteplase dosing

• 0.9mg/kg IV where 10% = bolus and 90% = infusion

• short half life of 4 minutes

• drug needs to be reconstituted

TNK dosing

• 0.25 mg/kg bolus

• max dose = 25 mg

• no reconstitution required

pharmacist’s role is to

• monitor

  • BP

  • CBC

  • aPTT

  • PT/INR

  • glucose - make sure sx are not bc of hypoglycemia

early aspirin therapy

should be given within 24-48 hours if there are no contraindications

• dual antiplatelet not long term rec

anticoag therapy

not recommended! only recommended if pt has afib

non pharm secondary prevention

• diet modification —> DASH diet

• weight loss for the obese

• exercise at least 10 minutes x 4 times per week

• avoid stimulant drugs

• stop smoking

non cardio embolic stroke tx

• antiplatelet therapy preferred

• first line

  • aspirin 81-325 mg PO

  • clopidogrel 75 mg PO QD

  • dypridamole + aspirin 25 mg BID

• may consider short term DAPT with ticagrelor + aspirin for TIA (21-30 days) —> continue aspirin alone

cardioembolic stroke tx

• anticoag is preferred

  • warfarin (INR goal 2-3)

  • apixaban

  • dabigatran

  • edoxaban

  • rivaroxaban

HTN tx

• BP goal <130/80

• tx with thiazide, ACEI, or ARB

diabetes tx with A1C goal <7.1%

• metformin +GLP1A or SGLT2I

• consider metformin for prediabetes

lipids tx

• no known ASCVD —> atorvastatin 80 mg PO QD

• yes ASCVD —> target LDL goal <70 and add zetia or others if not at that goal

• monitor lipids 4-12 weeks after statin initiation and every 3-12 months