PHRX 5040 Cardio Module - Exam #2 (Dr. Doyno's Section)

define acute ischemic stroke (AIS)

sudden loss of blood flow to an area of the bran with the resulting loss of neurologic function

what are 4 non modifiable risks actors for AIS?

- age = risk doubles every 10 yrs if 55+

- race = highest risk for black pts

- gender = males more than females

- prior neuro or cardio event history

what are 9 modifiable risk factors of AIS?

- HTN

- diabetes

- A fib

- hyperlipidemia

- PAD/CAD

- sickle cell disease

- secondary prevention for prior stroke or TIA

- other heart disease

- sedentary lifestyle

describe the overall cause of AIS

caused by thrombosis or embolism that occludes a cerebral vessel supplying a specific area of the brain

what are the 2 areas of brain affected by AIS? describe them

1 = core

- area where brain damage is irreversible = cell death

2 = penumbra

- area where loss of brain function is due to decreased blood flow but CAN be reversed in a timely manner

what is the main source of thrombus contributing to AIS?

- the heart

- especially if pt has A fib

what is signifigant to note about LVOs?

- occlusion of a major artery = damages larger areas of brain, causing disabling neuro deficits

- if this occurs it is an EMERGENCY, damages larger area of the brain

what are stroke mimics?

- nonvascular disease that presents with stroke like symptoms

- often indistinguishable from an actual stroke

what are 7 common stroke mimics?

- migraine with aura

- seizure with post octal paralysis

- metabolic derearrangements = hypoglycemia

- inoxication or med effects

- focal neurological pathology

- presyncope/syncope

- PRES

overall, describe transient ischemic attacks (TIAs)

- stroke warning signs = small strokes

- abrupt onset of symptoms often lasting just a few mins to 24 hrs

- requires monitoring as pts are at a high risk of recurrent stroke within 90 days with highest risk in first 48 hrs

what are 5 signs of stroke?

- numbers in face, arm or leg = generally unilateral

- confusion or trouble speaking or understanding speech

- trouble seeing in 1 or both eyes

- trouble walking, dizziness or problems with balance

- severe HA with no known cause

describe "act FAST" in relation to strokes

- F = face droops

- A = arm weakness

- S = speech difficulty

- T = time is critical

overall, describe the destination decision for pts with stroke systems

- if stroke is suspected assess probability of LVO and consider transport times

- choose the pathway that allows pt to get to reprerfusion FASTEST

- if there is a mobile stroke unit available = USE it

describe the use of EMS stroke screening

- allows EMS to identify pts with strokes from mimics

- there are specific pre hospital scales that EMS will use

what are the 3 goals of initial AIS assessment?

- ensure medical stability

- quickly reverse any conditions contributing to pts problem

- determine if pt with AIS is candidate for IVT or thrombectormy

during AIS initial assessment, what is done?

not enough time for a full workup so need to do what is important

- collect history and physical exam

- neuro assessment using NIHSS stroke sale

- obtain labs

- diagnostic testing

- additional testing = EKG for presence of A fib

what are 5 key lab tests to obtain during initial AIS assessment?

- blood glucose

- CBC

- PT/INR

- aPTT

- serum electrolyte and renal function tests

what are 4 key things to obtain during initial physical exam for AIS?

- establish time of onset and last known well time = KEY

- obtain med list

- pt weight

- vital signs = BP specifically

what are 4 goals of the neuro exam for a pt presenting with AIS?

- confirm presence of stroke symptoms

- distinguish stroke from mimics

- establish a neuro baseline

- establish stroke severity using NISS

describe the use of NIH stroke scale (NIHSS)

- 42 point scoring tool to determine neuro impairment

- allows rapid determination of severity and possible location of stroke

- scores strongly associated with outcomes

- helps identify if pts will likely benefit from IVT

what NIHSS score aligns with no stroke ?

0

what NIHSS score aligns with minor stroke severity?

0-4

what NIHSS score aligns with moderate stroke severity?

5-15

what NIHSS score aligns with moderate-severe stroke severity?

16-20

what NIHSS score aligns with severe stroke severity?

21-42

describe the order that neuroimaging is done when AIS is suspected

- 1st do a non contrast CT to see if pt has a bleed

- if hemorrhage is excluded and no contraindications, you CAN start IVT here before doing others

if no bleed:

- 2 = angiography with contrast to show which vessels are occluded

- 3 = CT perfusion = shows which tissue is core and which is salvigable

describe the use of DWI-FLAIR mismatch

advanced neuroimaging

- tells us WHEN the stroke occurred

- suggested a relatively recent AIS, often within 4.5 hrs

what are 3 short term goals of AIS therapy?

- reduce secondary brain damage

- re-establish and maintain adequate perfusion

- protect areas from the effects of ischemia

what are 3 long term goals of AIS therapy?

- prevent recurrent strokes

- reduction or modification of risk factors

- prevention of long term disability and death

what is the GOAL door to drug time?

- less than 30 mins for more than 50% of pts

- less than 60 mins for more than 80% of pts

describe the use of reperfusion therapy for AIS

- main short term goal and mainstay of therapy for AIS

- attempts to restore blood flow to ischemic tissue

- mechanisms of reperfusion = thrombolytics or mechanical thrombectomy

describe the MOA of thrombolytics

- binds to fibrin

- converts inactive plasminogen to active protease plasmin

- plasmin then allows for fibrin degradation = ensures clot does not grow and breaks down the fibrin mesh holding the clot together

what class of drugs are both TPA and TNK?

tissue plasminogen activators

- TPA = alteplase

- TKA = tenecteplase

what is the indication for alteplase admin?

- treatment of AIS if LKW is within 3 and 4.5 hrs

- best established window = 0-3 hrs

describe the dosing of alteplase

dose = 0.9 mg/kg with max 90 mg dose, total dose IV

- 10% of dose = IV bolus over 1 min

- 90% of dose = IV continuous infusion, over 1 hr immediately after bolus

what are 3 risks associated with alteplase use?

- key risk = bleeding

- increased rusk of symptomatic ICH

- angioedema

describe the use of alteplase in a minor, non-disabling stroke

generally avoid use

- more mild stroke is likely to benefit from a non lytic therapy with less bleed risk

describe what is needed and how the reconstitution of alteplase is done

- values pharmacist needs = pt weight and total dose

- bolus dose = 10% of dose

- continuous infusion dose = 90% of dose

- NEED to pull waste from 100 mg vial because the concentration is 1 mg/mL (100 ml total)

why do we need to pull waste from alteplase vial?

- the concentration is 1 mg/mL (100 ml total) and the max dose is 90 mg

- need to remove at least 10 mL if not more depending on the pts weight based dosing

overall, describe tenecteplase (TNK)

- tissue plasminogen activator shown to have higher affninity for fibrin and longer half life than alteplase

- allows it to only need 1 bolus dose

- and lower rates of systemic hemorrhage than alteplase

describe the dosing for TNK

- dose = 0.25 mg/mg IV bolus once

- max dose = 25 mg

describe the admin of TNK

- 1 IV bolus over 5 seconds

- do NOT need to pull waste

describe the use of TNK in minor, non disabling stroke

do NOT use

what does the 2026 guideline update recommend when using TPA/TNK

use either TNK or TPA in eligible pts within 4.5 hrs

describe the use of mechanical thrombectomy for AIS

- pts eligible for IVT may still be considered for this

- non pharm therapy where a stent is physically placed or the clot is removed via catheter

- may be beneficial up to 24 hrs after symptom onset in select pts

what are 3 key questions to ask when assessing pt eligibility for IVT in AIS?

- is the pt likely to benefit from thrombolytics?

- is the pt at unacceptable bleeding risk?

- can the pharmacist ensure safe and timely administration?

what may the pharmacist do to determine if the pt is likely to benefit from thrombolytics in AIS

confirm ischemic stroke, LKW treatment window and whether symptoms are diabling

what may the pharmacist do to determine if the pt at unacceptable bleeding risk in AIS

evaluate the following

- imaging

- BP

- anticoagulants on med list

- recent bleeding

- major procedures

what may the pharmacist do to determine if the pharmacist ensure safe and timely administration in AIS

verify the following:

- drug

- dose

- pt weight

- preparation

- BP control

- monitoring

- post treatment med restrictions

according to the 2026 AIS guideline update, in addition to NIHSS, what determines a pts eligibility to receive IVT?

disabling defects

what are the 5 inclusion criteria for a pt with AIS to receive IVT?

ALL should be met

- clinical diagnosis or suspicion of AIS with a disabling neuro deficit

- last known well within 4.5 hrs

- brain CT/MRI excludes ICH

- BP less than 185/110 before treatment

- no absolute contraindication

what are the 6 exclusion (potential contraindications) to IVT use in pts with AIS?

- ICH or extensive clear infract hypodensity

- low platelets, INR greater than 1.7, elevated aPPT or PT

- uncontrolled BP greater than 185/110 despite treatment

- active significant bleeding or susceptive aortic arch dissection

- suspected infective endocarditis or intra-axial IC tumor

- intracranial/spinal surgery or mod-severe TBI within 14 days

if a pt is currently taking warfarin and presents with AIS, what should the pharmacist verify?

- identify last dose and INR

- do NOT give IVT with INR greater than 1.7

if a pt is currently taking DOACs and presents with AIS, what should the pharmacist verify?

- collect exact agent, dose, last admin, renal function and drug specific acccessays

- recent exposure = within 48 hrs requires individualized specialist assessment

if a pt is currently taking UFH or LMWH and presents with AIS, what should the pharmacist verify?

- identify recent admin, aPTT or anti-Xa activity

- major concern with therapeutic LMWH within 24 hrs

if a pt is currently taking antiplatelets and presents with AIS, what should the pharmacist verify?

- aspirin or clopidogrel use alone is NOT an immediate exclusion to IVT

- need to look at platelet levels = less than 100,000 is contraindicated

describe the use of BP meds and pharmacist verification in the case of AIS

prepare IV labetaolol, nicardipine or clevidipine per protocol to achieve BP target before starting IVT

what 2 things should the pharmacist verify after IVT therapy?

- avoid routine antithrombotics for 24 hrs

- verify and follow up CT/MRI before restarting

overall, describe acute BP management in AIS

- elevated BP = very common in AIS

- typically decreases spontaneously

in terms of BP, what pts are candidates for reperfusion therapy?

- pts must have BP carefully lowered to less than 185/110 before IVT is initiated

- can use IV antihypertensives to do so

describe the BP goals in AIS if a pt has contraindications to IVT

BP goal = less than 220/120

- moderate HTN may help improve cerebral perfusion of ischemic tissue

what are 3 key things to monitor when thrombolytics are used in AIS?

- changes in mental status

- bleeding

- angioedema

describe the use of antiplatelet therapy after IVT is given

do NOT give anti platelet therapy for the first 24 hrs = contraindicated

describe the use of anti platelet therapy for minor non-cardioembolic strokes or high risk TIA

- can recommend short course dual anti platelet therapy (DAPT)

- guidelines support 21 days of DAPT with aspirin + clopidogrel

- followed by single anti platelet therapy in appropriate pts