PowerPoint Presentation

							Preventing Strokes
One at a Time

Putting It All
Together
2009
Learning Objectives

Upon completion, participants will be able to:

   Triage and participate in the appropriate timely
    management of a TIA or minor stroke patient using
    the four steps of secondary stroke prevention
   Practice according to the Canadian Best Practice
    Recommendations for Stroke Care.
   Identify the local strategies designed to address
    the needs of the Emergent, Urgent and Semi-
    urgent TIA or minor stroke patient.
              Insert Picture



Patient #1


             Mrs. Ivanna Nomore
Mrs. Ivanna Nomore

 63 year old female
 Mortgage consultant
 Presenting complaint in ED: sudden onset
  of weakness and numbness to right leg
  and arm
 Resolved 60 minutes later
Four Step Process

 Evaluate the Event
 Initiate Medications
 Implement Interventions
 Modify Stroke Risk Factors




Adapted from APSS, February 2009
Evaluate the Event: Mrs. Ivanna Nomore

History:
 HTN x 6 years: was on antihypertensive
  but stopped taking it a while ago
 Dyslipidemia: was on statin in the past
 Not presently taking any medications
Evaluate the Event: Mrs. Ivanna Nomore
Exam and Investigations
 ECG: Normal sinus rhythm
 Neuro exam: Normal
 BP: 146/95
 CT: Normal
 Blood work:
     INR= 0.9, BUN= 5.5mmol/L, Cr = 80umol/L
 Evaluate the Event: Risk of stroke?
  Is Mrs. Ivanna Nomore at risk of a stroke? Urgency?

     Emergent
       Symptoms within previous 24 hours with 2 or more high
        risk clinical features
       Acute/persistent or fluctuating stroke symptoms
       1 positive investigation
       Other factors based on individual presentation and
        clinical judgement
     Urgent
       TIA within 72 hours
     Semiurgent
       Does not fit in urgent or emergent
CMAJ 2008;179(12 Suppl):E1-E93.
Evaluate the Event: Timing of Tests
Canadian Best Practice Recommendations for Stroke Care, 2008

Diagnostic Test           Emergent    Urgent   Semiurgent

Assessment by             24 h        7d       30 d
medical specialist
trained in stroke
CT or MRI                 24 h        7d       30 d

Carotid Imaging           24 h        7d       30 d

ECG                       24 h        7d       30 d



CMAJ 2008;179(12 Suppl):E1-E93 #3.2
Acute Interventions & Management:
Mrs. Ivanna Nomore


   Consult to stroke prevention
    clinic/physician responsible for and capable
    of urgent triage and implementation of
    appropriate TIA/stroke management
Acute Interventions & Management:
Mrs. Ivanna Nomore

Next Steps…
 Initiate Medications
     Which medications?
       o   Patient was started on ASA in ED
   Implement Interventions
Acute Interventions and Management:
Mrs. Ivanna Nomore
 Antiplatelet        Dosage            Considerations
 ECASA               81-325 mg OD      If aspirin naïve- load with
                     (adults)          160mg then 81 mg OD
                     3-5 mg/kg/day     (adults)
                     children
 Aggrenox            25/200 mg BID     Possible severe headache x
 (ASA/SR                               first 5-7 days
 dypiridamole)
 Plavix              75 mg OD          Consider loading with 300
 (Clopidogrel)                         mg



 CMAJ 2008;179(12 Suppl):E1-E93 #3.2
Acute Interventions and Management:
Mrs. Ivanna Nomore (cont’d)


Other tests ordered:      Results:
 Echocardiogram           No thrombosis
 Carotid Doppler          Left carotid stenosis <50%
 Fasting Blood Glucose    6.5 mmol/L
 Fasting Lipid Profile    T-Chol= 5.7mmol/L
                           HDL= 0.8mmol/L
                           LDL = 3.6mmol/L
                           TG= 1.5mmol/L
Next Steps…

   Initiate Medications
     Should you consider any other medications?



   Implement Interventions:
     Based on carotid Doppler results what is next?
Diagnosis: TIA most likely due to small
vessel disease

Further investigations and medical management..
 Holter Monitor
 ASA changed to Plavix
 Samples of ACEI and Statin given with family
  physician to follow up in 1 week.
Hypertension and Stroke


      HTN & Stroke                Assessment & Management
 Injury to the blood      Proper assessment technique
 vessel walls             Target BP < 140/90,
             ↓           < 130/80 (Diabetes/Chronic
 Scar is formed          Kidney Disease)
             ↓            ACEI + diuretic= 1st line tx
 Build-up of plaque,      Tx > 1 agent
 fragile small arteries,  Lifestyle modification
 extra strain on heart &  Focus on adherence
 weakens heart walls
 Canadian Hypertension Education Program 2009
 CMAJ 2008;179(12 Suppl):E1-E93 #3.2
Acute Interventions & Management:
Mrs. Ivanna Nomore

Statins
 First line agents for dyslipidemia
 Reduce stroke risk by 25-30%
 Target LDL-C< 2.0 mmol/L
 Vascular health bonus: decrease
  progression and/or inducing regression of
  carotid artery plaque
Acute Interventions & Management:
What if ?


   What if Mrs. Ivanna Nomore’s Doppler
    showed 90% stenosis in left internal
    carotid..?
     Would her risk stratification be different?
     Would her management be different?
  Implement Interventions
    Canadian Best Practice Recommendations for Stroke Care, 2008



   2.7a Symptomatic Carotid Stenosis
      Patients with transient ischemic attack or
       nondisabling stroke and ipsilateral 70-99% internal
       carotid artery stenosis should be offered carotid
       endarterectomy (CAE) within 2 weeks of the incident
       TIA or stroke unless contraindicated.
         o   CAE should be performed by a surgeon with a known perioperative
             morbidity and mortality of <6%.



CMAJ 2008;179(12 Suppl):E1-E93 #2.7a
Acute Interventions & Management:
What if ?


   What if Mrs. Ivanna Nomore’s Holter
    shows atrial fibrillation?
     Would her risk stratification be different?
     Would her management be different?
Medication Management
Canadian Best Practice Recommendations for Stroke Care, 2008

2.6 Antithrombotic therapy in atrial fibrillation
 “Patients with stroke and atrial fibrillation
  should be treated with warfarin at a
  target INR of 2.5, range 2.0-3.0 … if
  they are likely to be complaint with the
  required monitoring and are not at high
  risk for bleeding complications.”

  CMAJ 2008;179(12 Suppl):E1-E93 #2.6
Modify Stroke Risk Factors


          Mrs. Ivanna Nomore
Modify Stroke Risk Factors: Mrs. Ivanna
Nomore
What are her modifiable risk factors?
     Hypertension            √
     Dyslipidemia            √
     Smoking
     Diabetes                ?
     Heart Disease (Atrial Fibrillation) ?
     Obesity
     Dietary Habits
     Physical Inactivity
     Excess alcohol intake
Modifying Risk Factors: Mrs. Ivanna Nomore
   Reviewed patient education booklets “ You’ve had
    a TIA” and/or “Taking Control” (HSFO)
   Reviewed modifiable risk factors
   Teaching provided on use of home BP monitoring
    and trending values
   Assisted in creating a plan to address blood
    pressure
   Discussed medication information sheets
   LDL and BP targets reviewed and impact on risk
    of recurrent stroke
   Discussed stroke warning signs and what to do
   Discussed local resources
Putting it all together: Local Resources
             Insert Picture



Patient #2


              Mr. Les Feeling
Putting it all together: Mr. Les Feeling


 52 yr old male
 Presented to ED with complaint of sudden
  onset of L arm numbness
 Lasted 5 minutes
 Symptoms now resolved
 Hx: smoker
 Meds: none
Putting it all together: Mr. Les Feeling

Evaluate the event:
 VS= 35.7, 83, 140/85, 16
Investigations Ordered:
 Blood work
     lytes, INR, BUN, CR, glucose
 CT, ECG, Doppler
 Neurological exam: normal
Putting it all together: Mr. Les Feeling

Evaluate the event: Investigations
 Blood work: normal
 Fasting glucose and lipids ordered
 ECG=NSR
 Doppler booked next week
 CT head= normal
Putting it all together: Mr. Les Feeling


 What is the urgency of managing Mr.
  Feeling?
                   Urgent
 What does this mean for the timing of his
  tests?
                   7days
Putting it all together: Mr. Les Feeling


   Lab requisition for:
     LFT, CK, FBS, Lipid Profile
   Results:
     Total Cholesterol=5.2, TG=2.97, HDL= .90,
      LDL= 3.7
     Fasting Blood Glucose=6.5mmol/L
     CK & LFT=Normal
Putting it all together: Mr. Les Feeling

It’s not emergent! Are we done?

   Yes
   No
What are Mr. Les Feeling’s Risk Factors?



     Hypertension           √ PreHTN
     High cholesterol
     Smoking                √
     Diabetes
     Heart Disease (Atrial Fibrillation)
     Obesity
     Physical Inactivity
     Excess alcohol intake
   Modify Stroke Risk Factors: Smoking
   Canadian Best Practice Recommendations for Stroke Care, 2008

   2.1.v. Smoking
    Smoking cessation and smoke free
     environment; Nicotine replacement
     therapy and behavioural therapy
    For nicotine replacement therapy,
     nortriptyline therapy, nicotine receptor
     partial agonist therapy and/or behavioural
     therapy should be considered.
CMAJ 2008;179(12 Suppl):E1-E93 #2.1 v
Putting it all together: Patient Resources


   Health care providers need to know how
    to support patients and families become
    better at self management

   Local Resources for smoking cessation?
Putting it all together: Mr. Les Feeling

 Warning Signs of Stroke, (HSFC, 2006)
     •Sudden loss of strength or sudden numbness in the face,
      arm or leg, even if temporary
     •Sudden difficulty speaking or understanding or sudden
      confusion, even if temporary
     •Sudden trouble with vision, even if temporary
     •Sudden severe and unusual headache
     •Sudden loss of balance especially with any of the above
      signs

                           CALL 911
Putting it all together: System Resources


   Local Systems for rapid evaluation and
    triage of TIA and minor stroke patients?
Summary

   Stroke is a leading cause of disability and death
   80% of strokes are preventable
   Acute management starts with symptom recognition
      Rapid ER protocols make a difference
      Rapid triage of TIAs prevent stroke
   Prevention strategies can have a dramatic impact
      HTN, Smoking Cessation, Healthy Lifestyles,
       Medication Adherence
   Canadian Best Practice Recommendations for Stroke
    Care, 2008 www.canadianstrokestrategy.ca
Canadian Best Practice Recommendations for Stroke Care, updated 2008
                   www.canadianstrokestrategy.ca