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CASE PRESENTATION Dr.Annie Pervaiz Presenting Complaint 90yr female presenting with falls. History of five falls in one week. Ongoing dizziness since.

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Presentation on theme: "CASE PRESENTATION Dr.Annie Pervaiz Presenting Complaint 90yr female presenting with falls. History of five falls in one week. Ongoing dizziness since."— Presentation transcript:



3 Presenting Complaint 90yr female presenting with falls. History of five falls in one week. Ongoing dizziness since few months. Occasional shortness of breath.

4 Past Medical History Atrial Fibrillation Breast Cancer Recurrent Falls Hip Hemiarthroplasty Cataract operation

5 Social History Lives alone. Mobilizes with frame. Carer OD Family helps with shopping Non-smoker

6 Medications Aspirin Omeprazole Letrozole Calceos (Warfarin stopped due to risk of falls)

7 Physical Examination Not in respiratory distress. Pulse: Irregularly irregular. HS: I+II+0 Chest: Bilateral air entry. Left basal crackles. Abdomen: Soft, non tender. CNS: GCS: 15/15. Grossly intact.

8 Investigations Temp: 36.8c BP: 236/116mmHg Pulse: 75/min, irregular R/R: 18/min Na+: 136 K+: 3.8 Urea: 8.5 Creatinine: 136 eGFR: 32 CRP: 17 Hb: 13.2 g/dl WBC and neutrophils: N Trop I : 21 D-Dimers: Positive.

9 Investigations (cont) Urine Dipstix: Positive for leukocytes, proteins and trace of blood. ECG: Atrial fibrillation. Rate ~76/min CXR: Nil focal Lung Lesion.

10 Impression Fraility Uncontrolled hypertension ?Postural hypotension

11 Management Plan Commenced on bisoprolol and Bendroflumethiazide. Lying and standing BP. PT/OT/social input. Commenced on trimethoprim for ?underlying UTI.

12 CRASH CALL 4/7 days post admission. GCS drop to 6/15. Flexion to pain. BM: 7.3. Blood Pressure: Unrecordable. Manual BP: 240/120mmHg L 220/120mmHg R I/v access 20G gained by anesthetist. O2 sats: 95% R/A Pulse: 74/min, irregular.

13 Examination Right sided weakness (new) R Plantars equivocal. Pupils equal and sluggishly reactive to light. Aphasic. Right sided neglect.

14 Next Plan Urgent CT Head. Enoxaparin and aspirin on hold. Monitor BP.

15 CT Head

16 Next Plan Patient not suitable for thrombolysis due to high risk of bleed. Aspirin 300mg commence for 2/52. Referral to stroke team. DNAR Inform the family. GTN Patch. NG Tube insertion.

17 Repeat CT Head

18 The Oxfordshire Classification of Stroke It defines four sub-categories of cerebral infarction on the basis of clinical localization of the infarct, as indicated by a clinical assessment of the presenting signs and symptoms: TACS — Total Anterior Circulation Stroke LACS — Lacunar Stroke PACS — Partial Anterior Circulation Stroke POCS — Posterior Circulation Stroke

19 TACS A combination of: New, higher cerebral dysfunction (eg dysphasia), Homonymous visual field defect Ipsilateral motor and / or sensory deficit of at least two areas out of face, arm and leg. *If drowsy with unilateral weakness, last two factors are assumed.

20 PACS No Drowsiness 2 of 3 criteria of TAC OR Higher cerebral dysfunction alone (eg dysphasia) OR Motor/sensory deficit more restricted than those classified as LAC (eg confined to one limb)

21 LACS Pure motor (most common). Complete or incomplete weakness of 1 side, involving the whole of 2 of 3 of the body areas of face, arm and leg). Pure sensory. Sensory symptoms and/or signs, same distribution as above. Sensori-motor. Combination of the above. Includes dysarthria (“clumsy hand syndrome”) and dysphasia Ataxic hemiparesis. Hemiparesis with ipsilateral cerebellar ataxia

22 POCS Affecting brainstem, cerebellar or occipital lobes Ipsilateral cranial nerve palsy with contralateral motor and / or sensory deficit Bilateral motor and / or sensory deficit. Disorder of conjugate eye movement Cerebellar dysfunction without ipsilateral long tract signs Isolated homonymous visual field defect

23 NICE Guidelines Definitions Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.

24 Cont Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM or HBPM daytime average blood pressure is 150/95 mmHg or higher. Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.

25 STEP 1 Offer people aged under 55 years step 1 antihypertensive treatment with an ACE inhibitor or a angiotensin-II receptor blocker. If an ACE inhibitor is prescribed and is not tolerated, offer a ARB. Do not combine an ACE inhibitor with an ARB to treat hypertension.

26 Cont If a CCB is not suitable e.g. because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic.

27 Cont If diuretic treatment is to be initiated or changed, offer a thiazide like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as BFZ or hydrochlorothiazide.

28 Cont Beta-blockers are not a preferred initial therapy for hypertension. However, beta-blockers may be considered in younger people, particularly: those with an intolerance or contraindication to ACE inhibitors and angiotensin II receptor antagonists or women of child-bearing potential or people with evidence of increased sympathetic drive.

29 Step 2 If blood pressure is not controlled by step 1 treatment, offer step 2 treatment with a CCB in combination with either an ACE inhibitor or an ARB. If a CCB is not suitable for step 2 treatment, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic.

30 Step 3 Before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal or best tolerated doses. If treatment with three drugs is required, the combination of ACE inhibitor or angiotensin II receptor blocker, calcium-channel blocker and thiazide-like diuretic should be used.

31 Step 4 For resistant hypertension consider further diuretic therapy with low dose spironolactone (25 mg once daily) if the blood potassium level is 4.5 or lower. If further diuretic therapy for resistant hypertension at step 4 is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker.


33 The ACCESS Study Evaluation of Acute Candesartan Cilexetil Therapy in Stroke Survivors ACCESS Study Published in June,2003. The current recommendation to tolerate acute hypertension in cerebral ischemia is based on the concept of disturbed autoregulation of cerebral blood flow in the penumbra surrounding the zone of necrosis. Given a pressure-dependent perfusion in the penumbra, any decrease in blood pressure is expected to impair tissue perfusion.

34 Background and Purpose The Acute Candesartan Cilexetil Therapy in Stroke Survivors (ACCESS) study was designed to assess the safety of modest blood pressure reduction by candesartan in the early treatment of stroke.

35 Methods Five hundred patients were recruited in a prospective, double-blind, placebo-controlled, randomized, multicenter phase II study.

36 Treatment Design Treatment was started with 4 mg candesartan daily or placebo on day 1. On day 2, dosage was increased to 8 or 16 mg candesartan or placebo if blood pressure exceeded 160 mm Hg systolic or 100 mm Hg diastolic. Treatment was targeted to a 10% to 15% blood pressure reduction within 24 hours.

37 Results No significant differences on day 0 and after 3 months (candesartan versus placebo). The cumulative 12-month mortality (candesartan versus placebo: 5 [2.9%] versus 12 [7.2%]. Number of vascular events (candesartan versus placebo: 17 [9.8%] versus 31 [18.7%]. This significantly favored the candesartan group Cardiovascular events, fatal and nonfatal: 2 versus 10; Cerebrovascular events, fatal and nonfatal: 13 versus 19; Noncardiovascular mortality: 1 versus 1.

38 Discussion The data reveal that a 7-day course of candesartan after an acute ischemic stroke significantly improves cardiovascular morbidity and mortality. The fact that no cardiovascular or cerebrovascular event occurred as a result of hypotension is of significant clinical importance. When there is need for or no contraindication against early antihypertensive therapy, candesartan is a safe therapeutic option according to the ACCESS results.

39 SCAST TRIAL The angiotensin-receptor blocker candesartan for treatment of acute stroke Published in Feb,2011. Raised blood pressure is common in acute stroke, and is associated with an increased risk of poor outcomes. Aim : To examine whether careful blood-pressure lowering treatment with the ARB candesartan is beneficial in patients with acute stroke and raised blood pressure.

40 Methods Participants in this randomised, placebo- controlled, double-blind trial were recruited from 146 centres in nine north European countries. Patients were randomly allocated to candesartan or placebo for 7 days, with doses increasing from 4 mg on day 1 to 16 mg on days 3 to 7.

41 Findings During the 7-day treatment period, blood pressures were significantly lower in patients allocated candesartan than in those on placebo (mean 147/82 mm Hg in the candesartan group on day 7 vs 152/84 mm Hg in the placebo group). During follow-up, nine (1%) patients on candesartan and five (<1%) on placebo had symptomatic hypotension, and renal failure was reported for 18 (2%) patients taking candesartan and 13 (1%) allocated placebo.

42 Conclusion There was no indication that careful blood- pressure lowering treatment with the angiotensin-receptor blocker candesartan is beneficial in patients with acute stroke and raised blood pressure. If anything, the evidence suggested a harmful effect.

43 Thank You

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