2. BRAIN ATTACK SECONDARY STROKE PREVENTION STRATEGIES: Recurrent Stroke Can Be Prevented! Carolyn Walker RN, BN January 2011

3. Learning Objectives Upon completion of this program, participants will be able to: Upon completion of this program, participants will be able to: Discuss the incidence of stroke and the risk of recurrent stroke Discuss the incidence of stroke and the risk of recurrent stroke Describe four components of secondary stroke prevention Describe four components of secondary stroke prevention Explain strategies to reduce the risk of recurrent stroke Explain strategies to reduce the risk of recurrent stroke

4. Second Strokes Stroke or TIA survivors have an increased risk of a subsequent stroke Stroke or TIA survivors have an increased risk of a subsequent stroke Recurrent strokes are more likely than initial strokes to result in disability and death Recurrent strokes are more likely than initial strokes to result in disability and death ~ 20%-40% of strokes are preceded by a TIA or non disabling stroke ~ 20%-40% of strokes are preceded by a TIA or non disabling stroke (Rothwell et al. Lancet Neurol 2006; 5: 323-331) Golden Opportunity for Stroke Prevention!

5. Modifiable Hypertension Hypertension Dyslipidemia Dyslipidemia Diabetes Diabetes Metabolic syndrome Metabolic syndrome Atrial fibrillation Atrial fibrillation TIA/prior stroke TIA/prior stroke Carotid stenosis Carotid stenosis Cigarette smoking Cigarette smoking Alcohol abuse Alcohol abuse Obesity Obesity Physical inactivity Physical inactivity Obstructive sleep apnea Obstructive sleep apnea Nonmodifiable Age Gender Race/ethnicity Heredity Cardiovascular Disease Goldstein L, et al. Circulation. 2001;103:163-182. Broderick J, et al. Stroke. 1998;29:415-421. Brown WV. Clin Cornerstone. 2004;6(suppl 3):S30-S34. Risk Factors for Stroke

6. Approach to Secondary Stroke Prevention Components: Evaluate the Event Evaluate the Event Implement Interventions Implement Interventions Initiate Medications Initiate Medications Modify Stroke Risk Factor: Continuous Monitoring Modify Stroke Risk Factor: Continuous Monitoring

7. Evaluate the Event TIA/Minor Stroke Risk Assessment TIA/Minor Stroke Risk Assessment Clinical Predictors Clinical Predictors Investigations Investigations CT, MRI, ECG, Carotid imaging, echocardiogram CT, MRI, ECG, Carotid imaging, echocardiogram

8. Evaluate the Event: TIA / Minor Stroke Risk Assessment TIA Stroke Risk Assessment High Risk 1. Symptom onset within the last 48 hours with any one of the following :  Motor deficit lasting more than 5 minutes  Speech deficit lasting more than 5 minutes  ABCD 2 score ≥ 4 2. Atrial fibrillation with TIA

9. Evaluate the Event: TIA / Minor Stroke Risk Assessment TIA Stroke Risk Assessment Medium Risk Symptom onset between 48 hours and 7 days with any one of the following :  Motor deficit lasting more than 5 minutes  Speech deficit lasting more than 5 minutes  ABCD 2 score ≥ 4 Low Risk 1. Symptom onset > 7 days 2. Symptom onset ≤ 7 days without the presence of high risk symptoms Speech deficit, motor deficit, ABCD 2 score ≥ 4, atrial fibrillation with TIA Speech deficit, motor deficit, ABCD 2 score ≥ 4, atrial fibrillation with TIA ** Isolated syncope or dizziness is rarely a TIA and may not require Stroke Prevention Clinic Referral

10. Evaluate the Event: Investigations CT or MRI CT or MRI Rule out mimics, identify stroke type Rule out mimics, identify stroke type Carotid Imaging (carotid duplex, CTA or MRA) Carotid Imaging (carotid duplex, CTA or MRA) Identify stenosis Identify stenosis ECG ECG ? Cardiac cause - afib ? Cardiac cause - afib Holter monitor Holter monitor Echocardiogram Echocardiogram If suspect cardiac cause If suspect cardiac cause Labs - CBC, lytes, Cr, gluc, PTT, INR, fasting lipids Labs - CBC, lytes, Cr, gluc, PTT, INR, fasting lipids

11. IMPLEMENT INTERVENTIONS ACT FAST WITH HIGH RISK PATIENTS!

13. Carotid Endarterectomy If TIA due to ≥ 50% stenosis in extracranial internal carotid artery consider CEA Greatest benefit if surgery within 2 weeks Rothwell et al. Lancet; 2004; 363: 915-25

14. INITIATE MEDICATIONS

15. Initiate Medications: Antithrombotic Therapy Aspirin (50-325 mg/day) is first line treatment If aspirin naïve- load with 160mg then 81 mg OD If aspirin naïve- load with 160mg then 81 mg OD May administer aspirin only if CT not available and symptoms resolved May administer aspirin only if CT not available and symptoms resolved If symptoms not resolved must have CT to exclude hemorrhage If symptoms not resolved must have CT to exclude hemorrhage Options: Aspirin/extended release dipyridamole 25mg/200mg BID 25mg/200mg BIDClopidogrel 75 mg OD, consider loading with 300 mg 75 mg OD, consider loading with 300 mg

16. Initiate Medications: Antithrombotic Therapy If cardioembolic source: Atrial Fibrillation Long-term anticoagulation (Warfarin) Long-term anticoagulation (Warfarin) Target INR 2.0 - 2.5 Target INR 2.0 - 2.5

17. Antiplatelet/Anticoagulation Therapy If cardioembolic source: Long-term anticoagulation – Dabigatran Long-term anticoagulation – Dabigatran Dabigatran 150 mg BID Dabigatran 150 mg BID

20. Leadership. Knowledge. Community.19  1. We recommend that all patients with AF or AFL (paroxysmal, persistent or permanent), should be stratified using a predictive index for stroke (e.g. CHADS 2 ) and for the risk of bleeding (e.g. HAS- BLED), and that most patients should receive antithrombotic therapy. (Strong recommendation, High Quality Evidence) Recommendations

21. Leadership. Knowledge. Community.20

22. Leadership. Knowledge. Community.21  1. We recommend that all patients with AF or AFL (paroxysmal, persistent or permanent), should be stratified using a predictive index for stroke (e.g. CHADS 2 ) and for the risk of bleeding (e.g. HAS- BLED), and that most patients should receive antithrombotic therapy. (Strong recommendation, High Qulaity Evidence) Recommendations

23. www.escardio.org Bleeding Risk – HAS-BLED Score

24. Leadership. Knowledge. Community.23  1. We recommend that all patients with AF or AFL (paroxysmal, persistant or permanent), should be stratified using a predictive index for stroke (e.g. CHADS 2 ) and for the risk of bleeding (e.g. HAS- BLED), and that most patients should receive antithrombotic therapy. (Strong Recommendation, High Quality Evidence) Recommendations

25. Leadership. Knowledge. Community.24  2. We recommend that patients at very low risk of stroke ( CHADS 2 = 0 ) should receive aspirin (75- 325 mg/day). (Strong recommendation, High Quality Evidence). We suggest that some young persons with no standard risk factors for stroke may not require ay antithrombotic therapy. (Conditional recommendation, Moderate Quality Evidence). Recommendations - Antithrombotic

26. Leadership. Knowledge. Community.25  3. We recommend that patients at low risk of stroke ( CHADS 2 = 1 ) should receive OAC therapy (either warfarin [INR 2 – 3] or dabigatran). (Strong recommendation, High Quality Evidence). We suggest, based on individual risk/benefit considerations, that aspirin is a reasonable alternative for some. (Conditional recommendation, Moderate Quality Evidence).  4. We recommend that patients at moderate risk of stroke ( CHADS 2 ≥ 2 ) should receive OAC therapy (either warfarin [INR 2 – 3] or dabigatran). (Strong recommendation, High Quality Evidence) Recommendations - Antithrombotic

27. Leadership. Knowledge. Community.26  5. We suggest, that when OAC therapy is indicated, most patients should receive dabigatran in preference to warfarin. In general, the dose of dabigatran 150 mg po bid is preferable to a dose of 110 mg po (exceptions discussed in text). (Conditional recommendation. High Quality Evidence). Recommendations - Antithrombotic

28. MODIFY RISK FACTORS Add diabetes and afib information

29. Modifiable Stroke Risk Factors Medical conditions  High Blood Pressure  High blood cholesterol  Obesity  Diabetes  Cardiac diseases Atrial fibrillation Atrial fibrillation Coronary artery disease Coronary artery disease  Carotid stenosis  Prior TIA or stroke Behaviors  Cigarette smoking  Heavy alcohol use  Physical inactivity

30. Treating Hypertension to Prevent Stroke HTN is the single most important modifiable risk factor for stroke HTN is the single most important modifiable risk factor for stroke HTN contributes to 70% of all strokes HTN contributes to 70% of all strokes Atheroma in carotids, aortic arch Atheroma in carotids, aortic arch Friability of small cerebral end arteries Friability of small cerebral end arteries LV dysfunction and atrial fibrillation LV dysfunction and atrial fibrillation

31. Benefits of Treating Hypertension Younger than 60 yrs Younger than 60 yrs Reduces the risk of stroke by 42% Reduces the risk of stroke by 42% Reduces the risk of coronary event by 14% Reduces the risk of coronary event by 14% Older than 60yrs Older than 60yrs Reduces overall mortality by 20% Reduces overall mortality by 20% Reduces cardiovascular mortality by 33% Reduces cardiovascular mortality by 33% Reduces incidence of stroke by 40% Reduces incidence of stroke by 40% Reduces coronary artery disease by 15% Reduces coronary artery disease by 15%

32. Treat Hypertension Aggressively Target most patients still < 140/90 Target most patients still < 140/90 Home Measurement: < 135/85 Home Measurement: < 135/85 Diabetics or chronic kidney disease: Diabetics or chronic kidney disease: < 130/80 < 130/80 Lifestyle Modification: Lifestyle Modification: Sodium restriction, DASH diet, physical activity, weight loss, alcohol restriction, smoking cessation Sodium restriction, DASH diet, physical activity, weight loss, alcohol restriction, smoking cessation Expect to use combination therapy Expect to use combination therapy ACE inhibitor, ARB, diuretic ACE inhibitor, ARB, diuretic

33. 1.Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat and salt in accordance with the DASH diet 2. Regular physical activity: optimum 20-60 minutes of moderate cardiorespiratory activity 3-5/week or more 3. Reduction in alcohol consumption in those who drink excessively (<2 drinks/ day) 4. Weight loss (> 5 Kg) in those who are over weight (BMI>25) 5. Smoke free environment Lifestyle Recommendations

34. Follow a Healthy Eating Plan Blood Pressure can be lowered by: Blood Pressure can be lowered by: Following the DASH eating plan Following the DASH eating plan Reducing the amount of sodium intake Reducing the amount of sodium intake Combination of both gives the biggest benefit Combination of both gives the biggest benefit

35. Dietary Approaches to Stop Hypertension: DASH Diet Rich in fruits, vegetables, low fat dairy foods, and low in fat, total fat, cholesterol and salt Rich in fruits, vegetables, low fat dairy foods, and low in fat, total fat, cholesterol and salt The low sodium DASH diet evaluated the effect of reducing sodium intake in combination with a DASH diet. BP fell 11.4/5.5 mmHg in hypertensive persons compared to 3.5/2.1 in normotensives The low sodium DASH diet evaluated the effect of reducing sodium intake in combination with a DASH diet. BP fell 11.4/5.5 mmHg in hypertensive persons compared to 3.5/2.1 in normotensives Source: Appel et al. N Engl J Med 1997;336:1117. The DASH eating plan is available at www.nhlbi.nih.gov/health/public/heart/hbp /dash The DASH eating plan is available at www.nhlbi.nih.gov/health/public/heart/hbp /dash

36. Sodium Reduction For hypertensive patients For hypertensive patients Ask how much fresh foods and unprocessed foods they consume Ask how much fresh foods and unprocessed foods they consume Ask about processed and fast foods Ask about processed and fast foods  dietary sodium to target range:  dietary sodium to target range: 65-100mmol/day (2/3-1 tsp table salt/day). 65-100mmol/day (2/3-1 tsp table salt/day). Counsel to avoid excessive salt intake Counsel to avoid excessive salt intake Avoid fast and processed foods Avoid fast and processed foods minimize use of salt at the table and during cooking minimize use of salt at the table and during cooking Up to 30% of hypertension can be attributed to high sodium diets Up to 30% of hypertension can be attributed to high sodium diets

37. Canadian Stroke Strategy 2010 Recommendation: Sodium Recommended Daily sodium intake: 9-50 years:1500mg 9-50 years:1500mg 50-70 years:1300mg 50-70 years:1300mg > 70 years:1200mg > 70 years:1200mg Daily upper limit:2300mg

38. Tips to Reduce Salt Buy fresh, plain frozen or canned “with no salt added” vegetables Buy fresh, plain frozen or canned “with no salt added” vegetables Use fresh poultry, fish and lean meat, rather than canned or processed Use fresh poultry, fish and lean meat, rather than canned or processed Use herbs, spices & salt-free seasoning blends Use herbs, spices & salt-free seasoning blends Cook rice, pasta & hot cereal without salt. Cut back on instant or flavoured dishes. Cook rice, pasta & hot cereal without salt. Cut back on instant or flavoured dishes. Cut back on frozen dinners, pizza, packaged mixes, canned soups and salad dressing Cut back on frozen dinners, pizza, packaged mixes, canned soups and salad dressing Rinse canned foods Rinse canned foods Limit cured foods (bacon and ham), foods packed in brine (pickles, pickled foods) & condiments. Limit cured foods (bacon and ham), foods packed in brine (pickles, pickled foods) & condiments.

39. Physical Activity Evidence that mild hypertension can be treated with moderate physical activity alone Evidence that mild hypertension can be treated with moderate physical activity alone Of particular note: Of particular note: Significant  BP after 4 to 5 wks Significant  BP after 4 to 5 wks Effect persisted as long as patient exercised, reversible if training stopped Effect persisted as long as patient exercised, reversible if training stopped Daily physical activity not essential to get antihypertensive effect Daily physical activity not essential to get antihypertensive effect Age, race, sex has no effect on the benefit derived Age, race, sex has no effect on the benefit derived

40. Physical Activity The Heart and Stroke Foundation recommends that clients be prescribed exercise to reduce blood pressure The Heart and Stroke Foundation recommends that clients be prescribed exercise to reduce blood pressure Think FITT Think FITT Frequent (4 or more days of the week) Frequent (4 or more days of the week) Intensity (moderate) Intensity (moderate) Time (optimum 30-60 minutes) Time (optimum 30-60 minutes) Type (dynamic – walking, cycling, swimming) Type (dynamic – walking, cycling, swimming) Physical activity should be prescribed as adjunctive therapy for those patients prescribed pharmacotherapy Physical activity should be prescribed as adjunctive therapy for those patients prescribed pharmacotherapy

41. Drink Alcohol in Moderation Low risk alcohol consumption Women: maximum of 9 standard drinks/week Men: maximum of 14 standard drinks/week 0-2 standard drinks/day A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or 12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).

42. Aim For A Healthy Weight Blood Pressure rises as body weight increases Blood Pressure rises as body weight increases Losing even 5-10 lbs can lower your BP Losing even 5-10 lbs can lower your BP Two key measures used: Two key measures used: Waist circumference: Waist circumference: <80 cm for women and <94 cm for men <80 cm for women and <94 cm for men BMI - weight (kg) / height (m2) BMI - weight (kg) / height (m2) an approximation of total body fat. an approximation of total body fat. Healthy BMI: 18.5-24.9 kg/m2 Healthy BMI: 18.5-24.9 kg/m2

43. Weight Management Being overweight puts extra strain on the body as it creates extra tissue that must be supplied with blood Being overweight puts extra strain on the body as it creates extra tissue that must be supplied with blood Greater chance of developing: Greater chance of developing: high blood pressure high blood pressure diabetes diabetes high cholesterol high cholesterol

44. Smoking Stroke risk may be doubled in smokers Stroke risk may be doubled in smokers Smoking: Smoking: raises blood pressure raises blood pressure thickens the blood thickens the blood speeds up hardening of the arteries speeds up hardening of the arteries decreases HDL decreases HDL

45. Suggested Smoking Cessation Approach: Using the Stages of Change Pre-contemplation Pre-contemplation Not thinking seriously about quitting Not thinking seriously about quitting Goal: Encourage smoker to think about the personal impact of smoking Goal: Encourage smoker to think about the personal impact of smoking Contemplation Contemplation Thinking about quitting in the next six months Thinking about quitting in the next six months Goal: Discuss health effects of smoking and benefits of quitting. Offer follow-up and set date for next appointment. Goal: Discuss health effects of smoking and benefits of quitting. Offer follow-up and set date for next appointment. Preparation Preparation Preparing to quit in next month and has tried to quit in the past year Preparing to quit in next month and has tried to quit in the past year Goal: Assist the patient to select the best plan to be smoke free. Set date for next appointment. Goal: Assist the patient to select the best plan to be smoke free. Set date for next appointment.

46. Suggested Approach, cont… Action Action Receptive to cessation advice. Actively trying to quit. Receptive to cessation advice. Actively trying to quit. Goal: Assist the patient in efforts to quit. Discuss relapse prevention and replacing smoking with other behaviours (physical activity, hobbies, etc.) Set date for next appointment. Goal: Assist the patient in efforts to quit. Discuss relapse prevention and replacing smoking with other behaviours (physical activity, hobbies, etc.) Set date for next appointment. Maintenance Maintenance Continues to remain smoke free for more than six months. May “slip” and have occasional cigarette. Continues to remain smoke free for more than six months. May “slip” and have occasional cigarette. Goal: Congratulate patient. Assist patient to find strategies to prevent relapse. Goal: Congratulate patient. Assist patient to find strategies to prevent relapse. Source: Prochaska JO, Diclemente CC. Understanding and using the stages of change. Program Training & Consultation Centre, Ontario Tobacco Strategy, 1995.

47. Canadian Stroke Strategy 2010 Recommendation: Smoking Combination of pharmaological therapy and behavioral therapy should be considered Combination of pharmaological therapy and behavioral therapy should be considered 3 classes of agent should be considered as first line therapy: 3 classes of agent should be considered as first line therapy: Nicotine replacement Nicotine replacement Bupropion Bupropion Varenicline Varenicline

48. Smoking Two years after smoking cessation - stroke risk is decreased Two years after smoking cessation - stroke risk is decreased Five years after smoking cessation - stroke risk is similar to that of a non-smoker Five years after smoking cessation - stroke risk is similar to that of a non-smoker It is never too late to quit!!! It is never too late to quit!!!

49. Stress Management “There is no evidence that stress management prevents hypertension, but there is some evidence that stress management can reduce BP in hypertensive patients.” “There is no evidence that stress management prevents hypertension, but there is some evidence that stress management can reduce BP in hypertensive patients.” Consider how stress contributes to hypertension (e.g., unhealthy lifestyle choices such as smoking, drinking and binge eating) Consider how stress contributes to hypertension (e.g., unhealthy lifestyle choices such as smoking, drinking and binge eating) Consider exercise as a treatment for stress management Consider exercise as a treatment for stress management In patients whom stress is an important issue, individualized cognitive behavioural interventions are more likely to be effective when relaxation techniques are employed In patients whom stress is an important issue, individualized cognitive behavioural interventions are more likely to be effective when relaxation techniques are employed CMAJ 1999;160 (9 Suppl):S47 & S48.

50. Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults InterventionAmountSBP/DBP Reduce foods with added sodium 1.8g or 78 mmol/d -5.1 / -2.7 Weight loss per kg lost -1.1 / -0.9 Alcohol intake - 3.6 drinks/day -3.9 / -2.4 Aerobic exercise 120-150 min/week -4.9 / -3.7 Dietary patterns DASH diet Hypertensive Normotensive -11.4 / -5.5 -3.6 / -1.8 Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat hypertension Padwal R. et al. CMAJ ･ SEPT. 27, 2005; 173 (7) 749-751 Source: 2008 CHEP Recommendations

51. Hypercholesterolemia: Using Statins for Secondary Prevention of Stroke Lipid-lowering trials using statins have shown benefit in decreasing progression and/or inducing regression of carotid artery plaque Lipid-lowering trials using statins have shown benefit in decreasing progression and/or inducing regression of carotid artery plaque Lipid-lowering trials using statins for secondary prevention (of CHD) have shown benefit in stroke prevention Lipid-lowering trials using statins for secondary prevention (of CHD) have shown benefit in stroke prevention

52. Why Should Statins Prevent Ischemic Stroke? Lipid effects = LDL lowering Lipid effects = LDL lowering Target LDL-C < 2.0 mmol/L (in stroke patients) Target LDL-C < 2.0 mmol/L (in stroke patients) Non-lipid effects = Non-lipid effects = Stabilizing plaques Stabilizing plaques Improving endothelial function Improving endothelial function Decreasing inflammation Decreasing inflammation Decreasing platelet aggregation Decreasing platelet aggregation Directly lowering blood pressure Directly lowering blood pressure Decreasing cardiac emboli Decreasing cardiac emboli

53. Cholesterol Lowering----- Interventions to Control Cholesterol: Interventions to Control Cholesterol: Diet Diet Exercise Exercise Smoking Cessation Smoking Cessation Alcohol Reduction Alcohol Reduction Glycemic Control Glycemic Control Medications Medications

54. Secondary Stroke Prevention Evaluate the Event : Identify Events requiring Urgent intervention / Identify cause Identify Events requiring Urgent intervention / Identify cause TIA / Minor Stroke Risk Assessment TIA / Minor Stroke Risk Assessment Investigations Investigations CT, MRI, ECG, Carotid imaging, echocardiogram CT, MRI, ECG, Carotid imaging, echocardiogram Implement Interventions Carotid Endarterectomy Carotid Endarterectomy Stroke Prevention Clinic Stroke Prevention Clinic Initiate Medications Antiplatelets /anticoagulants, ACE-I, Diuretics, ARB, statins Antiplatelets /anticoagulants, ACE-I, Diuretics, ARB, statins Modify Stroke Risk Factors Vascular Risk Factors Vascular Risk Factors Behavioral/Lifestyle Risk Factors Behavioral/Lifestyle Risk Factors

55. Impact of Prevention Strategies Do they work ?

56. *Based on estimated 700,000 annual strokes. Gorelick PB. Arch Neurol. 1995;52:347-355. Gorelick PB. Stroke. 2002;33:862-875. 0100,000200,000300,000400,000 360,500 146,000 89,500 68,500 34,500 Number of Preventable Strokes* Hypertension Cholesterol Cigarettes Atrial Fibrillation Heavy Alcohol Use How Many Strokes Annually Can Be Prevented by Risk-Factor Control? 25,000 10,000 5000 6400 2500

57. BRAIN ATTACK STROKE CAN BE PREVENTED!