1. Preventing Strokes One at a Time Putting It All Together 2009

2. 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.

3. Patient #1 Mrs. Ivanna Nomore Insert Picture

4. 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

5. Four Step Process  Evaluate the Event  Initiate Medications  Implement Interventions  Modify Stroke Risk Factors Adapted from APSS, February 2009

6. 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

7. Evaluate the Event: Mrs. Ivanna Nomore  ECG: Normal sinus rhythm  Neuro exam: Normal  BP: 146/95  CT: Normal  Blood work:  INR= 0.9, BUN= 5.5mmol/L, Cr = 80umol/L Exam and Investigations

8. Evaluate the Event: Risk of stroke?  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 Is Mrs. Ivanna Nomore at risk of a stroke? Urgency? CMAJ 2008;179(12 Suppl):E1-E93.

9. Evaluate the Event: Timing of Tests Diagnostic TestEmergentUrgentSemiurgent Assessment by medical specialist trained in stroke 24 h7 d30 d CT or MRI24 h7 d30 d Carotid Imaging24 h7 d30 d ECG24 h7 d30 d CMAJ 2008;179(12 Suppl):E1-E93 #3.2 Canadian Best Practice Recommendations for Stroke Care, 2008

10. 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

11. Acute Interventions & Management: Mrs. Ivanna Nomore Next Steps…  Initiate Medications  Which medications? o Patient was started on ASA in ED  Implement Interventions

12. Acute Interventions and Management: Mrs. Ivanna Nomore AntiplateletDosageConsiderations ECASA81-325 mg OD (adults) 3-5 mg/kg/day children If aspirin naïve- load with 160mg then 81 mg OD (adults) Aggrenox (ASA/SR dypiridamole) 25/200 mg BIDPossible severe headache x first 5-7 days Plavix (Clopidogrel) 75 mg ODConsider loading with 300 mg CMAJ 2008;179(12 Suppl):E1-E93 #3.2

13. Acute Interventions and Management: Mrs. Ivanna Nomore (cont’d) Other tests ordered:  Echocardiogram  Carotid Doppler  Fasting Blood Glucose  Fasting Lipid Profile Results:  No thrombosis  Left carotid stenosis <50%  6.5 mmol/L  T-Chol= 5.7 mmol/L  HDL= 0.8 mmol/L  LDL = 3.6 mmol/L  TG= 1.5 mmol/L

14. Next Steps…  Initiate Medications  Should you consider any other medications?  Implement Interventions:  Based on carotid Doppler results what is next?

15. 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.

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

17. 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

18. 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?

19. Implement Interventions  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%. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.7a

20. 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?

21. Medication Management 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 Canadian Best Practice Recommendations for Stroke Care, 2008

22. Modify Stroke Risk Factors Mrs. Ivanna Nomore

23. Modify Stroke Risk Factors: Mrs. Ivanna Nomore  Hypertension  Dyslipidemia  Smoking  Diabetes  Heart Disease (Atrial Fibrillation)  Obesity  Dietary Habits  Physical Inactivity  Excess alcohol intake √ √ ? ? What are her modifiable risk factors?

24. 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

25. Putting it all together: Local Resources

26. Patient #2 Mr. Les Feeling Insert Picture

27. 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

28. 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

29. 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

30. 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

31. 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

32. Putting it all together: Mr. Les Feeling It’s not emergent! Are we done? Yes No

33. What are Mr. Les Feeling’s Risk Factors?  Hypertension  High cholesterol  Smoking  Diabetes  Heart Disease (Atrial Fibrillation)  Obesity  Physical Inactivity  Excess alcohol intake √ PreHTN √

34. Modify Stroke Risk Factors: Smoking 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 Canadian Best Practice Recommendations for Stroke Care, 2008

35. 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?

36. Putting it all together: Mr. Les Feeling 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 Warning Signs of Stroke, (HSFC, 2006)

37. Putting it all together: System Resources  Local Systems for rapid evaluation and triage of TIA and minor stroke patients?

38. 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.cawww.canadianstrokestrategy.ca

39. Canadian Best Practice Recommendations for Stroke Care, updated 2008 www.canadianstrokestrategy.ca