Preventing Strokes One at a Time Acute Interventions and Management 2009

Acute Interventions & Management Upon completion, participants will be able to:  State the goal of managing patients with medications following a transient ischemic attack (TIA) or minor stroke  Teach patients about their medications and the importance of medication adherence  Practice according to the Canadian Best Practice Recommendations for Stroke Care as they relate to interventional & medication management Learning Objectives

Implement Interventions  3.2. Acute management of TIA and minor stroke  Patients who present with symptoms suggestive of minor stroke or TIA must undergo a comprehensive evaluation to confirm the diagnosis and begin treatment to reduce the risk of major stroke as soon as it is appropriate to the clinical situation. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #3.2

Implement Interventions Medication Management  Antihypertensives  ACEI (Angiotensin Converting enzyme)  ARB (Angiotensin Receptor Blocker)  Diuretics  Calcium Channel Blockers  Lipid lowering agents  Statins  Antithrombotic  Antiplatelet  Anticoagulant (Atrial fibrillation)  Optimize diabetes management Interventional Procedures  Carotid Stenosis  Carotid Endarterectomy  Carotid Artery Stenting

Medication Management

 Goals of managing patients with medications following a TIA or minor stroke :  Minimize plaque formation  Stabilize existing plaque  Lowering risk of emboli in appropriate individuals  Medications include :  Antihypertensive  Statin  Antithrombotic

Blood Pressure & Antihypertensives

Blood Pressure  Hypertension is the most significant modifiable risk factor for stroke  Hypertension contributes up to 75% of all strokes Injury to the blood vessel walls ↓ Scar is formed ↓ Build-up of plaque in arteries ↓ Atherosclerosis Fragile arteries Left Ventricle dysfunction

Blood Pressure 2.2 Blood Pressure Assessment  All persons at risk for stroke should have their blood pressure measured at each healthcare encounter but no less than once annually.  Proper standardized techniques, as described by the Canadian Hypertension Education Program, should be followed for blood pressure measurement  Patients found to have elevated blood pressure should undergo thorough assessment for the diagnosis of hypertension following the current guidelines of the Canadian Hypertension Education Program.  Patients with hypertension or at risk for hypertension should be advised on lifestyle modifications. CMAJ 2008;179(12 Suppl):E1-E93. Canadian Best Practice Recommendations for Stroke Care, 2008

Blood Pressure 2.2 Blood Pressure Management  The Canadian Stroke Strategy recommends target blood pressure levels as defined by CHEP guidelines for prevention of first stroke, recurrent stroke and other vascular events.  RCTs have not defined the optimal time to initiate blood pressure lowering therapy after stroke/TIA. It is recommended that blood pressure lowering treatment be initiated (or modified) prior to discharge from hospital. For patients with non-disabling stroke or TIA not requiring hospitalization, it is recommended that blood pressure lowering treatment be initiated (or modified) at the time of first medical assessment. CMAJ 2008;179(12 Suppl):E1-E93. Canadian Best Practice Recommendations for Stroke Care, 2008

Blood Pressure  Blood pressure is to be assessed at all appropriate visits  Encourage patients to use appropriate devices and proper techniques for home BP measuring  Home measurement aids blood pressure control  Helps to diagnose white coat and masked hypertension  Improves medication adherence  Aids in faster diagnosis 2009 Canadian Hypertension Education Program Recommendations Assessment Highlights (CHEP, 2009)

Blood Pressure Management Highlights, (CHEP, 2009)  Treat to target  <140/90 mmHg  <130/80 mmHg (diabetes or chronic kidney disease)  Age should not be a consideration in treatment  Sustained lifestyle modification to manage overall cardiovascular risk  Self efficacy and engagement are key to adherence  Treat hypertension with multiple antihypertensives  Reduce dietary sodium  Canadian Hypertension Education Program Recommendations

Blood Pressure Treatment in TIA/Previous stroke (CHEP, 2009)  Initial therapy:  Treatment with combination of ACEI & diuretic preferred  Choice of agent will depend on comorbidities o Other choices: ARB, Calcium Channel Blocker, Beta Blockers  Second–line therapy:  Combinations of additional agents  Notes/Cautions:  Recommendations do not apply to acute stroke  BP reduction reduces CV events in stable patients  Combination of an ACEI & ARB is not recommended 2009 Canadian Hypertension Education Program Recommendations

Blood Pressure Patient Education: Angiotensin Converting Enzyme Inhibitor  Take same time every day  Contraindicated in patients with renal stenosis  May increase creatinine, urea and potassium  May have a persistent, dry cough  Can cause angioedema (1/500)  Other S/E:  Dizziness, feeling faint  Swelling of feet  Diarrhea  Taste disturbance  HA

Blood Pressure Patient Education: Angiotensin II Receptor Blockers  Well tolerated  Contraindicated in patients with renal stenosis  May increase creatinine, urea and potassium

LIPIDS & STATINS “High cholesterol and lipids in the blood are associated with a higher risk of both stroke and heart attack.” CMAJ 2008;179(12 Suppl):E1-E93 #2.3.

Lipids  What is a “lipid profile”  Made up of cholesterol and triglycerides o LDL: “bad” cholesterol o HDL: good cholesterol o Triglycerides: “bad”  Impacted by gender, age, genetics, lifestyle and eating habits

Lipids  Fasting lipid levels (TC,TG,LDL-C,HDL-C) should be measured every 1-3 years for all men 40 years or older and post menopausal women and/or 50 years or older.  More frequent testing should be done for patients with abnormal values or if treatment is initiated.  Adults at any age should have their blood lipid levels measured if they have a history of diabetes, smoking, hypertension, obesity, ischemic heart disease, renal vascular disease, peripheral vascular disease, ischemic stroke, TIA or symptomatic carotid stenosis. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.3a 2.3a Lipid Assessment

Lipids Canadian Best Practice Recommendations for Stroke Care 2.3b. Lipid Management  Ischemic stroke patients with LDL-C of >2mmol/L should be managed with lifestyle modification and dietary guidelines.  Statin agents should be prescribed for most patients who have had an ischemic stroke or TIA to achieve current recommended lipid levels. CMAJ 2008;179(12 Suppl):E1-E93.

Lipids Statins  First line agents for dyslipidemia  Reduce stroke risk by 25-30%  Target LDL-C< 2.0 mmol/L  Decrease progression and/or induce regression of carotid artery plaque  Treatment based on assessment of absolute risk of CVD not just LDL value Heart Protection Study

Lipids How do statins prevent ischemic stroke?  Lipid effects  LDL lowering  Non-Lipid effects  Stabilizing plaques  Improving endothelial function  Decreasing inflammation  Decreasing platelet aggregation  Directly lowering blood pressure  Decreasing cardiac emboli

Lipids Statins: Patient Education Points  Take once a day with largest meal in evening  May be prescribed when cholesterol levels are normal  Blood work required for follow-up  May interact with antidepressants, antibiotics & immunosuppressants  Avoid grapefruit juice  Possible side effects:  Mild nausea, diarrhea, constipation  Some muscle pain/weakness is normal (2-10%)  Extreme muscle pain/weakness (serious but rare)

Antithrombotics Antiplatelets Anticoagulants

2.5 Antiplatelet Therapy Canadian Best Practice Recommendations for Stroke Care, 2008  All patients with ischemic stroke or transient ischemic attack should be prescribed antiplatelet therapy for secondary prevention of recurrent stroke unless there is an indication for anticoagulation.  ASA, combined ASA (25 mg) and extended-release dipyridamole (200mg) or Clopidogrel may be used depending on the clinical circumstances. CMAJ 2008;179(12 Suppl):E1-E93 #2.5

2.5 Antiplatelet Therapy continued  For adult patients on ASA, the usual maintenance dosage is mg/day and in children with stroke the usual maintenance dosage of ASA is 3- 5 mg/kg/day for the prevention of recurrent stroke  Long term combination of ASA & Clopidogrel are not recommended for secondary stroke prevention Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.5

Aspirin: Patient Education Points  Take one pill, once a day, everyday  More is not better  Most common side effects include  GI upset (take with meals, use EC-ASA)  bruise easier  bleed longer  Consult a doctor immediately if you have unusual or excessive bleeding

Aggrenox: Patient Education  Do not chew or crush  1/5 people will have a headache in first 5 days  Always have a “plan B”  If by the 5 th day HA is intolerable, call the physician and resume ASA  Other side effects:  GI upset (take with food or water)  Bleeding

Clopidogrel: Patient Education  Take once a day, every day  Best to take with meals  Side effects:  Usually mild & improve on their own  GI upset  Bleeding  Skin rash

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 (target INR of 3.0 for mechanical cardiac valves, range ) if they are likely to be compliant 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

Antithrombotic therapy in atrial fibrillation  Patients with atrial fibrillation properly anticoagulated = 68% RRR in recurrent stroke Cochrane, 2003  Optimal time to begin anticoagulation varies but should be prior to discharge

Warfarin: Patient Education Points  Doses of warfarin vary based on INR  INR testing  Initially every few days  Repeat 5-7 days after changing the dose of any drug  Take same time every day  Patient compliance essential to therapeutic levels  Avoid contact sports; report falls/unusual bleeding  Avoid drastic changes in diet/eating habits  Keep dietary vitamin K consistent in diet  Alcohol may affect action of warfarin

Adherence Those who self administer their medications typically take less than ½ of the prescribed doses Complex issue affected by patient factors, physician based factors and health care factors

Implement Interventional Procedures  Options for the TIA patient with carotid stenosis  Carotid Endarterectomy  Carotid Stenting

2.7a Symptomatic Carotid Stenosis  Patients with transient ischemic attack or nondisabling stroke and ipsilateral 70-99% internal carotid artery stenosis (measured on a catheter angiogram or by 2 concordant non invasive imaging modalities) should be offered carotid endarterectomy within 2 weeks of the incident TIA or stroke unless contraindicated. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.7a

2.7a Symptomatic Carotid Stenosis cont.  Carotid endarterectomy is recommended for selected patients with moderate (50 to 69%) symptomatic stenosis and these patients should be evaluated by a physician with expertise in stroke management  Carotid endarterectomy should be performed by a surgeon with a known perioperative morbidity and mortality of <6%.  Carotid stenting may be considered for patients who are not operative candidates for technical, anatomical or medical reasons.  Carotid endarterectomy is contraindicated for patients with mild (<50%) stenosis. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.7a

2.7b Asymptomatic Carotid Stenosis  Carotid endarterectomy may be considered for selected patients with asymptomatic 60-99% carotid stenosis.  Patients should be less than 75 years old with a surgical risk 5 years, and be evaluated by a physician with expertise in stroke management. Canadian Best Practice Recommendations for Stroke Care, 2008 CMAJ 2008;179(12 Suppl):E1-E93 #2.7b

Studies to Support Acting Fast  EXPRESS Study (Rothwell et al. Lancet; 2007:370: )  Studied the effect of providing urgent treatment with existing secondary stroke preventative strategies to TIA/minor strokes not admitted to hospital  Result: 80% reduction in risk of recurrent stroke in 90 days  SOS-TIA (Lavallee et al, 2007, Neurology)  Suspected TIAs admitted to 24 hr clinic, investigations completed within 4 hrs of admission  Results: 90 day stroke rate=1.24% predicted rate estimated from the ABCD2 score was 5.92%

Systems/Strategies Needed?  Role of a stroke prevention clinic is key to evaluation and triage of all TIA and minor stroke patients….treated surgically and medically  A process is needed to triage TIA and stroke patients urgently  Timely investigations need to be completed to determine etiology  Appropriate medications need to be initiated  Access to timely carotid intervention is required when implicated CMAJ 2008;179(12 Suppl):E1-E93.

An Approach to Secondary Stroke Prevention Four Step Process  Evaluate the Event √  Initiate Medications √  Implement Interventions √  Modify Stroke Risk Factors APSS, February 2009

Canadian Best Practice Recommendations for Stroke Care, updated