1. Risky Business: Strategies to Prevent Stroke Presented by: Melanie Keiffer ANP-BC, MSN, CCRN Against All Odds: Lifestyle Changes for Stroke Prevention

2. Objectives Describe primary prevention strategies to reduce the risk of stroke. Review secondary prevention measures to prevent the occurrence of a stroke. Identify patients who are at greatest risk for stroke. Describe tertiary measures to address the prevention of recurrent stroke.

3. Epidemiology of Stroke 800,000 Americans/year experience stroke. 3 rd leading cause of death. Leading cause of functional impairment: –1 in 5 stroke survivors require institutional care. –1 in 3 stroke survivors are permanently disabled. Major stroke is viewed as “worse than death”. Affects patients, families and caregivers

4. Primary Prevention Activities designed to prevent the onset of stroke. Most effective way to prevent stroke is to avoid risk factors. AHA/ASA Guidelines: focus on an individual patient-oriented approach to stroke prevention.

5. Non-modifiable Risk Factors Age Sex Low Birth Weight Race Genetic Factors

6. Modifiable Risk Factors Hypertension Cigarette Smoking Diabetes Dyslipidemia Atrial Fibrillation Obesity Physical Inactivity

7. Hypertension Major risk: infarct and ICH JNC-7 Pre-hypertension: 12-139/80-89 BP Goals: < 140/90 DM or renal: < 130/80

8. Cigarette Smoking Smoking 1 cigarette increases heart rate, mean BP, CI, decreases arterial distensibility. Active and passive exposure associated with development of atherosclerosis. Triples risk of cryptogenic stroke in patient without atherosclerosis or cardiac source of stroke. Smoking cessation: counseling, nicotine replacement, medications, address at EVERY patient encounter.

9. Diabetes Treat hypertension: ACEI or ARB. Treat with a statin. May consider use of fibrates: lowers trigs/increases HDL. Consider adding aspirin if high CVD risk.

10. Dyslipidemia Statin: LDL goal < 100. LDL goal < 70 if CHD risk. Diet, weight management, physical activity. Can’t tolerate statins: fibrates, bile sequestrants, niacin, ezetimide.

11. Atrial Fibrillation Pulse check in outpatient setting. Warfarin (INR goal: 2-3). Recently approved: dabigatran, direct thrombin inhibitor. ASA for antiplatelet if can’t take coumadin in low risk patients. High risk patients who can’t take coumadin: ASA/Plavix.

12. Obesity/Physical Inactivity BMI 30= obese. Active lifestyle=30% reduced risk of stroke or death. Protective effect: reduces BP, blood sugar, cholesterol, excess body weight. 150 minutes/week moderate intensity or 75 minutes vigorous aerobics activity.

13. Modifiable Risk Factors Other Cardiac Conditions Asymptomatic Carotid Stenosis Sickle Cell Disease Post Menopausal Hormone Therapy Oral Contraceptives

14. To Screen or Not to Screen Obtain family history. Genetic screening not recommended. Screening for unruptured aneurysms not generally recommended (non-invasive screening > 2 relatives with SAH/aneurysms reasonable).

15. Less Well Documented Risks Migraine Metabolic Syndrome Alcohol Consumption Drug Abuse Sleep Disordered Breathing Hyperhomocysteinemia Hypercoagulability Inflammation and Infection

16. Case Studies

17. Case # 1 18 year old female J.L. CC: Admitted to ED with acute onset LUE/LLE 0/5 weakness. BP 110/70 mmHg. Grade II/VI systolic murmur inferior left side of the sternum. ROS: chronic diarrhea, abdominal pain, poor appetite and abdominal distension.

18. Lab Workup J.L. CRP negative, sed rate 19, B12 and folate levels were normal. PT/PTT 13.6/29. Fibrinogen, protein C, protein S, antithrombin levels WNL. HIV, lupus anticoagulants, antinuclear antibody, anti-doublestranded DNA, anticardiolipin antibody (Ig)G and (Ig)M serologies negative, Factor V Leiden and prothrombin GA20210 mutations not detected.

19. MRI/MRA: Acute R MCA stroke with occlusion of the right middle cerebral artery

20. TTE with Bubble/TEE Dilated Cardiomyopathy No Thrombus No Patent Foramen Ovale

21. Clinical Outcome An intestinal biopsy revealed celiac disease. Gluten-free diet and rehabilitation with PT/OT resulted in regression of symptoms on day 18. Muscle strength at week 7 was 5/5 and neurologic exam was normal. Etiology of stroke: celiac disease, dilated cardiomyopathy

22. Case # 2: 69 year old male T.M. C.C. slurring words x 1 hour, “left arm felt a bit heavy and clumsy”, symptoms are now resolved. PMH: hypertension, high cholesterol, CAD. T.M. is admitted to the hospital. BP on admit, 160/102, Initial HCT negative. Dx: TIA, r/o stroke. MRI/MRA, ECG, 2D echo, labs, neurology consult ordered.

23. ABCD2 Score Age >/= 60 = 1 point Blood pressure systolic > 140 mm Hg and/or diastolic >/= 90 mm Hg = 1 point Clinical features (unilateral weakness = 2 points, speech disturbance without weakness = 1 point, other symptoms = 0 points) Duration of symptoms in minutes >/= 60 = 2 points, 10-59 = 1 point, < 10 = 0 points Diabetes= 1 point

24. T.M.’s ABCD2 Score=6 According to the validation study, –6-7 points: –2-Day Stroke Risk: 8.1%. –7-Day Stroke Risk: 11.7%. –90-Day Stroke Risk: 17.8%.

25. MRA of Neck Reveals Loss of flow signal in the proximal right ICA, significant carotid artery stenosis (MRA may overestimate). Cerebral angio= 79% stenosis.

26. Clinical Outcome MRI showed pinpoint lacunes. T.M. was referred to a local hospital (NIH)-sponsored CREST, and he was randomized to Carotid Endarterectomy. He underwent a successful right CE and was free of symptoms at 3 months after surgery.

27. Options for Carotid Stenosis Asymptomatic CS: screen for treatable risk factors, lifestyle changes, medical therapy. Carotid artery stenting in highly selected asymptomatic patients with > 70% stenosis on CDUS. Advantage of stenting over medical therapy is not established.

28. Case # 3: 40 year old female S.F. CC: Acute onset aphasia 2 hrs PTA, Rt. Pronator drift, NIH=3. PMH: DVT at age 23, htn, BMI 31, 17 pack/year smoker, on OC. Admitted to hospital: BP 128/88, IV tPA, admitted to hospital for stroke workop Dx: Left MCA stroke.

29. Oral Contraceptives and Stroke Stroke risk associated with OC is low. OC’s may be harmful in women with co-morbid factors (age, smoking, hypertension, hypercholesterolemia and prothrombotic mutations). Increased pro-coagulant effects with higher doses of estrogrens.

30. Clinical Outcome S.F. MRI/MRA: Left MCA ischemic stroke 2 D echo bubble negative, CDUS negative, LDL 148, HgbA1C 5.9%, negative hypercoagulable workup. D/C on day 3, NIH=0. Astute follow-up for risk factor reduction: antiplatelet therapy, statin, smoking cessation, weight loss, DASH diet, exercise.

31. Aspirin and Stroke Prevention ASA for CV prophylaxis is recommended for persons whose risk is high and outweighs risk of treatment. ASA 81 mg daily can be useful for prevention of first stroke among women who are high risk. ASA is not useful for persons at low risk.

32. Primary Prevention in the ED Smoking cessation programs and interventions are recommended. ID atrial fib and evaluate for anticoagulation. Screen for hypertension. Referral for drug or etoh abuse. Brief interventions/referrals for treatment of risk factors may be useful.

33. Assessing Risk of First Stroke Stroke risk assessment goal: identify people who aren’t aware they are at risk. Risk assessment tools (optimal tool does not yet exist). Community stroke-screening programs.

34. Secondary Prevention Lifestyle changes: smoking cessation, diet, exercise Hypertension control Diabetes control Atrial fibrillation control Complying with medication regimens Lowering cholesterol

35. Tertiary Prevention Aimed at the prevention of recurrent stroke. Overlap with secondary prevention: carotid ultrasonography, transthoracic echocardiography, Holter monitoring, MRI/MRA,TEE, CTA, carotid endarterectomy. Rehabilitation: minimizing disability with the goals of improving quality of life.

36. Clinical Pearls Take Action! Translate guidelines into practice: EMR, computer based reminder systems, incorporate screening and reminders into flowsheets. Discuss adherence/compliance to recommendations at every patient interaction. Measure outcomes: audit and feedback. Celebrate success!

38. References Larry B. Goldstein, MD, FAHA, Chair; Cheryl D. Bushnell, MD, MHS, FAHA, Co-Chair; Robert J. Adams, MS, MD, FAHA; Lawrence J. Appel, MD, MPH, FAHA; Lynne T. Braun, PhD, CNP, FAHA; Seemant Chaturvedi, MD, FAHA; Mark A. Creager, MD, FAHA; Antonio Culebras, MD, FAHA; Robert H. Eckel, MD, FAHA; Robert G. Hart, MD, FAHA; Judith A. Hinchey, MD, MS, FAHA; Virginia J. Howard, PhD, FAHA; Edward C. Jauch, MD, MS, FAHA; Steven R. Levine, MD, FAHA; James F. Meschia, MD, FAHA; Wesley S. Moore, MD, FAHA; J.V. (Ian) Nixon, MD, FAHA; Thomas A. Pearson, MD, FAHA on behalf of the American Heart Association Stroke Council Council on Cardiovascular Nursing Council on Epidemiology and Prevention Council for High Blood Pressure Research, Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Guidelines for the Primary Prevention of Stroke; Stroke. 2011;42:517-584 available @ http://stroke.ahajournals.org/cgi/content/short/42/2/517http://stroke.ahajournals.org/cgi/content/short/42/2/517