Stroke Prevention - The Intersection of Cardiology & Neurology

Stroke Prevention - The Intersection of Cardiology & Neurology

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Description: Dyslipidemia: - Statin therapy if significant 10-year stroke risk. Nonstatins if statins not tolerated but no established efficacy. Other Cardiac: - Mitral stenosis with embolic event– Anticoagulation.

Mitral stenosis with LA thrombus – Anticoagulation. Aortic mechanical valve – Warfarin (INR 2-3) + aspirin 81 mg, With risk factors (INR 2.5-3.5) +ASA 81 mg. Other mechanical valves (INR 2.5-3.5)+ASA 81 mg.

 
Author: Michael R.K. Jacoby MD  | Visits: 107 | Page Views: 393
Domain:  Medicine Category: Therapy 
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Contents:
Stroke Prevention 2016

Intersection of Cardiology & Neurology
Summary of Recommendations
Michael R.K. Jacoby, MD, FAHA
Medical Director, Mercy Stroke Center

Stroke Disclosures
•  Speaker for Boehringer-Ingelheim

Stroke 2016
Summary of Recommendations
•  American Stroke Association
•  American Heart Association
•  American Academy of Neurology
•  Jacoby

Stroke 2016
Summary Content
•  Primary Stroke Prevention
•  Acute Stroke Treatment
•  Secondary Stroke Prevention

Primary Stroke Prevention
2016

Healthful Lifestyles-always
•  Diet/Nutrition
•  Physical Activity

Diet/Nutrition
•  Reduce Sodium 190 mg/dL
–  High dose

•  Age >21 and LDL 70-189 mg/dL
•  Mod-High dose

Dyslipidemia
•  High Dose Statins reduce LDL >50%
–  Atorvastatin 80 mg
–  Rosuvastatin 40 mg

•  Moderate Dose Statins reduce LDL 30%
–  Atorvastatin 10 mg
–  Rosuvastatin 10 mg
–  Pravastatin 40 mg
–  Lovastatin 40 mg
–  Fluvastatin 40 mg

Obesity/Fat
•  BMI 25 Km/m2
–  Weight reduction

Diabetes
•  Target BP /= 2
–  Warfarin target INR 2-3
–  Dabigatran, apixaban, rivaroxaban ok

•  LAA closure may be considered if risk of
anticoagulation high

Other Cardiac
•  Mitral stenosis with embolic event
–  Anticoagulation

•  Mitral stenosis with LA thrombus
–  Anticoagulation

•  Aortic mechanical valve
–  Warfarin (INR 2-3) + aspirin 81 mg
–  With risk factors (INR 2.5-3.5) +ASA 81 mg

•  Other mechanical valves (INR 2.5-3.5)
+ASA 81 mg

Other Cardiac
•  Bioprosthetic valves
–  Warfarin (INR 2-3) for 3 months
–  Aspirin chronically

•  Masses
–  excise

Carotid Stenosis

(asymptomatic)

•  ASA + Statin
•  >70% stenosis
–  Surgery (CAS in highly selected patients)

•  >50% stenosis
–  Yearly ultrasound

•  Screening low risk patients not
recommended

Other cardiac
•  CHF
–  Anticoagulants or antiplatelets

•  STEMI + mural thrombus/anterior apical
akinesis or dyskinesis
–  Warfarin

•  Mitral stenosis and LAE >55mm
–  Consider anticoagulation

•  No treatment for asymptomatic PFO

Migraine with aura
•  No smoke
•  Alternates to Ocs
•  Treat migraine frequency
•  No PFO closure

Alcohol consumption
•  80
Anticoagulation
NIHSS >25
Imaging >1/3 territory
h/o stroke and diabetes

Acute tPA treatment
•  Non VKA/NOACs exclude within 48 hours
or testing that demonstrates negligible
activity.
–  idarucizumab (Praxbind) may allow for
immediate administration for patient who
have received dabigatran (Pradaxa)

Acute stroke treatment
•  O2 sat >94%
•  Treat hyperthermia
•  Treat hypoglycemia /= 180 mg/dL
•  Maintain normovolemia with isotonic fluids
•  Intubate if airway issues
•  Avoid indwelling urinary catheters

Acute stroke treatment
•  Anticoagulation
–  Emergent use for stroke or for non stroke in
moderate to severe strokes contraindicated

•  Antiplatelets
–  ASA 325 mg within 48 hours
–  No other agents as first dose

Acute stroke treatment
Endovascular
•  2013 Trials
–  IMS III
–  MR RESCUE
–  SYNTHESIS Expansion
–  All suggested that endovascular therapy was
no more effective than intravenous t-PA
alone.

Acute stroke treatment
Endovascular
•  2015 Trials
–  MR Clean
–  ESCAPE
–  SWIFT-PRIME
–  EXTEND-IA
–  REVASCAT
–  All showed similar
benefit of intravenous
thrombolysis with
endovascular therapy
over intravenous
alone.

Endovascular Acute Stroke
Therapy (study summary)
•  Intravenous thrombolytic (t-PA mostly) within 4.5 hours
• 

to approximately 1300 patients.
Intraarterial treatments with thrombectomy devices up
to 6 hours from symptom onset
–  No age limit
–  Median time to groin puncture 185-269 mins
(115-340)
–  NIHSS median 16-17 (3, 13-20, 30)
–  Anterior circulation occlusion with small Core lesion or
high ASPECTs score.
–  Benefit 1/3-1/7 for mRS of 2 or less
–  No difference in death or symptomatic hemorrhage

General Care
•  Specialized units
•  Standardized order sets
•  SQ anticoagulants for DVT prevention
•  ICS for non anticoagulant patients
•  NG feeding 2-3 weeks before PEG
•  Swallow assess before oral
•  No routine bladder catheters
•  Early mobilization

Secondary Stroke/TIA
Prevention 2016

Hypertension
•  Previously untreated
–  may start after 2 days if bp >/= 140/90

•  Previously treated
–  Restart after 2 days

Dyslipidemia
•  Intensive statin all TIA/Stroke
–  Best evidence for atorvastatin LDL >100

Diet/Nutrition & Exercise
•  If physically able, refer to comprehensive

program
•  Exercise same as pre stroke
•  No vitamins
•  Reduce sodium to < 1.5 g/day (2.4 g/day
an acceptable goal)
•  Mediterranean diet

Sleep Apnea
•  Consider all patients

Carotid Stenosis
•  CAS alternative to CEA
–  >50% stenosis by cath (select individuals)
–  >70% stenosis by non invasive
–  Experienced operator
–  Within two weeks

•  CEA for older than 70

Intracranial Disease
•  Stroke/TIA 50%
•  Bp 70%
•  High intensity statin + Clopidogrel x 90 days + ASA

•  Angioplasty
–  Stenosis 70%
•  Bp + statin first, most instances investigational

Atrial Fibrillation
•  Non valvular
–  VKA (warfarin), apixaban and dabigatran
(class I), rivoroxaban (class II)
–  Combination with antiplatelet possible with
acute coronary or following stent
–  ASA if anticoagulant intolerant
–  Start within 14 days with no contraindications
–  Closure uncertain

MI
•  Warfarin (INR 2-3) x 3 months
–  Acute anterior, STEMI with apical akinesis, or
dyskinesis
–  Non VKA if warfarin intolerant

Cardiomyopathy
•  Warfarin (INR 2-3)
–  Thrombus
–  Non VKA if warfarin intolerant

Valvular Disease
•  RHD + Afib
–  Warfarin (INR 2-3)
–  ASA if adequate VKA treatment

•  All non mechanical valves
–  Antiplatelet

•  Mechanical Valves
–  Aortic
•  Warfarin (INR 2-3) + asa
–  Mitral
•  Warfarin (INR 2.5-3.5) + asa

Aortic Arch Disease
•  Antiplatelets
•  No anticoagulants
•  Statin Therapy

Antiplatelets
•  Antiplatelets for most stroke
•  ASA + Clopidogrel x 90 days for acute

stroke (long term without benefit and with
increased risk of bleeding)
•  Combination with warfarin typically not
indicated except stenting or special
circumstances

PFO
•  Antiplatelet
•  PFO + venous source
–  Anticoagulate

•  PFO + cryptogenic
–  No evidence to support closure

Stroke Prevention 2016

Intersection of Cardiology & Neurology
Summary of Recommendations
Michael R.K. Jacoby, MD, FAHA
Medical Director, Mercy Stroke Center