Page 793 - TNFlipTest

Toronto Notes 2019 Stroke
Primary and Secondary Prevention of Ischemic Stroke
Anti-Platelet Therapy
• primaryprevention
■ no firm evidence for a protective role for antiplatelet agents for low-risk patients without a prior
stroke/TIA
• secondaryprevention
■ initial choice: ASA
■ if cerebrovascular symptoms while on ASA or if unable to tolerate ASA: Aggrenox® (ESPRIT trial),
clopidogrel (CAPRIE trial)
Carotid Stenosis
• primaryprevention(asymptomatic)
■ carotid endarterectomy is controversial: if stenosis >60%, risk of stroke is 2% per yr; carotid
endarterectomy reduces the risk of stroke by 1% per yr (but 5% risk of complications)
• secondaryprevention(previousstroke/TIAincarotidterritory)
■ carotid endarterectomy clearly benefits those with symptomatic severe stenosis (70-99%), and is less beneficial for those with symptomatic moderate stenosis (50-69%) (NASCET trial),
see Vascular Surgery, VS8
• accordingtotheCRESTtrial,endarterectomyandcarotidstentinghavesimilarbenefitsinacomposite endpoint of reduction of stroke, MI, and death; however, in the periprocedural period, stenting results in a higher rate of stroke, while endarterectomy results in a higher rate of MI
Atrial Fibrillation
• primaryandsecondarypreventionwithanticoagulation
■ classical risk stratification used CHADS2 score (0-6), but Stroke 2014 guidelines recommend that
virtually all patients with atrial fibrillation without contraindication be anticoagulated
◆ 0 (low risk, 1.9% annual stroke risk): antiplatelet
◆ 1 (intermediate risk, 2.8% annual stroke risk): anticoagulant or antiplatelet – patient specific
decision
◆ >2 (high risk, 4-18.2% annual stroke risk): anticoagulant
■ anticoagulationtherapy
◆ warfarin (titrate to INR 2-3)
◆ dabigatran (110 or 150 mg PO bid), apixaban (2.5 or 5 mg PO bid) or rivaroxaban (15 or 20 mg
PO daily) may be alternatives to warfarin, but should be used cautiously; Praxbind reversal agent for dagibatran if necessary
Hypertension
• primaryprevention
■ targets: BP <140/90 (sBP <120 for high risk without diabetes [SPRINT trial] or <130/80 for diabetics
or renal disease)
■ ACEI: ramipril 10 mg PO OD is effective in patients at high risk for cardiovascular disease (HOPE
trial)
• secondaryprevention
■ ACEI and thiazide diuretics are recommended in patients with previous stroke/TIA (PROGRESS trial)
Hypercholesterolemia
• primaryprevention
■ statins in patients with CAD or at high risk for cardiovascular events, even with normal cholesterol
(CARE trial)
• secondaryprevention
■ high dose atorvastatin (SPARCL trial) but lower doses may be more appropriate if patient cannot tolerate high dose
Diabetes
• idealmanagement:HbA1c<7%,fastingbloodglucose4-7
Smoking
• primaryprevention:smokingincreasesriskofstrokeinadose-dependentmanner
• secondaryprevention:aftersmokingcessation,theriskofstrokedecreasestobaselinewithin2-5yr
Physical Activity
• beneficialeffectofregularphysicalactivityhasadose-relatedresponseintermsofintensityand duration of activity
Stroke Rehabilitation
• individualizedbasedonseverityandnatureofimpairment;mayrequireinpatientprogramand continuation through home care or outpatient services
• multidisciplinaryapproachincludesdysphagiaassessmentanddietarymodifications;communication rehabilitation; cognitive and psychological assessments including screen for depression; therapeutic exercise programs; assessment of ambulation and evaluation of need for assistive devices; splints or braces; vocational rehabilitation
Neurology N51
CHADS2
Stroke risk stratification for patients with atrial fibrillation
CHF (1 point)
HTN sBP >160 mmHg/treated HTN (1 point) Age >75 yr (1 point)
DM (1 point)
Prior Stroke or TIA (2 points)
Carotid endarterectomy needs to be done within 2 wk of the ischemic event for the most benefit
2 ABCD Score
To predict/identify individuals at high risk of stroke following TIA
Age: 1 point for age >60 yr
Blood pressure (at presentation):
1 point for HTN
(>140/90 mmHg at initial evaluation) Clinical features: 2 points for unilateral weakness, 1 point for speech disturbance without weakness
Duration of symptoms: 1 point for
10-59 min, 2 points for >60 min
DM: 1 point
Stroke risk: 0-3: low risk, 4-5: moderate risk, 6-7: high risk
Long-Term Results of Stenting vs. Endarterectomy for Carotid-Artery Stenosis
NEJM 2016; 374:1021-1031
Study: Patients were randomly assigned to stenting or endarterectomy and assessed every 6 mo for up to 10 yr. Population: 2502 patients at 117 centres with carotid- artery stenosis.
Outcome: Primary composite outcome was stroke, myocardial infarction, or death during periprocedural period or subsequent ipsilateral stroke.
Results: There was no significant difference in outcomes of either primary composite endpoint (HR 1.10; 95%
CI 0.83-1.44) or post-procedural stroke (HR 0.99;
95% CI 0.64-1.52) in patients treated with stenting
or endarterectomy. Asymptomatic and symptomatic patients showed no significant between-group differences in either endpoint.
Conclusions: The rate of periprocedural stroke, myocardial infarction, death, and subsequent ipsliateral stroke did not differ between carotid-artery stenosis patients treated with stenting or endarterectomy at 10 yr of follow-up.
Endovascular Treatment vs. Medical Care Alone for Ischaemic Stroke: Systematic Review and Meta-Analysis
BMJ 2016;353:i1754
Purpose: To evaluate the evidence for endovascular intervention in the treatment of ischemic stroke. Study: Systematic review and meta-analysis of
10 RCTs of 2,925 patients testing the efficacy and safety of adjunctive endovascular intervention in patients suffering acute, ischemic stroke in the anterior circulation versus medical therapy, including thrombolysis, alone.
Results: The 7 RCTs published or presented in 2015 were without significant heterogeneity and formed the basis for the analysis. The majority of patients (86%) received stent retrievers and experienced higher than expected rates of recanalization (>58%). Risk ratio for good functional outcomes was 1.56 (95%CI 1.38-1.75) and 0.86 for mortality (95% CI 0.69-1.06). There was no difference in symptomatic intracranial hemorrhage following therapy.
Conclusions: Endovascular therapy is safe and improves functional outcomes when added to medical care with thrombolysis when administered within 6-8 h of large vessel, anterior circulation ischemic stroke. A trend towards improved mortality exists with complete follow-up results of several key trials pending.