Cerebrovascular Dz Flashcards Preview

Therapeutics II Exam 3 > Cerebrovascular Dz > Flashcards

Flashcards in Cerebrovascular Dz Deck (55):
1

How is an ischemic CVA caused?

Reduction of blood supply to different areas of the brain due to obstruction of blood vessel

Obstruction can be d/t:
-Atherosclerosis
-Vessel injury
-Plaque rupture

2

What are the 2 types of ischemic CVA? Definition?

Thrombotic--local vessel obstruction

Embolic--clot travels from somewhere else to the brain & obstruct a cerebro-vessel

3

Definition of Transient Ischemic Attack (TIA)?

Pre-CVA
-brief episode of neurological dysfunction caused by focal brain or retinal ischemia w/ clinical sx lasting <1hr
-w/o residual neurological dysfunction

4

Definition Ischemic CVA

Cerebrovascular infarct
IRREVERSIBLE damage occurs
w/ residual neurological defect

5

Risk Factors for Ischemic CVA

-HTN (uncontrolled)
-uncontrolled DM
-Hyperlipidemia
-Carotid Stenosis
-High homocysteine
-Hx non-cardioembolic stroke
-Smoking
-A-fib

6

Which of the following is a risk factor specific for EMBOLIC stroke?

a. Hyperlipidemia
b. Carotid Stenosis
c. A-fib
d. HTN

A-fib!
Risk factor for cardio-EMBOLIC stroke only

7

Presentation of Ischemic CVA

-may vary depending on parts of brain involved
-hemiparesis
-face asymmetry
-gaze deviation
-dysphasia/aphasia
-dysarthria
-limb incoordination
-ataxia (+/- vertigo)
-one sided sensory sx

8

Which of the following is NOT a sx of ischemic CVA?

a. dysarthria
b. loss of vision
c. ataxia
d. hemiparesis

B. loss of vision

pt may have gaze deviation

9

What therapeutic class drugs are appropriate 1st choice therapy for a Non-Cardioembolic stroke (not from a-fib)?

a. NSAID
b. antiplatelet
c. anticoagulant
d. thrombolytic

B. Antiplatelet therapy

Aspirin 50-325mg/day**
Aggrenox (ASA +dipyridamole) BID
Clopidogrel (Plavix) 75mg/day
Ticagrelor 90mg/day

10

When would you give ticagrelor in a pt with a non-cardioembolic stroke?

If they have an aspirin allergy

Not inferior to aspirin, can be used as alternative option--can cause more bleeding

11

Which antiplatelet drug would you to start a pt on with noncardioembolic stroke that isn't being treated with a thrombolytic?

ASPIRIN

12

What therapeutic class of drugs are appropriate therapy for cardio-embolic stroke (from a-fib)?

Anticoagulants

Warfarin (INR 2-3)
Dabigatran (150mg BID)
Rivaroxaban (20mg daily)
Apixaban (5mg BID)
Edoxaban (60mg daily)
Aspirin (81mg)

13

What pathway of the clotting cascade do anticoagulant affect?

Intrinsic pathway

14

What is CHA2DS2-VASC used for?

Determines risk of a cardioembolic stroke for pt w/ a-fib ONLY

15

What does CHA2DS2-VASC stand for?

Congestive HF
Hypertension
Age >75yo / 65-74yo
Diabetes
Stroke
Vascular Dz (MI, PAD)
Female

16

Which 2 risk factors from CHA2DS2-VASC counts for 2points

Age >75yo
Stroke

17

If a pt has no risk factors for thromboemoblism, what drug therapy should they be on?

Aspirin

18

If a pt has 1 risk factor for thromboembolism which drugs could they be on?

Warfarin
Dabigatran
Apixaban
Rivarxaban
Edoxaban
Aspirin

19

If a pt has 2 or more risk factors for thromboembolism, which drugs could they be on?

Warfarin
Dabigatran
Apixaban
Rivarxaban
Edoxaban

20

Whether the pt had a thrombotic or embolic stroke, what other class of drugs should the pt be on?

STATIN

21

What statin should the pt be on and what dose?

Atorvastatin 80mg once a day

REGARDLESS of cholesterol profile

22

Aspirin (Dose/ADR)

50-325mg
GI bleed, stomach upset

23

Dipyridamole (Dose/ADR)

ASA 25mg + Dipyridamole 200mg (aggrenox)

BLEEDING

24

Clopidogrel (Dose/ADR)

75mg/day

THROMBOCYTOPENIA, bleeding

25

Ticagrelor (Dose/ADR)

90mg BID

BRADYCARDIA, bleeding

26

Warfarin (Dose/monitor)

Dose to INR 2-3 indefinitely

INR, consistent vit K intake, DDI

27

Direct Anti-Xa inhibitors Monitor

Bleeding
Renal function

28

Statins (monitor/ADR)

LFT
Muscle pain

29

What are the direct oral anticoagulants (DOA)?

Dabigatran
Rivaroxaban
Apixaban
Edoxaban

30

Which of the DOA are dosed BID?

Dabigatran
Apixaban

31

Which DOA are MORE EFFECTIVE than warfarin?

Dabigatran
Apixaban

32

Which DOA is a direct thrombin inhibitor?

Dabigatran

33

Which of the following drugs are eligible for a pt w/ cardioembolic stroke & CKD?

a. dabigatran
b. apixaban
c. warfarin
d. rivaroxaban

Warfarin

34

What is the initial approach for a pt coming in with a CVA

-IV fluid
-eval for eligibility for thrombolytic therapy
-plan on initiating/re-initiating antiplatelet, antithrombotic therapy
-conservative HTN mgmt
-Mgmt underlying etiologies for stroke
-other supportive care

35

What does thrombolytic therapy do?

Dissolve clots

36

What are pt at high risk for if on thrombolytic therapy?

BLEEDING

37

What is time frame allows for admin of thrombolytic therapy after a stroke?

a. 2.0-3.5hrs
b. 3.0-4.5hrs
c. 3.5-5.0hrs
d. any time

B. 3.0-4.5 hrs after stroke

given over 1hr

38

Once a thrombolytic has been administered, what is the following steps of their mgmt?

-IVF NS at 75-100mL/hr
-No blood thinners for 24hrs (heparin, warfarin, ASA, clopidogrel or dipyridamole)
-get brain CT/MRI at 24hrs

39

If pt wasn't eligible for thrombolytic, how should they be managed?

-IVF NS at 75-100mL/hr
-Aspirin 325mg w/i 1st 24hrs of hospital admission
-Anticoagulants (heparin/warfarin) in cardioembolic stroke AFTER 24hrs & pt is STABLE
-Repeat brain CT/MRI 24-48hrs after stroke or prn

40

If pt is given tpA at 2pm, can they take their aspirin at 10am the next day?

NO. they can't restart any blood thinner within 24hrs after admin of tpA

41

Pt started experiencing dysarthria, hemiparesis, and face asymmetry, at 4pm and arrived at the ER at 10pm. No a-fib, They're on aspirin 81mg, labetolol 10mg and simvastatin 15mg. How would manage this pt?

Pt isn't eligible for tpA bc they arrived over >4.5hrs after the stroke occurred.

-Give them higher dose aspirin (325mg) within 24hrs of admission
-give them intensive statin therapy (atorvastatin 80mg)

42

Can pt be on anticoagulants for DVT/PE prophylaxis within 24hr of stroke?

YES
-bleeding risk is small bc dose is tiny
-used to prevent DVT as complication of stroke bc pt will be bed bound; NOT used to tx the stroke

Low dose heparin (5000units sc BID or TID)
LMWH (Enoxaparin 30 or 40mg QD)
Fonadaparinux (2.5mg SC QD)

43

Complications Post Acute Ischemic Stroke

-cerebral hemorrhage
-cerebral edema
-DVT/PE
-Seizure

44

What BP lvl is the cut off for thrombolytic therapy?

Systolic 220
Diastolic 140

45

What can be given to pt w/ BP >220/140

Labetalol or Nicardipine

Can add Nitroprusside if uncontrolled

46

What % reduction of BP are you aiming for?

10-15% reduction

47

Is BP 210/140 eligible for thrombolytic therapy?

Yes! just need to lower it to be <185/110
w/ antihypertensive therapy (BB or CCB)

48

How would you manage a pt w/ BP 185/110

-Check BP q15min for 2hr, then q30min for 6hrs, then q1hr for 16hrs
-Labetalol (may repeat or give nitropaste) or
-Nicardipine drip
-if uncontrolled, add Nitroprusside
-Aim for 10-15% reduction of BP

49

IV Heparin, monitor?

aPTT 1.5-2.5x baseline
platelets

50

LMWH, monitor?

Platelets

51

Labetolol, monitor?

BP

52

Nicardipine, monitor?

BP

53

Nitroprusside, monitor?

BP
Cyanide toxicity
Renal fucntion

54

Nitroglycerin, monitor?

BP
HA
sign of tachyphylaxis (when used for >2-3 days continuously)

55

Which BP lowering drug should you monitor for cyanide toxicity?

A. Labetolol
B. Nicardipine
C. Nitroprusside
D. Nitroglycerine

C. Nitroprusside

also monitor BP and renal function!