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Stroke Flashcards

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1
Q

What are the different types of strokes?

A
  • Haemorrhagic stroke (Intracerebral haemorrhage)
  • Ischaemic stroke
  • Transient ischaemic stroke (TIA)
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2
Q

What are the common symptoms of a stroke?

A

Acronym ‘Think FAST’

  • Face drops
  • Arm weakness
  • Slurred speech
  • Time to dial 999
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3
Q

What is the initial management for TIA (also known as mini stroke)?

A
  • Aspirin 300mg (only when haemorrhagic stroke has been excluded)
  • Clopidogrel can be given if intolerant to aspirin
  • After a confirmed diagnosis, patients should receive treatment for secondary prevention immediately
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4
Q

What is the initial management for Ischaemic stroke?

A
  • Alteplase if patient present within 4.5 hours of stroke onset
    IF intracranial haemorrhage has been excluded

Then within 24 or asap, start them on:
* Aspirin 300mg or clopidogrel 75mg OD for 14 days

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5
Q

What is the long term management of TIA and Ischaemic stroke?

A

If stroke is NOT associated with AF, treat with antiplatelets:
* Clopidogrel 75mg daily is recommended.

If contraindicated:
* Dipyridamole MR 200mg + aspirin (if clopidogrel is contraindicated)

If clopidogrel and aspirin are contraindicated:
* Dipyridamole MR 200mg alone

If clopidogrel and dipyridamole are contraindicated:
* Aspirin alone

If stroke IS associated with AF, treat with anticoagulants:
* Warfarin, or other anticoagulant
(same thing if patient has embolism or venous thrombosis)

Initiate high intensity statin (e.g. atorv 20-80mg) 48 hours after stroke

Advice on lifestyle changes (diet, exercise, weight, alcohol and smoking)

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6
Q

What needs to be monitored with long term management of ischaemic stroke and T.I.A?

A

Monitor BP.
Target is less than 130/80mmHg.

If higher, treat with antihypertensive drugs.
But avoid beta blockers (unless indicated for co-existing condition)

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7
Q

What is the initial management of Intracerebral haemorrhage?

A
  • Surgery
  • AVOID ALL MEDICATIONS

Long term management is treat hypertension but avoid all other drugs.

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8
Q

What are Coumarins and Phenindiones?

A

Medication used to treat and prevent thrombosis, thromboembolism in veins etc.

Examples are: warfarin, acenocoumarol, phenindione

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9
Q

What is the mechanism of action for COUMARINS AND PHENINDIONES?

A

Antagonises vitamin K.
It is used to prevent thrombus formation in the veins.
They take 48-72 hours to give a full anticoagulant effect.

So if you want an immediate effect, you must use unfractionated heparin (heparin) or LMWH

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10
Q

What are the different strengths of Warfarin?

A

0.5mg, 1mg, 3mg, 5mg

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11
Q

What are the different colours of warfarin?

A

0.5mg - white
1mg - Brown
3mg - Blue
5mg - Pink

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12
Q

What are the two MHRA advice given with warfarin?

A
  1. Calciphylaxis
    This is a painful rash.
    Common in patients with renal disease.
    REFER TO GP!
  2. Miconazole (daktarin) oral gel interaction
    - causes bleeding
    - patients must be told to stop and seek medical advice if unexplained bruising, nose bleeds and blood in urine
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13
Q

What is the antidote for warfarin?

A

Phytomenadione (vitamin K).

So certain foods that contain vitamin K should not be increased or decreased in the patient’s diet whilst taking warfarin.

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14
Q

What are some examples of foods containing phytomenadione (vitamin K)?

A
  • Cranberry juice
  • Pomegranate juice
  • Liver
  • Sprouts
  • Broccoli
  • Green tea
  • Salads and leafy green vegetables

AND avoid alcohol as it decreases effects of warfarin

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15
Q

Can warfarin and coumarins be taken during pregnanacy?

A

No!
Because they are highly teratogenic.

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16
Q

What anti coagulation medications can be taken during pregnancy?

A

LWMH

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17
Q

How does target INR work?

A

INR stand for international normalised ratio (INR).

It is a blood test that tells you how long it takes for your blood to clot.
It is used to test clotting times in people taking warfarin.
Your doctor will use your INR result to work out what dose of warfarin you should take.

Less warfarin, the lower the INR

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18
Q

What is warfarin used for?

A

Used to treat and prevent blood clots

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19
Q

What is the target INR for most patients? And what is an acceptable INR?

A

The target INR for most patients is 2.5.

INR should be within 0.5 of this target value.

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20
Q

Which conditions require an INR of 3.5?

A
  • Recurrent DVT or PE
  • Mechanical prosthetic heart valves
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21
Q

What are the indications of Warfarin?

A
  • Prevention of embolisation in rheumatic heart disease and AF
  • Prevention after insertion of prosthetic heart valve
  • Prevention and treatment of venous thrombosis and pulmonary embolism
  • T.I.A
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22
Q

What’s the initial and maintenance dose of Warfarin?

A

Initially 5-10mg take on day 1

Then subsequent dose dependent on INR.

A lower induction dose can be given to elderly patients and patience who don’t require quick anticoagulation.

Maintenance dose is 3-9mg daily, to be taken at the same time each day.

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23
Q

For patients taking warfarin, what should be done if they are bleeding and INR is more than 8?

A

Stop warfarin and give IV vitamin k (phytomenadione) slowly. A slow IV injection.
Repeat if INR is still high after 24hrs.

Then restart warfarin when INR is <5.

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24
Q

For patients taking warfarin, what should be done if their INR is more than 8 but there’s no bleeding?

A

Stop warfarin and give oral vitamin K . Repeat if INR is still high after 24 hours.

Restart warfarin if INR is less than 5.

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25
For patients taking warfarin, what should be done if they are bleeding and their INR is between 5-8?
Stop warfarin. And give Phytomenadione (vitamin k). Restart when INR is less than 5.
26
For patients taking warfarin, what should be done if they are not bleeding and their INR is between 5-8?
Withhold 1-2 doses of warfarin and reduce subsequent maintenance dose. Measure INR again after 2-3 days.
27
What drug increases the effect of warfarin?
- Miconazole - usually avoid use. Unless INR can be closely monitored - monitor for signs of bleeding and bruising. Fluconazole & Clarithromycin - monitor INR and adjust dose. - Itraconazole - Amiodarone - Bezafibrate - Cranberry and pomegranate juice - AVOID
28
What drug decreases the effect of warfarin?
- St John's Wort - Alcohol & leafy greens - changes in diet can effect anticoagulation control - Carbamazepine
29
What drug, taken alongside warfarin increases the risk of bleeding?
Antiplatelets like aspirin
30
What antiplatelet is preferred, is an antiplatelet is necessary in a patient taking wafarin?
Aspirin
31
What are some examples of antiplatelets drugs?
- Aspirin - Clopidogrel - for prevention of stroke, acs etc. - Dipyridamole - prevention of thromboembolism associated with prosthetic heart valves. MR preparation used for secondary prevention of ischaemic stroke and T.I.A - Ticagrelor - Prasugrel - Cangrelor
32
What's the dose for dipyridamole for strokes?
MR preparation 200mg BD, taken with food.
33
What dispensing information should be given with Dipyridamole?
MR capsules should be dispensed in original container (as pack contains a desiccant) and any remaining capsules should be discarded 6 weeks after opening.
34
What advice is given with Warfarin?
Warfarin can cause Calcifilaxis, which is a painful rash. This is common with patients with renal disease. You must refer this to the GP. Taken with Miconazole - Causes bleeding. bleeding. You must stop and seek medical advice if unexplained bruising, nose bleeds, or blood in urine occur.
35
What are the two types of heparin?
- Low weight molecular heparin (LWMH) - Unfractionated heparin
36
Examples of LWMH?
* Enoxaparin * Dalteparin * Tinzaparin
37
Which type of heparin initiates anticoagulation more rapidly?
Unfractionated heparin (aka standard heparin) BUT it ha a shorter duration of action.
38
Which heparin is safe to use in pregnancy?
Unfractionated heparin is safe to use in pregnancy as it does not cross the placenta
39
Which heparin can be used in those who are at high risk of bleeding?
Unfractionated heparin, because it's effects can be terminated rapidly by stopping the infusion
40
Which heparin is used in the prevention of DVT and treatment of DVT, PE and MI?
Low weight molecular heparin
41
Which heparin is usually preferred? And why?
LWMH due to a lower risk of heparin-induced thrombocytopenia (HIT). And standardly, it does not require monitoring. And can be given once daily due to duration of action being longer, making it convenient for self-admiration.
42
What other indications do Dalteparin and Tinzaparin have?
Prophylaxis of VT in patients with solid tumours At a dose of 20,000unit/ml syringe.
43
What is used as secondary prevention of CVD?
Low dose aspirin, clopidogrel, or ticagrelor (for stroke prevention). Antihypertensives for patients with a blood pressure of >140/90mmHg. Statins can be used as a lipid lowering drug. Atorvastatin is preferred over simvastatin due to the risk of myopathy with high-dose simvastatin
44
What must patients taking NOACs (aka DOACs) have?
Alert cards And label 10 - take with information
45
What is the mechanism of action for NOACs (aka DOCAs)?
They either: 1. Inhibit thrombin 2. Inhibit factor Xa
46
Which NOACs inhibit thrombin?
Dabigatran
47
Which NOACs inhibit factor Xa?
- Apixaban - Edoxaban - Rivaroxaban
48
What warning is given with Rivaroxaban?
Rivaroxaban 15mg and 20mg strengths should be taken with food or just after food/meal
49
What is the indication for Apixaban?
Prevention of stroke and systemic embolism in non-valvular AF and at least one risk factor
50
What are the risk factors a patient must have to use Apixaban?
Must have had: - A stroke - Heart failure - Has diabetes - Has hypertension - Over the age of 75 or over
51
Why might Novel oral anticoagulants (NOACs) (aka DOACs) be preferred than warfarin?
Causes less bleeding and no monitoring is required
52
What dose is given for Apixaban?
Adult dose is 5mg twice daily. Dose is reduced to 2.5mg twice daily in patients with at least two of these: - Age 80 or over - Body weight 60kg or less - Creatinine level is 133mcmol/L or over - Creatinine clearance is 12-29ml/min - Taking drugs like verapamil, amiodarone, erythromycin, ciclosporin These are the ABCs of Apixaban
53
What is the reversal agent for Warfarin?
Phytomenadione (vitamin k)
54
What is the reversal agent for Unfractionated heparin?
Protamine Sulphate
55
What is the reversal agent for Apixaban and Rivaroxaban?
Andexanet Alfa (Ondexxya)
56
What is the reversal agent for Dabigatran?
Idarucizumab
57
What is used for primary prevention of CVD?
Antihypertensives are only offered to patients at a high risk of CVD and those with a blood pressure of >140/90mmHg. Lipid lowering drug - NICE recommends atorvastatin as first choice for patients with a 10-year CVD risk of >10% Aspirin is not recommended
58
Examples of Glycoprotein lib/illa inhibitors?
- Abcixmab - Tirofiban - Eptifibatide
59
When is DOCAs preferred vs when warfarin is preferred?
DOCAs is preferred in non-valvar AF Warfarin is preferred in valvar AF
60
When do you use a DOAC for the prevention of stroke?
When the patient has at least one of the risk factors (CHADVASC risk factors): - diabetes - hypertension - previous stroke / T.I.A - age above 75
61
When do you give a reduced dose of DOACs?
- Above the age of 80 - Body weight is 60kg or less - Creatinine clearance - Drugs (taking drugs like verapamil, amiodarone, erythromycin, ciclosporin)
62
Which DOACs can be used in ACS/heart attacks?
Only Rivaroxaban can be used in heart attacks - ACS
63
Examples of DOACs and their usual doses?
Rivaroxaban & Edoxaban - Once daily Apixaban and Dabigatran - twice daily
64
What is the VTE prophylaxis dose for Rivaroxaban and Apixaban?
Rivaroxaban - 10mg OD for stroke 20mg OD Apixaban - 2.5mg BD and for stroke 5mg BD
65
What must be monitored with DOACs?
Monitor the kidneys Monitor bleeding and anemia
66
What are DOACs contraindicated with?
Antiphospholipid syndrome
67
Which DOAC does not have a reversal agent?
Edoxaban
68
What is the mechanism of action for warfarin?
Inhibits vitamin K
69
What are the doses for Warfarin?
Initial - 5-10mg, for day 1 Adjust according to INR later Maintenance - 3-9mg (same time each day)
70
What are the doses for Rivaroxaban?
Prophylaxis of stroke/TIA with one risk factor - 20mg OD Prophylaxis of VTE for knee replacement - 10mg OD for 2 weeks Prophylaxis of VTE for hip replacement - 10mg OD for 5 weeks Treatment of VTE of PE - Initial 15mg BD for 21 days, maintenance: 20mg OD Prophylaxis of recurrent DVT or PE - 10mg OD or 20mg in high risk Prophylaxis of ACS and other heart conditions - 2.5mg BD for 12 months
71
What are the doses for Apixaban?
Prophylaxis of stroke/AF with at least one risk factor - 5mg BD Reduce to 2.5mg BD if at least 2 risk factors Prophylaxis of knee replacement - 2/5mg BD for 10-14 days Prophylaxis of hip replacement - 2.5mg BD for 28-32 days Treatment of DVT and PE - 10mg OD for 7 days; maintenance 5mg BD Prophylaxis recurrent PE or DVT - 2.5mg BD
72
What are the doses for Dabigatran?
Prophylaxis of stroke - 110mg - 150mg BD 18-74 years: Prophylaxis of VTE for knee replacement - 110mg for 1-4 hours. Then after surgery 220mg OD for 10 days 75 years and over 75mg for 1-4 hrs, then 150 OD for 10 days Treatment of VTE and prevention of VTE - - For 18-74 years old, 150 BD for at least 5 days. - For ages 75-79, 110-150 BD - For 80 and over, 110 BD
73
What are the doses for Edoxaban?
Everything is based on the patients weight Adult under 61kg - 30mg BD Adult over 61kg - 60mg OD Duration of treatment is adjusted according to risk factors.
74
What the cautionary label for Edoxaban and Apixaban?
Label 10 Warning - read the additional information given with this medicine
75
What are the brand names for the DOACs?
R - Xarelto E - Lixiana A - Eliquis D - Pradaxa
76
What the cautionary label for Dabigatran?
Label 10 Warning - read the additional information given with this medicine. Label 25 Swallow this medicine whole. Do not chew or crush
77
What are the contraindications for DOACs?
- You can't use DOACs together as increases risk of bleeding. Example - if switching from warfarin to rivaroxaban; stop warfarin first, before staring rivaroxaban to reduce risk of bleeding - Avoid in conditions with significant risk factors for bleeding - Antiphospholipid syndrome

Cardiovascular System (8 decks)

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