Therapeutics Exam 4 (Stroke) Flashcards by TheOneandOnly Ash

what is a stroke?

An acute focal injury due to lack of blood/oxygen to the CNS that causes neurological deficits

-short or long term

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What are the 2 main types of stroke?

Ischemic

Hemorrhagic

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What is an ischemic stroke?

An infarction of brain tissue that results from compromised blood flow

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What are the 2 types of ischemic stroke?

Atherosclerotic
Cardioembolic

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What is a hemorrhagic stroke?

Bleeding in the brain due to rupture of a cerebral artery

*AKA intracranial hemorrhage (ICH)

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What causes an atherosclerotic stroke?

Cholesterol plaque buildup

-a blood clot gets stuck between it and the wall and leads to a blocked artery

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What causes a cardioembolic stroke?

*Primarily afib

-clot blocks blood flow to part of the brain

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What causes hemorrhagic stroke?

Aneurysm in cerebral artery breaks open and causes bleeding around the brain

-the pressure of blood on the brain causes brain tissue death

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What are the modifiable risk factors for stroke?

CV disease
Diabetes
Hyperlipidemia
Hypertension

Lifestyle:
-Illicit Drug/Alcohol Abuse
-Obesity/Physical Inactivity
-Cigarette Smoking

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What is the clinical presentation of stroke?

Dysphagia (difficulty speaking)

Facial droop

Unilateral/Bilateral weakness

Ataxia (unable to coordinate muscle movement)

Vision changes

Headache

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If a patient has an ischemic stroke and an ECG show afib or valvular abnormalities, what kind of stroke is it?

Cardioembolic

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If a patient has an ischemic stroke and an ECG shows normal sinus rhythm, what kind of stroke is it?

Atherosclerotic

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Why do we differentiate the two types of ischemic stroke?

They have the same initial management but different preventative therapy

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How can hypoglycemia affect strokes?

-Can cause neurological changes that mimic a stroke

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How can hyperglycemia affect strokes?

Elevated BG >180 has resulted in worse morbidity + mortality

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How often do we check BP in stroke patients?

q 15 minutes for 2h

then q 30 minutes for 6h

then q 1 hour for 16h

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What is the blood pressure goal for ischemic stroke?

No tPA: <220/110

tPA: <180/105

After 48 hours goal lowers to outpatient goal (160/90 then 130/80)

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What are our treatment options for acute hypertension treatment?

Parenteral Agents

-Labetalol
-Nicardipine
-Sodium Nitroprusside

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How do we manage hypertension after 48 hours?

Start PO medications if able to take

-restart home meds if applicable

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What are the thrombolytics we can use for acute ischemic stroke?

tPA’s:

-Alteplase
-Tenecteplase

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What strokes do we use thrombolytics for?

Ischemic
-atherosclerotic AND cardioembolic

DO NOT USE FOR HEMORRHAGIC

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Why do we use thrombolytics in ischemic stroke?

-Improve functional capabilities
-DO NOT IMPACT MORTALITY
-Can improve neurologic function

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What are the inclusion criteria to be able to use a thrombolytic?

-Ischemic stroke
-Symptom onset </= 4.5 hrs
-Adult

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What are the exclusion criteria that prevent use of a thrombolytic?

BP > 185/110

BG < 50

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How do we dose alteplase and what is the max dose?

0.9 mg/kg IV bolus Max: 90mg

How do we dose tenecteplase and what is the max dose?

0.25 mg/kg IV bolus Max: 25mg

What does BP need to be kept under while using tPA agents to reduce bleeding/hemorrhagic stroke risk?

<180/105 (note that this is different than the exclusion BP of >185/110)

If a patient experiences bleeding, how long do we hold antiplatelets and anticoags?

For 24 hours after

Antiplatelets are primarily used for what stroke?

Atherosclerotic

What are the antiplatelet options for acute ischemic stroke?

Aspirin Monotherapy Aspirin + Clopidogrel Ticagrelor Aspirin + Ticagrelor

What antiplatelet is considered first-line for acute ischemic stroke?

Aspirin

How do we dose aspirin for acute ischemic stroke?

High dose (160-325mg daily) for 2-4 weeks

Who gets aspirin for stroke?

All ischemic stroke patients initially unless contraindicated *Wait 24 hours if tPA administered *Give immediately if no tPA

How does tPA administration affect aspirin use in acute ischemic stroke patients?

Need to wait >/= 24 hours to administer aspirin if a tPA is given *Otherwise we give patients aspirin immediately

Who should receive aspirin + clopidogrel combination antiplatelet therapy?

Minor ischemic strokes only *second line option

Who should receive ticagrelor antiplatelet therapy?

Minor ischemic strokes only *not superior to aspirin and combination showed no difference in disability with an increased bleeding risk Second line but not used much, consider in true aspirin allergy!!!!

What do we do if a patient came in on anticoagulation?

Discontinue it and transition to aspirin instead **Do not use a tPA if on anticoagulation

Which type of stroke do we want to use anticoagulation in and when?

Cardioembolic stroke -start >/= 2-14 days after stroke *typically start after 7 days *discontinue aspirin when starting anticoagulation

What is the distinguishing symptom of hemorrhagic stroke?

Headache

Which type of stroke has a worse prognosis?

Hemorrhagic

What type of hemorrhagic stroke do we use nimodipine for?

Subarachnoid Hemorrhage

What medication might we use in acute management of hemorrhagic stroke that we do not use in ischemic stroke?

Anticonvulsants

What medications can cause hemorrhagic stroke?

Warfarin Heparin DOACs Antiplatelet

What is the reversal agent for warfarin?

IV vitamin K

What is the reversal agent for heparin?

Protamine

What is the reversal agent for Dabigatran?

Idarucizumab (Praxabind)

Besides Dabigatran, what is the reversal agent for the other DOACs?

Recombinant coagulation factor Xa (Andexxa)

Which class of medications that can cause hemorrhagic stroke does not have an antidote?

Antiplatelets

When do we treat BP in hemorrhagic stroke?

When SB > 180

What is the BP goal for hemorrhagic stroke?

First 24 hrs: <180/110 After 24 hrs: <160/90 After 48 hrs: Transition to outpatient goal

When is nimodipine used and why?

Subarachnoid Hemorrhagic Stroke -to prevent cerebral vasospasm which can worsen ischemia -give q4H for 21 days

When should we consider giving stroke patients anticonvulsants?

Hemorrhagic stroke only and only if they have a documented seizure history

What drugs do we use for secondary stroke prevention in ischemic stroke?

Atherosclerotic: Antiplatelets Cardioembolic: Anticoagulants

How long are atherosclerotic stroke patients on antiplatelets for for secondary prevention?

Indefinitely -until they have complications

What are the antiplatelets that can be used for secondary prevention in atherosclerotic stroke?

Aspirin *first-line Dipyridamole + Aspirin Clopidogrel Clopidogrel + Aspirin

What is the first-line antiplatelet choice for secondary stroke prevention in atherosclerotic stroke?

Aspirin -high dose for 2-4 weeks (162-325) then low dose (81) indefinitely

What is the role of dipyridamole/aspirin combination therapy in secondary atherosclerotic stroke prevention?

First-line antiplatelet therapy to use after transition off high dose aspirin -would not start this until after using 2-4 weeks of high dose aspirin -has shown some increased benefit over monotherapy

What is a major side effect of dipyridamole/aspirin use?

Headache -can titrate up slowly to minimize risk

What is the role of clopidogrel in secondary atherosclerotic stroke prevention?

Second-Line treatment *use in aspirin intolerant patients

What is the role of clopidogrel + aspirin combination therapy in secondary atherosclerotic stroke prevention?

Second-line therapy **First-line for minor strokes (NIHSS

What antiplatelet therapy should not be used in secondary prevention of atherosclerotic stroke?

Ticagrelor + Aspirin Prasugrel

Overall: what are the first-line antiplatelet treatment options for secondary prevention of atherosclerotic stroke?

Aspirin Dipyridamole + Aspirin Clopidogrel + Aspirin (only minor strokes with NIHSS

Overall: what are the second-line antiplatelet treatment options for secondary prevention of atherosclerotic stroke?

Clopidogrel monotherapy

Overall: what drug is contraindicated in antiplatelet secondary prevention of atherosclerotic stroke?

Prasugrel

When do we use anticoagulants in secondary stroke prevention?

Cardioembolic stroke *caused by afib*, valvular disease, or HF

How long after a stroke should anticoagulant secondary prevention be initiated?

>/= 2-14 days (7 on average) -want to use aspirin immediately after stroke and then d/c and switch to anticoagulant

What drugs can we use as anticoagulant secondary stroke prevention?

All DOACs Warfarin

What stroke patients must receive Warfarin or Rivaroxaban for anticoagulant secondary prevention?

Mechanical Mitral Valve or LV Thrombus

How long do we use anticoagulants in cardioembolic stroke patients?

Indefinitely

What is the long-term BP goal for all stroke patients?

<130/80

What is first-line antihypertensive therapy in African American patients?

CCB or Thiazide

What is first-line therapy antihypertensive therapy in CAD?

BB + ACE/ARB

What is first-line antihypertensive therapy in HFrEF?

ARNi + BB + Aldosterone Antagonist

What is first-line antihypertensive therapy in Afib patients?

BB or Non-DHP CCB

What is first-line antihypertensive therapy in Diabetes and CKD patients?

ACEi/ARB

What additional long-term therapy should all patients who had an atherosclerotic ischemic stroke be started on?

High-intensity statin Atorvastatin 80mg Rosuvastatin 20-40mg

What is the LDL goal in atherosclerotic stroke patients?

<70

What additional drug should most stroke patients of any type receive?

Antidepressants

What antidepressants can be used for stroke management?

SSRIs: sertraline, fluoxetine, escitalopram, citalopram

What antidepressants should be avoided in stroke treatment?

Paroxetine Tricyclic antidepressants

Therapeutics Exam 4 (Stroke) Flashcards

(80 cards)