stroke- overview, management and prevention

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Slide 1 : DR. MATIUR RAHMAN ASSOCIATE PROF. OF NEUROLOGY SOMC,SYLHET STROKE- OVERVIEW, MANAGEMENT AND PREVENTION
Slide 2 : Learning objectives What is stroke? To know its pathophysiology To know the current medical management guidelines To know the current status of interventions How to prevent stroke?
Slide 3 : Sources AHA /ASA guideline- May-07 National clinical guideline for diagnosis and initial management of acute stroke and TIA-Royal college of Physicians-08 PROGRESS, HOPE, MATCH, PRoFESS trials etc
Slide 4 : What is Stroke ? A clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin (WHO).
Slide 5 : GLOBAL BURDEN Stroke has is now the second most common cause of death globally and the major cause of disability. Up to 20 million stroke events occur yearly, Worldwide, Accounts for 5.7 million deaths each year.” The incidence is expected to increase by another 30 percent by 2020 Prof. Geoffrey A. Donnan (Melbourne), president of the World Stroke Organization (WSO), World Stroke Congress 2008.
Slide 6 : BANGLADESH Not known (10% of all emergency admission in medical wards) SOMCH-13% of all medical admission
Slide 7 : RISK FACTORS
Slide 8 : RISK FACTORS
Slide 9 : A proposed structure for consideration for modifiable stroke risk factors 1 First-tier factors • The “big three” factors (based on population attributable risk) a. Hypertension b. Diabetes c. Cigarette smoking • Other first-tier factors a. Heart diseases b. Atrial fi brillation c. Left ventricular hypertrophy
Slide 10 : A proposed structure for consideration for modifi able stroke risk factors 2 Second-tier factors • Risk factors for risk factors. Examples: a. Obesity and body fat distribution b. Physical inactivity Risk factors important to control (regardless of stroke risk). Examples: a. Dyslipidemia b. Metabolic syndrome • Risk factors important in special populations a. Asymptomatic carotid stenosis b. Postmenopausal hormone therapy c. Sickle-cell condition Risk factors with a smaller effect or questionable effect (others)
Slide 11 : CLASSIFICATION OF STROKE
Slide 12 :
Slide 13 : Clinical features Sudden onset of: Weakness or paralysis – face, arm, hand, leg Numbness – face, arm, hand, leg Inability to speak or understand others Speech that is slurred or diffi cult to understand Dizziness (vertigo) or imbalance with walking Loss of vision in one or both eyes Unusually severe headache Can occur at any time, usually not with pain Symptoms usually occur in combination – area of brain injury
Slide 14 : Differential diagnosis of acute ischemic stroke
Slide 15 : Contd
Slide 16 : ACUTE STROKE MANAGEMENT Five mainstays Treatment of general condition that need to be stabilized Specific therapy directed against particular aspects of stroke pathogenesis Prophylaxis & treatment of complications which may be either neurological or medical Early secondary prevention Early rehabilitation
Slide 17 : Definition of Classes and Levels of Evidence Used in AHA Recommendations Classification     Class I Conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effective      Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment          Class IIa The weight of evidence or opinion is in favor of the procedure or treatment.          Class IIb Usefulness/efficacy is less well established by evidence or opinion.      Class III Conditions for which there is evidence and/or general agreement that the procedure or treatment is not useful/effective and in some cases may be harmful    
Slide 18 : Level of evidence for recommendation  A -Data derived from multiple prospective cohort studies that used a reference standard applied by a masked evaluator      B- Data derived from a single grade A study or one or more case–control studies or studies that used a reference standard applied by an unmasked evaluator      C- Consensus opinion of experts
Slide 19 : EMS Management of Patients With Suspected Stroke Recommended ABCs Cardiac monitoring IV access Oxygen (as required O2 saturation <92%) Assess for hypoglycemia Nil per os (NPO) Alert receiving ED Rapid transport to closest appropriate facility Not Recommended Dextrose-containing fluids in nonhypoglycemic patients Hypotension/excessive blood pressure reduction Excessive intravenous fluids
Slide 20 : Emergency Evaluation and Diagnosis of Acute Ischemic Stroke An organized protocol for the emergency evaluation of patients with suspected stroke is recommended (Class I, Level of Evidence B). Designation of an acute stroke team that includes physicians, nurses, and laboratory/radiology personnel is encouraged. Patients with stroke should have a careful clinical assessment, including neurological examination. The use of a stroke rating scale, preferably NIHSS is recommended (Class I, Level of Evidence B)
Slide 21 : Immediate Diagnostic Studies-AHA/ASA All patients Noncontrast CT or MRI Blood glucose Serum electrolytes/renal function tests ECG Markers of cardiac ischemia Complete blood count, including platelet count Prothrombin time/INR APTT Oxygen saturation Selected patients Hepatic function tests Toxicology screen Blood alcohol level Pregnancy test Arterial blood gas tests Chest radiography (if lung disease is suspected) Lumbar puncture (if SAH is suspected and CT scan is negative ) EEG (if seizures are suspected)
Slide 22 : CT scan Imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke (Class I, Level of Evidence A). Parenchymal haemorrhage can be identified almost immediately But smaller haemorrhages/ischaemic infarcts, particularly in brain stem may be missed Can detect majority of SAH
Slide 23 : Multimodal CT Whole-brain perfusion CT provides a map of cerebral blood volume &ischemic core. Dynamic perfusion CT provide absolute measures of CBF, mean transit time, and CBV. CT angiography provides a means to rapidly and noninvasively evaluate the vasculature, both intracranially and extracranially
Slide 24 : CT in a 37-year-old woman obtained 0.5 h after the onset of aphasia and right hemiparesis witnessed by her husband. The arrows indicate an area with subtle hypo-attenuating brain tissue.
Slide 25 : MRI Standard MRI sequences (T1 weighted, T2 weighted, and proton density) are relatively insensitive to the changes of acute ischemia.
Slide 26 : Multimodal MRI Diffusion-weighted imaging DWI allows visualization of ischemic regions within minutes Early identification of the lesion size, site, and age. Detect relatively small cortical or subcortical lesions, & brain stem or cerebellum, Perfusion-weighted imaging Measures the relative rate of blood flow to the brain Perfusion-diffusion mismatch (i.e. perfusion has reduced but DW signal change has not yet occurred) represent ‘ ischaemic penumbra’ GRE- can detect clinically silent prior microbleeds not visualized on CT
Slide 27 : Magnetic resonance imaging in acute stroke. Left: Diffusion-weighted MRI in acute ischemic stroke performed 35 minutes after symptom onset. Right: Apparent diffusion coefficient (ADC) map obtained from the same patient at the same time.
Slide 28 : Magnetic resonance imaging in acute stroke. Diffusion-perfusion mismatch in acute ischemic stroke. The perfusion abnormality (right) is larger than the diffusion abnormality (left), indicating the ischemic penumbra, which is at risk of infarction.
Slide 29 : Doppler ultrasound, MRA and CT angiography Imaging of carotid arteries should be undertaken in all patients with TIA & minor or recovered stroke in anterior circulation who are fit & willing surgery- RCP
Slide 30 : General Supportive Care and Treatment of Acute Complications Airway support and ventilatory assistance who have decreased consciousness or bulbar dysfunction causing compromise of the airway (Class I, Level of Evidence C. Hypoxic patients should receive supplemental oxygen (Class I, Level of Evidence C). Antipyretic to lower temperature in febrile patients (Class I, Level of Evidence C). Cardiac monitoring should be performed during the first 24 hours (Class I, Level of Evidence B).
Slide 31 : Management of arterial hypertension Remains controversial. Data to guide recommendations for treatment are inconclusive or conflicting. Many patients have spontaneous declines in BP during the first 24 hours . Until more definitive data are available, a cautious approach should be recommended (Class I, Level of Evidence C).
Slide 32 : Management before, during, and after treatment with reperfusion therapy Before treatment: If systolic pressure is >185 mm Hg or diastolic is >110 mm Hg Labetalol 10–20 mg IV over 1–2 minutes, may repeat ×1, or Nitropaste – apply 1–2 inches, or Nicardipine infusion, 5 mg/h, titrate dose by 0.25 mg/h at 5- to 10-minute intervals, maximum dose 15 mg/h achieve desiredblood pressure, reduce to 3 mg/h
Slide 33 : Contd : If systolic pressure is 180–230 mm Hg or diastolic is 105–120 mm Hg Labetalol 10 mg IV over 1–2 minutes, may repeat every 10–20 minutes, maximum dose of 300 mg, or Labetalol 10 mg IV followed by an infusion of 2–8 mg/min If systolic pressure is >230 mm Hg or diastolic is 121–140 mm Hg Labetalol 10 mg IV over 1–2 minutes, repeat every 10–20 minutes, maximum dose of 300 mg, or Labetalol 10 mg IV followed by an infusion of 2–8 mg/min, or
Slide 34 : Contd Nicardipine infusion, 5 mg/h, titrate dose of 0.25 mg/h at 5- to 10-minute intervals, maximum dose, 15 mg/h achieve desired blood pressure, reduce to 3 mg/h If blood pressure remains elevated, consider infusion of sodium nitroprusside
Slide 35 : Patients not given reperfusion therapies If systolic pressure is >220 mm Hg or diastolic pressure is >120 mm Hg Treat with medications similar to those patients given reperfusion therapies
Slide 36 : Contd. Hypovolemia should be corrected with normal saline, and cardiac arrhythmias that might be reducing cardiac output should be corrected (Class I, Level of Evidence C). Hypoglycemia should be treated (Class I, Level of Evidence C). The goal is to achieve normoglycemia. Marked elevation of blood glucose levels should be avoided.
Slide 37 : Contd. Evidence indicates that persistent hyperglycemia (>140 mg/dL) during the first 24 hours after stroke is associated with poor outcomes The serum glucose concentrations (possibly >140 to 185 mg/dL) probably should trigger administration of insulin(Class IIa, Level of Evidence C).
Slide 38 : Fluid & electrolyte management Monitoring & correction of electrolyte & fluid disturbances Hypotonic solutions are contraindicated due to risk of brain oedema Virtually all stroke patients need IV fluid, with a more or less positive balance, but avoid overloading A slightly negative fluid balance is recommended in presence of brain oedema
Slide 39 : Specific therapy Thrombolytic therapy- rtPA IV rtPA (0.9 mg/kg max. 90mg), with 10% IV bolus followed by inf. over 60 min. within 4.5 hrs. Favorable outcomes were achieved in 31% to 50% of patients treated with rtPA, as compared with 20% to 38% of patients given placebo at 3 M & 1 yr with respect to complete to near complete neurological recovery- NINDS
Slide 40 : Diagnosis of ischemic stroke causing measurable N. deficit Signs should not be clearing spontaneously. The neurological signs should not be minor and isolated. Caution should be exercised in treating a patient with major deficits. The symptoms of stroke should not be suggestive of SAH. Onset of symptoms <3 hours before beginning treatment No head trauma or prior stroke in previous 3 months No myocardial infarction in the previous 3 months No GI or urinary tract hemorrhage in previous 21 days No major surgery in the previous 14 days No arterial puncture at a noncompressible site in last 7 D No history of previous intracranial hemorrhage Characteristics of Patients Who Could Be Treated With rtPA
Slide 41 : BP not elevated (systolic <185 /110 mm Hg) No evidence of active bleeding or acute trauma (fracture) on examination Not taking an oral anticoagulant or, if anticoagulant being taken, INR <1.7 If receiving heparin in previous 48 hours, aPTT must be in normal range. Platelet count >100 000 mm3 Blood glucose concentration >50 mg/dL (2.7 mmol/L) No seizure with postictal residual neurological impairments CT does not show a multilobar infarction (hypo density >1/3 cerebral hemisphere). The patient or family members understand the potential risks and benefits from treatment AHA/ASA Contd.
Slide 42 : Infuse 0.9 mg/kg (max. 90 mg) over 60 min. with 10% given as a bolus over 1 min. Admit the patient to an ICU or Stroke unit for monitoring. Perform neurological assessments every 15 min, during the infusion and every 30 min. thereafter for the next 6 hrs, then hourly until 24 hrs. If the patient develops severe headache, acute hypertension, nausea, or vomiting, discontinue the inf. & obtain emergency CT . Measure BP every 15 min. for the first 2 hrs and subsequently every 30 min. for the next 6 hrs, then hourly until 24 hrs . Increase the frequency of BP measurements if a SBP is >180 mm Hg or if a DBP is >105 mm Hg; administer antihypertensive medications to maintain BP at or below these levels Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters. Obtain a follow-up CT scan at 24 hours before starting anticoagulants or antiplatelet agents. Treatment of Acute Ischemic Stroke: IV rtPA
Slide 43 : Antiplatelets The oral administration of aspirin (initial dose is 325 mg) within 24 to 48 hours after stroke onse(Class I, Level of Evidence A). If thrombolytic therapy is planned, no aspirin should be given Aspirin is not allowed for 24 hrs after thrombolytic therapy Who is allergic to or genuinely intolerant of aspirin should be given an alternative antiplatelet agent
Slide 44 : Newer antiplatelets Clopidogrel alone or in combination with aspirin is not recommended (Class III, Level of Evidence C). Outside the setting of clinical trials, the intravenous administration of antiplatelet agents that inhibit the glycoprotein IIb/IIIa receptor is not recommended (Class III, Level of Evidence B).
Slide 45 : Intra-Arterial Thrombolysis Intra-arterial thrombolysis for treatment of selected patients who have major stroke of <6 hours' duration due to occlusions of the middle cerebral artery (MCA) and who are not otherwise candidates for intravenous rtPA (Class I, Level of Evidence B).
Slide 46 : Anticoagulants Urgent anticoagulation with the goal of preventing early recurrent stroke, halting neurological worsening, or improving outcomes after acute ischemic stroke is not recommended (Class III, Level of Evidence A) Anticoagulant therapy confers no additional benefit over antiplatelet agents in acute stroke (and may be harmful) in the absence of specific indications- The Cochrane review
Slide 47 : Hemodilution in Acute Ischemic Stroke Hemodilution with or without venesection and volume expansion is not recommended for treatment of patients with acute ischemic stroke (Class III, Level of Evidence A). Vasodilators in Acute Ischemic Stroke The administration of medications such as pentoxifylline is not recommended for treatment of patients with acute ischemic stroke (Class III, Level of Evidence A).
Slide 48 : Recommendations for Surgical Interventions Data on the safety and effectiveness of CEA and other operations are not sufficient to permit a recommendation. Surgical procedures may have serious risks and may not favorably alter the outcome of the patient. Endovascular Interventions Although the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) device is a reasonable intervention for extraction of intra-arterial thrombi in carefully selected patients, the panel also recognizes that the utility of the device in improving outcomes after stroke is unclear (Class IIb, LOE B) AHA/ASA
Slide 49 : Neuroprotective Agents At present, no intervention with putative neuroprotective actions has been established as effective in improving outcomes after stroke, and therefore none currently can be recommended (Class III, Level of Evidence A).
Slide 50 : stroke units The use of comprehensive specialized stroke care (stroke units) incorporating rehabilitation is recommended (Class I, Level of Evidence A). Most effective with 87% of patients avoiding death or institutionalization after one year compared to conventional care Severe complications were reduced (5.9% vs. 25%, p<0.001).
Slide 51 : Definition of a stroke unit: A discrete area in the hospital Staffed by a specialist multidisciplinary team Access to equipment for monitoring and rehabilitating patients Regular multidisciplinary meetings occur for goal setting.
Slide 52 : Treatment of Acute Neurological Complications Major infarctions affecting the cerebral hemisphere or cerebellum are at high risk for complicating brain edema and? ICP. Measures to lessen the risk of edema and close monitoring of the patient for signs of neurological worsening during the first days are recommended Recurrent seizures after stroke should be treated in a manner similar to other acute neurological conditions (Class I, Level of Evidence B).
Slide 53 : Cerebral edema and increased intracranial pressure Osmotherapy using mannitol or hypertonic saline Intubation and hyperventilation Placement of intraventricular catheter – drainage of cerebrospinal fl uid Cerebellar infarction Surgical decompression With or without resection of necrotic tissue
Slide 54 : Early mobilization and optimumpositioning of people with acute stroke Should be mobilized as soon as possible (when their clinical condition permits) as part of an active management programme Should be helped to sit up as soon as possible (when their clinical condition permits)
Slide 55 : Prevention of Stroke Secondary prevention- measures taken to prevent recurrent attacks of stroke in persons who has already had at least one attack. Primary prevention- measure taken to prevent the very first attack of stroke.
Slide 56 : Primary Prevention Aim To reduce the risk of stroke in asymptomatic people Arterial hypertension Lowering high blood pressure substantially reduces the risk, depending on the magnitude by which BP is lowered Most studies comparing different drugs have not suggested that any class is superior Blood pressure should be lowered <140/<90 mmHg
Slide 57 : Primary Prevention-contd. Diabetes mellitus To treat DM appropriately More aggressive lowering BP<130/80 mmHg. Aspirin in diabetic patients older than 30 yrs Hyperlipidaemia Cholesterol lowering therapy is recommended for high risk patients
Slide 58 : Primary Prevention-contd. Cigarette smoking Smoking doubles the risk of ischaemic stroke Subjects who stop smoking reduce risk by 50% Alcohol consumption Heavy alcohol consumption should be avoided AHA/ASA
Slide 59 : Primary Prevention-contd. Lifestyle modification- Vigorous exercise was associated decreased risk of stroke: beneficial effect on body weight, BP, serum cholesterol & glucose tolerance A low salt, low saturated fat, high fruit & vegetable diet rich in fibre is recommended Subjects with elevated BMI should take weight reducing diet
Slide 60 : Primary Prevention-contd. Antithrombotic therapy Although aspirin does not reduce the risk of stroke in healthy subjects, it does reduce the risk of MI and can be recommended in subjects with one or more vascular risk factors Clopidrogrel, ticlopidine,trifusal and dipiridamole have not been studied in asymptomatic subjects and therefore can not be recommended for primary stroke prevention
Slide 61 : Primary Prevention-contd Antithrombotic therapy-contd Asymptomatic patients with a greater than 50% internal ICA stenosis should receive aspirin in order to reduce the risk of MI Long term oral anticoagulation therapy (target INR 2.5; range 2-3) should be considered for all AF patients at high risk of embolism: age >75,or age>60 plus risk factors such as high BP,LV dysfunction,& DM
Slide 62 : Primary Prevention-contd Antithrombotic therapy-contd Long-term aspirin (325mg/d) or warferin are recommended for patients with non-valvular AF at moderate risk of embolism: age 60-75 yrs. without additional risk factors Warferin is recommended for AF patients aged 60-75 yrs. with DM or coronary heart disease
Slide 63 : Primary Prevention-contd Antithrombotic therapy-contd Although not yet established by random studies, in patients over 75 yrs. warferin may be used with a lower INR ( target 2.0: range 1.6-2.5) to decrease the risk of haemorrhage Patients with AF unable to receive oral anticoagulants should be offered aspirin
Slide 64 : Primary Prevention-contd Carotid surgery and endovascular treatment for asymptomatic carotid stenosis Carotid surgery may be indicated for some asymptomatic patients with a 60-99% stenosis of the ICA. The carotid endarterectomy related risk of stroke or death must be less than 3%,and patients with a life expectancy of at least 5 yrs,( or under age of 80 yrs)
Slide 65 : Primary Prevention-contd Carotid artery angioplasty and stenting for asymptomatic stenosis Carotid artery angioplasty,with or without stenting, is not routinely recommended for patients with asymptomatic carotid stenosis
Slide 66 : Secondary Prevention Antiplatelet therapy The Antiplatelet Trialists Collaboration found a 36% reduction in myocardial infarction and a 16% reduction in vascular death in patients with stroke or TIA treated with antiplatelet agents Aspirin 50-325 mg should be given to reduce stroke recurrence
Slide 67 : Secondary Prevention-contd. Where available, the combination of aspirin (50mg) and long release dipiridamole (200mg twice daily) can be given as first choice Clopidrogrel is slightly more effective than aspirin It may also be prescribed as first choice or when aspirin and dipiridamole are not tolerated and in high risk patients
Slide 68 : Most recent recommendations From the XVII ESO released at the European Stroke Consortium in Nice, France in May 2008 use of antithrombotic therapy, where patients not requiring anticoagulation should receive antiplatelet therapy, with the combination of aspirin and dipyridamole, or clopidogrel alone where possible. Alternately, aspirin alone or trifusal alone may be used;
Slide 69 : Dual antiplatelet MATCH trial showed a small, nonsignificant benefit from dual therapy for short term (15.7% vs 16.7%; P = .24) There are three choices left now for neurologists treating high-risk stroke patients," Prof Hans-Christoph Diener (Essen University, Germany) said. "They can choose to use aspirin alone, clopidogrel alone, or dipyridamole plus aspirin."
Slide 70 : Antihypertensive treatment For the prevention of recurrent stroke and other vascular events in persons who have had an ischemic stroke or TIA and are beyond the hyperacute period (Class I,Level of Evidence A). Absolute BP target level and reduction is uncertain and should be individualized, but benefit has been associated with an average reduction of˜10/5 mm Hg, and normal BP levels have been defined as <120/80 mm Hg by the JNC 7 (Class IIa,Level of Evidence B).
Slide 71 : Contd As benefit extends to persons with and without a history of hypertension, this recommendation should be considered for all ischemic stroke and TIA patients (Class IIa, Level of Evidence B). Optimal drug regimen remains uncertain; the available data support the use of diuretics and the combination of diureticsand an ACE-I
Slide 72 : Contd Lifestyle modifications have been associated with BP reductions and should be included as part of comprehensive antihypertensive therapy (Class IIb,Level of Evidence C). The choice of specific drugs and targets should be individualized with consideration of specific patient characteristics (e.g., extracranial cerebrovascular occlusive disease, renal impairment, cardiac disease, and diabetes) (Class IIb, Level of Evidence C).
Slide 73 : Gontd To prevent stroke recurrence in patients with or without hypertension, only indapamide alone in PATS trial and indamide+perindopril in PROGRESS trial have been validated. Because the latter combination therapy decreased stroke recurrence risk by 43%, whereas indamide alone decreased it only by 29%, the combination therapy "indapamide+perindopril" should now be considered as the gold standard of secondary stroke prevention.
Slide 74 : ARB MOSES study has unequivocally shown that patients with a history of CV events, Eprosartan is more protective against both CV event recurrence and cardiac complications than nitrendipine. To establish which bitherapy is the most efficient in secondary stroke prevention, we propose that in association with indapamide (or another thiazide), Eprosartan (or another sartan) be compared with perindopril (or ramipril which decreased stroke risk by 32% in HOPE trial,).- Franz Messerli, MD . St Lukes-Roosevelt Hospital Center, New York
Slide 75 : Dyslipidemia Ischemic stroke or TIA patients with elevated cholesterol, comorbid CAD, or evidence of an atherosclerotic origin should be managed according to the NCEP III guidelines, which include lifestyle modification, dietary guidelines, and medication recommendations (Class I, Level A). Statin agents are recommended, and the target goal for cholesterol lowering for those with CHD or symptomatic atherosclerotic disease is an LDL-C of <100 mg/dL and an LDL-C of <70 mg/dL for very high-risk persons with multiple risk factors (Class I,Level A).
Slide 76 : Contd On the basis of the SPARCL trial, the administration of statin therapy with intensive lipid-lowering effects is recommended for patients with atherosclerotic ischemic stroke or TIA and without known CHD to reduce the risk of stroke and cardiovascular event (Class I, Level B). Ischemic stroke or TIA patients with low HDL-C may be considered for treatment with niacin or gemfi brozil (Class IIb, Level B).
Slide 77 : Contd Majority of patients with a history of ischemic stroke or TIA could benefit from stating use- AHA/ASA Scientific Advisory The consensus is that it would be safe to start stations after 48 hours- RCP
Slide 78 : Diabetes More rigorous control of BP and lipids should be considered in patients with diabetes (Class IIa, Level B). Although all major classes of antihypertensives are suitable for the control of BP, most patients will require more than 1 agent. ACE-Is and ARBs are more effective in reducing the progression of renal disease and are recommended as first-choice medications for patients with DM (Class I, Level A).
Slide 79 : Contd Glucose control is recommended to nearnormoglycemic levels among diabetics with ischemic stroke or TIA to reduce microvascular complications (Class I, Level A). The goal for HbA1C should be =7% (Class IIa, LevelB).
Slide 80 : Secondary Prevention-smoking Cigarette smoking substantially increases risk of stroke with relative risk values of 1.5 to 2.2. Risk of stroke increases with the number of cigarettes smoked. Smoking cessation promptly reduces risk of stroke - AHA
Slide 81 : Contd All ischemic stroke or TIA patients who have smoked in the past year should be strongly encouraged not to smoke (Class I, Level C). Counseling, nicotine products, and oral smoking cessation medications have been found to be effective for smokers (Class IIa, Level B). 3 Avoid environmental smoke (Class IIa, Level C).
Slide 82 : Alcohol Patients with prior ischemic stroke or TIA who are heavy drinkers should eliminate or reduce their consumption of alcohol (Class I, Level A). Light to moderate levels of =2 drinks per day for men and 1 drink per day for nonpregnant women may be considered (Class IIb, Level C).
Slide 83 : Obesity Weight reduction may be considered for all overweight ischemic stroke or TIA patients to maintain the goal of a BMI of 18.5–24.9 kg/m2 and a waist circumference of <35 inches for women and <40 inches for men. Clinicians should encourage weight management through an appropriate balance of caloric intake, physical activity, and behavioral counseling (Class IIb, Level C
Slide 84 : Physical activity For those with ischemic stroke or TIA who are capable of engaging in physical activity, at least 30 minutes of moderate-intensity physical exercise on most days may be considered to reduce risk factors and comorbid conditions that increase the likelihood of recurrence of stroke. For those with disability after ischemic stroke, a supervised therapeutic exercise regimen is recommended (Class IIb, Level C).
Slide 85 : Benefi t of CEA in symptomatic patients in the NASCET study *Angiographic measurement according to the NASCET method. †Risk of ipsilateral stroke. ‡Numbers needed to treat (NNT) to prevent one stroke at 2 years.
Slide 86 : Secondary Prevention- CEA The risk of ipsilateral stroke was reduced significantly (p=0.045) in patients with carotid stenosis 50-69% Patients with stenosis of 70-99% showed the most significant reduction (p < 0.001) in the rate of ipsilateral stroke While patients with stenosis of <50% did not show a significantly lower rate of ipsilateral stroke- NASCET CEA should not be performed in centers not exhibiting low complication rates (<6%)
Slide 87 : Carotid atherosclerotic disease For patients with recent TIA or ischemic stroke within the last 6 months and ipsilateral severe (70–99%) carotid artery stenosis, CEA is recommended by a surgeon with a perioperative morbidity and mortality of <6% (Class I, Level A). For patients with recent TIA or ischemic stroke and ipsilateral moderate (50–69%) carotid stenosis, CEA is recommended, depending on patient-specifi c factors such as age, gender, comorbidities, and severity of initial symptoms (Class I, Level A).
Slide 88 : Contd When degree of stenosis is <50%, there is no indication for CEA (Class III, Level A). When CEA is indicated, surgery within 2 weeks rather than delayed surgery is suggested (Class IIa, Level B). Among patients with symptomatic severe stenosis (>70%) in whom the stenosis is diffi cult to access surgically, medical conditions are present that greatly increase the risk for surgery, or when other specific circumstances exist such as radiation-induceds tenosis or restenosis after CEA; carotid artery stenting (CAS) is not inferior to endarterectomy and may be considered (Class IIb, Level B).
Slide 89 : Contd CAS is reasonable when performed by operators with established peri-procedural morbidity and mortality rates of 4–6%, similar to those observed in trials of CEA and CAS (Class IIa, Level B). Among patients with symptomatic carotid occlusion, extracranial circulation/intracranial circulation bypasssurgery is not routinely recommended (Class III,Level A).
Slide 90 : Contd Endovascular treatment of patients with symptomatic extracranial vertebral stenosis may be considered when patients are having symptoms despite medical therapies (antithrombotics, statins, and other treatments for risk factors) (Class IIb, Level C). CAS is reasonable when performed by operators with established peri-procedural morbidity and mortality rates of 4–6%, similar to those observed in trials of CEA and CAS (Class IIa, Level B).
Slide 91 : Contd. People with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according to the ECST criteria, should: Not undergo surgery Receive best medical treatment Carotid imaging reports should clearly state which criteria (ECST or NASCET) were used when measuring the extent of carotid stenosis.
Slide 92 : Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis Patients with symptomatic carotid stenosis of 60% or more, the rates of death and stroke at 1 and 6 months were lower with endarterectomy than with stenting-Jean-Louis Mas, M.D et alN Engl J Med 2007; 356:305-307
Slide 93 : Intracranial stenosis The usefulness of endovascular therapy (angioplasty and/or stent placement) is uncertain for patients with hemodynamically signifi cant intracranial stenoses who have symptoms despite medical therapies (antithrombotics, statins, and other treatments for risk factors) and is considered investigational (Class IIb, Level C).
Slide 94 : Cardioembolic strokes Atrial fibrillation For patients with ischemic stroke or TIA with persistent or paroxysmal (intermittent) AF, anticoagulation with adjusted-dose warfarin (target INR, 2.5; range, 2.0–3.0) is recommended (Class I, Level A). Patients unable to take oral anticoagulants, aspirin 325 mg/d is recommended (Class I, Level A).
Slide 95 : Acute MI and left ventricular thrombus For patients with an ischemic stroke caused by an acute MI in whom LV mural thrombus is identifi ed by echocardiography or another form of cardiac imaging, oral anticoagulation is reasonable, aiming for an INR of 2.0–3.0 for at least 3 months and up to 1 year (Class IIa, Level B). Aspirin should be used concurrently for the ischemic CAD patient during oral anticoagulant therapy in doses up to 162 mg/d, preferably in the enteric-coated form(Class IIa, Level A).
Slide 96 : Cardiomyopathy For patients with ischemic stroke or TIA who have dilated cardiomyopathy, either warfarin (INR, 2.0–3.0) or antiplatelet therapy may be considered for the prevention of recurrent events (Class IIb, Level C).
Slide 97 : Valvular heart disease Rheumatic mitral valve disease Ischemic stroke or TIA who have rheumatic mitral valve disease, whether or not AF ispresent, long-term warfarin therapy is reasonable, with a target INR of 2.5 (range, 2.0–3.0) (Class IIa, Level C). Antiplatelet agents should not be routinely added to warfarin in the interest of avoiding additional bleedingrisk (Class III, Level C).
Slide 98 : Contd For ischemic stroke or TIA patients with rheumatic mitral valve disease, whether or not AF is present, who have a recurrent embolism while receiving warfarin, adding aspirin (81 mg/d) is suggested (Class IIa, Level C).
Slide 99 : Contd Mitral valve prolapse For patients with MVP who have ischemic stroke or TIAs, long-term antiplatelet therapy is reasonable (ClassIIa, Level C). Mitral annular calcifi cation - For patients with ischemic stroke or TIA and MAC not documented to be calcifi c, antiplatelet therapy may be considered (Class IIb, Level C). Among patients with mitral regurgitation resulting from MAC without AF, antiplatelet or warfarin therapy may be considered (Class IIb, Level C).
Slide 100 : Aortic valve disease 1 For patients with ischemic stroke or TIA and aortic valve disease who do not have AF, antiplatelet therapy may be considered (Class IIa, Level C).
Slide 101 : Prosthetic heart valves Ischemic stroke or TIA who have modern mechanical prosthetic heart valves, oral anticoagulants are recommended, with an INR target of 3.0 (range, 2.5–3.5) (Class I, Level B). Mechanical prosthetic heart valves who have an ischemic stroke or systemic embolism despite adequate therapy with oral anticoagulants, aspirin 75– 100 mg/d, in addition to oral anticoagulants, and maintenance of the INR at a target of 3.0 (range, 2.5–3.5) are reasonable (Class IIa, Level B).
Slide 102 : Contd For patients with ischemic stroke or TIA who have bioprosthetic heart valves with no other source of thromboembolism, anticoagulation with warfarin (INR, 2.0–3.0) may be considered (Class IIb, Level C).
Slide 103 : Non-cardioembolic strokes For patients with non-cardioembolic ischemic stroke or TIA, antiplatelet agents rather than oral anticoagulation are recommended to reduce the risk of recurrent stroke and other cardiovascular events (Class I, Level A). Aspirin (50–325 mg/d) monotherapy, the combination of aspirin and extended-release dipyridamole, and clopidogrel monotherapy are all acceptable options for initial therapy (Class I, Level A).
Slide 104 : Contd The combination of aspirin and extended-release dipyridamole is recommended over aspirin alone (Class I, Level B). Clopidogrel may be considered over aspirin alone on the basis of direct-comparison trials (Class IIb, Level B). For patients allergic to aspirin, clopidogrel is reasonable (Class IIa, Level B).
Slide 105 : Contd 6 Addition of aspirin to clopidogrel increases the risk of hemorrhage and is not routinely recommended for ischemic stroke or TIA patients unless they have a specifi c indication for this therapy (i.e., coronary stent or acute coronary syndrome) (Class III).
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