stroke prevention talk3 feb 23 2016 · 2/19/2016 4 risk of first stroke 1 in 6 for men 1 in 5 for...

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Acute Stroke Best Practices Workshop“Advancing Best Practices in Acute Stroke Care”

Secondary Stroke Prevention

February 23, 2016

Sharon Jaspers NP

TBRHSC Stroke Prevention Clinic

Commerical Interests

Honorariums

Pfizer

Bayer

Moderator

Boehringer Ingelheim

Mitigating Factors for Conflict of Interest

No promotion of one particular medication, focus is onclass effect.

Objectives

Define main causative factors for stroke

Explore lifestyle/behaviour strategies that reduce stroke risk

Explore pharmacologic strategies for secondary strokeprevention

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Role of Stroke Prevention Clinic

• Outpatient clinic, in building adjacent to TBRHSC

• To assess people who have possible symptoms of TIA ormild non-disabling stroke

• Referral from E.D. , community/family MD/NP

• Fast track high risk cases in NWO

• Follow up care for patients diagnosed with stroke whohave been discharged from TBRHSC

• To investigate/review cause of stroke/TIA and assist withstrategies to prevent re-occurrence (secondary strokeprevention)

Our brains are incredibly complex

.←

Image copyright of FRONTIER Frontotemporal Dementia Research Group, 2008

http://functionofarubberduck.files.wordpress.com/2012/10/brain-dominance1.png

…..unless you are Homer

Images from http://www.angelfire.com/oh5/pearly/homer/homer-brain.html

Leading causes of death, Canada, 2007,males and females combined

http://www5.statcan.gc.ca/bsolc/olc-cel/olc-cel?catno=84-215-XWE&lang=eng

Adapted from: Ten leading causes of death, Canada, 2007. Statistics Canada

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Heart and Stroke: Canada Stats• Every year, patients with stroke spend more than 639,000

days in acute care in Canadian hospitals and 4.5 milliondays in residential care facilities (CSN, 2011b).

• Stroke costs the Canadian economy $3.6 billion a year inphysician services, hospital costs, lost wages, anddecreased productivity (2000 statistic) (PHAC, 2009)

• For every minute delay in treating a stroke, the averagepatient loses 1.9 million brain cells, 13.8 billion synapses,and 12 km of axonal fibers (Saver, 2006).

• Each hour in which treatment does notoccur, the brain loses as many neuronsas it does in almost 3.6 years of normal

aging (Saver, 2006).

Ontario Stroke Network: Stroke Report 2014• Fewer Canadians are dying from stroke, thanks to advances in

prevention, care and treatment….but still challenges ahead• Today’s stroke patient is sicker with two-thirds having one or more

chronic conditions, making treatment more complex• The population is aging and stroke is age-related – most common age

70 +• Younger patients are having strokes and this trend is expected to

continue –alarming escalation among those under 70. Over the pastdecade, strokes in people in their 50’s have increased by 24 %, thosein their 60’s by 13%

• Coordinated systems are the best way to ensurethe “right resources, in the right place,at the right time”.

• For every symptomatic stroke there are 9 silent strokesaffecting cognitive impairment “tsunami”

www.ontariostrokenetwork.ca

Your Life Time Risk of Stroke

Any guesses on what is your lifetime risk ofstroke if you were in the ages between

55 – 75 years of age?

http://www.ncbi.nlm.nih.gov/pubmed/16397184

Lifetime Risk of Stroke

1. 5%

2. 10%

3. 18-20%

4. 40%

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Risk of First Stroke1 in 6 for men

1 in 5 for women

• Females are slightly higher after age 85 due to longer lifeexpectancies

• Men have higher risk up to age 84.

• there are gender differences in stroke such as type of stroke,survival rates, outcomes, risk factors, etiologies that aredifficult to explain

• What are you currently doing that will help lower your overallstroke risk?

Falcone, G. 2007. Geriatrics and aging. http://www.medscape.com/viewarticle/564629

http://www.ncbi.nlm.nih.gov/pubmed/16397184

Image from http://www.firstnationswriter.com/images/photos/LarryStanding.jpg

Mike

Mike

retired

Last bloodtests when?

Sedentary lifestyledue to cold

winters

Family History ofatherosclerosis

Bloodpressure

nottreated,

Smoker

Dog died,stoppedwalking

Familyhistory ofDiabetes

Poor dietarypractices

Male

Previous MI,A-fibrillation

Waist circumference 117 cm

• STROKE !!!!!

• ISCHEMIC stroke

******* (Ischemic stroke is the focus for today)

What is Mike at High Risk for?

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What percentage of strokes areischemic type ?

1. 10%

2. 40%

3. 85%

4. 100%

Albers et al. Chest 2004; 126 (3 Suppl): 438S–512S.

Thom T, et al. Circulation 2006; 113(6): e85–e151.

Image from http://media-cache-ec0.pinimg.com/736x/6e/f3/44/6ef344297d1f0000144787d7bd83e265.jpg

Difference between an Ischemic Stroke and TIA

Image from http://0.tqn.com/d/stroke/1/U/8/-/-/-/stroke.jpg

What is the risk for recurrent strokeafter a TIA event in the first 48 hours?

1. 29%

2. 10%

3. 2%

4. 0%

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TIA – the Risk of Recurrent Event

25% of strokes are preceded by TIA25% of strokes are preceded by TIA (Rothwell & Warlow, 2005)

Early risk of stroke after TIA event2 days = 10%

30 days = 13.4%

90 days = 17.3% (Wu,C.M. et al 2007)

EXPRESS study – 80% reduction in the risk ofearly recurrent stroke with urgent assessmentand immediate initiation of treatment(Rothwell et.al. 2007)

THE OCCURRENCE OF A TIA provides a UNIQUEOPPORTUNITY for STROKE PREVENTION

“In TIA and mild Strokes, the emphasis is on rapididentification and treatment of the underlyingcause in order to prevent a recurrent and possiblymore severe event, whereas in a severe stroke theinitial emphasis of investigation is on targetingtreatment to minimize subsequent deficit”

(Rothwell, 2005)

Unlike an MI, there is no biological marker than can identify a TIA

Identifying signs of TIA/Stroke

(911 or equivalentin remotecommunities)

Public Campaign“New” Signs of Stroke Campaign (HSF 2014)

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Health Care Provider Campaignadapted from Canadian Stroke Best Practice

Recommendations 2014

NWO Regional Stroke Network, Thunder Bay Regional Health Sciences 2015

Health CareProviders

(Emergency/Primary Care)

TIA and MildNon-DisablingStroke Triage

Algorithm

Stroke Types and Incidence

LargeVessel Disease 20%

SmallVessel Disease 25%

Cardio embolism 20% atrial fibrillation valvular disease

Other 5% hyper-coaguable state Arterial dissection

Vertebral or carotid

Cryptogenic (ESUS) 30%

ESUS = Embolic Stroke of Undetermined Source

Public domain

Albers et al. Chest 2004; 126 (3 Suppl): 438S–512S. Thom T, et al. Circulation 2006; 113(6): e85–e151.


LargeVessel Disease 20% SmallVessel Disease 25%






Public domain


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Large Vessel Disease vsSmall Vessel Disease Stroke (aka Lacunar stroke)

Large Vessel

Small Vessel

http://www.bing.com/images/search?q=ischemic+stroke+penetrating+arteries&qs=n&form=QBIRMH&pq=ischemic+stroke+penetrating+arteries&sc=0-19&sp=-1&sk=&adlt=strict#view=detail&id=7FAB0484A53CDE0715F2FAE55EB77416F1ACDA6B&selectedIndex=3

MRI images of stroke

L

Small Vessel Disease Stroke

or Lacunar Stroke

http://www.hindawi.com/journals/srt/2011/726573.fig.006.jpg

http://www.ucl.ac.uk/ion/departments/repair/themes/stroke/images/Acute_Lacunar_Infarction2.JPG

Large VesselDisease Stroke

What is this?

1. Tim Horton donut

2. Diseased heart valve

3. Bull’s eye

4. Cross section of artery

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What is this?

Image from http://multivu.prnewswire.com/mnr/uaa/37598/images/37598-hi-Athero_Progression.jpg

Large Vessel Disease = Atherosclerosis

Image from http://howikis.com/images/thumb/7/71/Virtual.marian_ischemic_stroke.jpg/300px-Virtual.marian_ischemic_stroke.jpg

http://www.ijri.org/articles/2013/23/1/images/IndianJRadiolImaging_2013_23_1_26_113616_f11.jpg

CTA imagingCarotid Doppler Imaging

http://www.vascular.com.hk/attachments/Image/stroke/carotid2_eng_(Stroke).jpg

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Carotid Stenosis(extra-cranial stenosis/internal carotid arteries)

• Symptomatic pts with 50-99 % ICA stenosis should beoffered carotid artery procedure ASAP, with goal of within14 days of event– NNT 9 (one death or severe stroke is prevented for every 9

patients with symptomatic severe ICA stenosis– NNT 22 for moderate stenosis and no benefit for mild stenosis

• Asymptomatic and remotely symptomatic (> 3 mo) may beconsidered-stroke risk reduces from 2%/yr to 1%/yr

• Carotid endarterectomy is more appropriate than carotidstenting for pts over 70

Canadian Stroke Best Practice Recommendations 2014Cochrane Review (Rerkasem & Rothwell ) 2011NNINS:http://www.nids.nih.gov/disorders/stroke/carotid_endarterectomy/backgrounder.htm

http://www.northernsydneyvascular.com.au/images/CarotidArteryDisease5.jpg

http://media-cache-ec0.pinimg.com/736x/df/91/f3/df91f3e6a21686866c700b0cb3929b41.jpg

Endarterectomy vs Carotid Stenting

Intracranial StenosisStenting not recommended for recently

symptomatic intracranial stenosis

Aggressive medical management

was superior to intracranial

stenting for patients with

70-99% stenosis of a major

intracranial artery

SAMMPRIS trial 2011

http://neuro4students.files.wordpress.com/2010/03/cropped.jpg?w=510

Antiplatelet Therapy(large vessel disease)

• Which drug listed below is an antiplatelet?

• 1. apixaban

• 2. clopidogrel

• 3. warfarin

• 4. ASA

• 5. Aggrenox

• 6. 2 and 4 and 5

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Antiplatelet therapy• Substantial evidence from randomized trials and meta-

analyses supports the use of antithrombotic agents inpatients who have experienced an ischemic stroke toreduce the risk of future events. (Charisma Trial 2006, Profess Trial 2007, CSBPR 2014)

• Most commonly recommended antiplatelet agents forsecondary stroke prevention in North America andEurope are acetylsalicylic acid (ASA, 75 to 325 mg/day),clopidogrel and the combination of ASA and extended-release dipyridamole. (Canadian Stroke Best Practice Recommendations 2014)

– ASA 81 mg or– Clopidogrel 75 mg or– Aggrenox 1 tab bid

• CHANCE Trial (2013) small study with ASA/Plavix for short period, not yetutilized for best practice (Stroke. 2013; 44: 3623-3624)

• POINT Trial pending – larger population

Antiplatelets – Teaching Tip

• Advise patients that this medication is like alubricant, makes blood slippery

• Platelets or blood cells can “slip and glide”

• Teflon on frying pan

• Long term

• Take daily

• Not a true blood thinner

Image from http://wwwchem.csustan.edu/CHEM1102/IMAGES/honorlip.gif

Blood Fats and Atherosclerosis

Cholesterol Sources

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So what is Cholesterol?• Cholesterol is a fat like substance, or lipid

found in the blood stream

• It is a soft, waxy substance sometimes called ablood fat

• The body needs cholesterol: essential formaking hormones and vitamin D, producingbile salts to help in digestion, and for buildingcell walls.

Blood Fat or Lipid (LDL) Sources

http://www.lipidsonline.org/slides/talk_cme_activity.cfm?CME_activityid=71&talk_pk=31&tk=31&shownotes=1

Target Values• Target values depend on the patient’s risk of developing disease

which takes into account a number of factors (age, gender,cholesterol levels, smoker, family and personal history and lifestyle)

• Low risk – target LDL <5.0 mmol/L

• Moderate risk – LDL <3.5 mmol/L

• High risk Group Targets• LDL <2.0 mmol/L• Or apo B lipoprotein <0.80 g/l• NEW!!!!! Or non HDL < 2.6 mmol/L

CHEP 2014 Canadian Lipid Guidelines 2014

Canadian Cardiovascular Society Dyslipidemia Recommendations:http://www.onlinecjc.ca/article/S0828-282X(12)01510-3/abstract

http://myintrinsichealth.files.wordpress.com/2012/02/hdl20cholesterol.jpg

Management of Dyslipidemia• Lifestyle change in diet and exercise can lower cholesterol levels by

10 to 15%

– Not focusing on source of food containing cholesterol, butfocusing on lowering overall fat intake NEW!!!!!

• If this is not enough to achieve target, medication may be required

• Statins include:

– Pravachol (pravastatin),

– Zocor (simvastatin),

– Lipitor (atorvastatin) and

– Crestor (rosuvastatin)

• SPARCL trial 2006 found high dose statin therapy reducedrecurrent stroke events (RRR 16%) www.nejm.org/doi/full/10.1056/NEJMoa061894

• Plant Sterols: some data that they reduce LDL, but no studies yetto reduce recurrent stroke. www.hc-sc.gc.ca/fn-an/label-etiquet/nutrition/cons/claims-reclam/faq-eng.php

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How do Statins Work?• Decreases the manufacturing process of cholesterol

by the liver– HMG-CoA reductase inhibitor-causes competition of liver manufacture of cholesterol,

hence less is made.

Side Effects:- Considered to be safe, well tolerated- Muscle aches can occur- Rarely myopathy, need to measure liver enzymes by simple

blood testing 8-12 weeks after initiation of drug

– Can not interact with commonly prescribed drugs such asketoconazole, erythromycin, caution with large amounts ofgrapefruit juice in some statins

Role of Medications• STATINs

– LDL lowering medication

– Has only if any small impact on HDL and TRIG

– Appear to have additional effects that reducesatherosclerosis not sure why

• Anti inflammatory (prevent vessel injury)

• Anti thrombotic (prevent blood clumping)

• Plaque stability ( prevent instability and embolus)

• Plaque reduction (high doses of statin)

• Decreases hs CRP and increases nitric oxide

• Enhances endothelial growth and neuroprotection

• Proven to decrease risk of another stroke

Lifestyle Factors that reduceAtherosclerosis –Large vessel disease

• Smoking cessation

• Hypertension management

– Exercise

– Dietary – Sodium

– Healthy weight

– Alcohol consumption

• Obstructive Sleep Apnea management

Impact of lifestyle therapies onblood pressure

InterventionSystolic BP

(mmHg)Diastolic BP

(mmHg)

Diet and weight control -6.0 -4.8

Reduced salt/sodium intake -3.4 -2.2

Reduced alcohol intake (heavydrinkers)

-3.4 -3.4

DASH diet -11.4 -5.5

Physical activity -3.1 -1.8

Relaxation therapies -3.7 -3.5

Multiple interventions -5.5 -4.5

Clinical Guideline : Methods, evidence and recommendations National Institute for Health and Clinical Excellence(NICE) May 2011CHEP 2015

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Why treat hypertension?

A decrease of 10/5mm Hg(one medication or achange in lifestyle) reducesyour risk of developingserious hypertension-

related diseases.

CHEP 2014

BP Technique• Appropriate Cuff size

– Bladder of cuff should encircle 80% min. of the arm• 26-33 cm –standard size• 33-52 cm –large, obese adult

• Sitting is preferred (diagnostic & monitoring)

• Measure both arms at least once,arm with highest reading should be used thereafter

• At least three measurements should be taken in thesame arm, patient in same position. The first readingshould be discarded and the latter two averaged

RNAO, Best Practice Guidelines, Hypertension, 2009CHEP 2013

Dietary Approaches to StopHypertension DASH Diet

•The low sodium DASH diet evaluated the effect ofreducing sodium intake in combination with a DASHdiet. BP fell 11.4/5.5 mmHg in hypertensive personscompared to 3.5/2.1 in normotensives

•Mediterranean diet -Rich in fruits, vegetables, andnuts

low fat dairy foods, and low in fat, cholesterol andsalt

Appel et al. N Engl J Med 1997;336:1117.

CSBPR 2014

Sodium in Food (target < 2000 mg/day)

Pizza, hamburgers and hotdogs haveabout 1000 – 1200 mg sodium per serving

pickle = 800 mg sodium

http://everythingbecky.com/wp-content/uploads/2012/05/pickle.jpg

http://www.livestrong.com/article/264858-list-of-foods-that-have-sodium-nitrate/

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Sodium reduction interventions are as effective assmoking cessation interventions in saving lives

Dea

ths

(mill

ion

s)13.8

8.5

5.5

The Lancet, Volume 370, Issue 9604, 2044-2053, December 2007CHEP 2014

Changes in DBP, sodium intakeand stroke deaths in Finland

5600 mg

3360 mg

DBP Sodium Stroke

Karppanen H et al Progress, Cardiovascular Disease 2006;49:59-75CHEP 2014

5600 mg

3360 mg

Courtesy J.P. Després 2006CHEP 2014

Measure here

Iliac crest

Waist Circumference Measurement

Waist Circumference Men <102cm Women < 88 cm

ALCOHOL and Stroke Risk

• What is your definition of excessive alcoholintake?

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Lower Risk Drinking Guidelines

–15 standard drinks/wk for men(no more than 3/day)

– 10 standard drinks/week for women(no more than 2/day)

1 standard drink= 1 bottle beer or 1.5 oz liquor or spirits or 5 oz of wine

•In Canada, it is estimated that 8% ofhypertension in males is attributed to excessalcohol consumption

• Canadian Centre on Substance Abuse 2012

Antihypertensive Medications

Angiotensin Converting Enzyme Inhibitor (ACE)

Angiotensin Receptor Blocker (ARB)

Diuretics

Calcium Channel Blockers (CCB)

Beta Blockers

Image fromhttp://www.uky.edu/~mtp/hypertension/bhkahy.jpg

Canadian Hypertension EducationProgram 2015

Target Blood Pressure

• < 140/90

• Not optimally defined by research

• Elevated BP is significant risk factor– accounts for 60% of strokes

– Epidemiologic data have shown that those with aresponse to treatment attaining blood pressurelevels well below 140 systolic and 90 diastolic havebetter outcomes yet these treatment trials havenot yet clearly defined how far blood pressureshould be lowered

Canadian Best Practice Recommendations 2014

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Treatment of Hypertension in Association With Stroke

Acute Stroke: Onset to 72 Hours

Treat extreme BP elevation (systolic> 220 mmHg, diastolic > 120 mmHg)

by 15-25% over the first 24 hourwith gradual reduction after.

•If eligible for thrombolytic therapytreat very high BP (>185/110 mmHg)

Acuteischemic

Stroke

Avoid excessive lowering of BP which can exacerbate ischemia

CHEP 2014

Strongly consider blood pressure reduction in all patients afterthe acute phase of stroke or TIA .

Target BP < 140/90 mmHg

An ACEI or

ACEI/diuretic combinationis preferred

StrokeTIA

Combinations of an ACEI with an ARB are not recommended

Treatment of Hypertension in Association With StrokeAfter 72 hours

CHEP 2014

Summary: Treatment ofHypertension - stroke

CONSIDER

• Nonadherence• Secondary HTN• Interfering drugs or

lifestyle• White coat effect

Thiazidediuretic

Long-actingDHP CCB

Dual therapy

Triple therapy

Lifestyle modificationtherapy

ACE/ARB

TARGET <140 mmHg, < 130 if Diabetes or < 150 mmHg for age > 80 years

*If blood pressure is still notcontrolled, or there are adverseeffects, other classes ofantihypertensive drugs may becombined (such as ACEinhibitors, alpha blockers,centrally acting agents, ornondihydropyridine calciumchannel blocker).

• Low doses of multiple drugs may bemore effective and better tolerated thanhigher doses of fewer drugs

CHEP 2014

Public Domain

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What is the #1 Modifiable Stroke RiskFactor

A. Smoking

B. Hypertension

C. Alcohol Abuse

D. Dyslipidemia

Blood pressure target values for treatment of hypertension

Condition Target

SBP and DBP mmHg

Isolated systolic hypertension

Age > 80 years

<140

< 150

Systolic/Diastolic Hypertension

• Systolic BP

• Diastolic BP

<140

<90

Diabetes

• Systolic

• Diastolic

<130

<80

Goals of Therapy

CHEP 2014









Public domain


Large Vessel Disease vsSmall Vessel Disease Stroke (aka Lacunar stroke)

Large Vessel

Small Vessel

http://www.bing.com/images/search?q=ischemic+stroke+penetrating+arteries&qs=n&form=QBIRMH&pq=ischemic+stroke+penetrating+arteries&sc=0-19&sp=-1&sk=&adlt=strict#view=detail&id=7FAB0484A53CDE0715F2FAE55EB77416F1ACDA6B&selectedIndex=3

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MRI images of stroke

L

Small Vessel Disease Stroke

or Lacunar Stroke

http://www.hindawi.com/journals/srt/2011/726573.fig.006.jpg

http://www.ucl.ac.uk/ion/departments/repair/themes/stroke/images/Acute_Lacunar_Infarction2.JPG

Large VesselDisease Stroke

Small Vessel Disease of the Brain

1. HYPERTENSION• But multi-factorial

– Lifestyle factors

2. Smoking

3. Diabetes

Hypertension

• What BP is recommended for a personwithout diabetes?

1. < 150/90

2. > 140/80

3. < 140/90

4. < 120/80

5. < 130/80

SMOKING• 5 A’s

– Ask• Do you smoke?• Have you tried quitting?

– Advise• Have you thought of quiting,

– Assess• How important is it to you to quit? Scale of 1 – 10• How confident are you to quit? Scale of 1 – 10

– Assist• Talk about options/quit plan/support available

– Arrange• Follow up contact person/telephone

***** motivational interviewing*******

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Smoking• Nicotine Replacement Therapies 2x more

successful than “cold turkey” or “laser” or“hypnosis”

• Nicotine Replacement– 1 cigarette = 1 mg nicotine

– Match nicotine to cigarettes/day

– Inhalers/lozenges/nasal NRT is quick fix

– NRT patch provides slow/background nicotine

• E- cigarette – research unsure yet

• Varenicline – 3x more effective

• Buproprian CAMH –TEACH Program

Blood Glucose Control

• Diabetes is a major risk factor forcardiovascular disease and is recognized as anindependent risk factor for ischemic stroke

• risk of stroke is increased 1 – 3X , with a higherrisk of ischemic, rather than hemorrhagicstroke (Irdis et al. 2006).

Target A1c– Non diabetes <6%

– Diabetes <7% frail elderly <8.5%(Canadian stroke Best Practice Recommendations 2014, CDA Clinical Practice Guidelines 2015)

Ischemic Stroke LargeVessel Disease 20% SmallVessel Disease 25%



Vertebral or carotid Cryptogenic 30% (aka ESUS)

Embolic strokes may result from subclinical or “covert”AF, which mightrepresent one the of most commonly under diagnosed and untreated riskfactors for recurrent strokes

“There have also been important studies showing the benefits of various monitoring technologies todetect AF in high-risk populations, such as patients with cryptogenic stroke”.

(Canadian Journal of Cardiology vol 30, 2014)

Albers et al. Chest 2004; 126 (3 Suppl): 438S–512S.

Thom T, et al. Circulation 2006; 113(6): e85–e151.

http://www.nhlbi.nih.gov/health/health-topics/topics/af/signs.html

What’s the Differencebetween AntiThrombotics?

• ANTIPLATELET MEDICATIONSvs

• ANTICOAGULANT MEDICATIONSAntiplatelet

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Cardio-embolic source of clots

Atrial Fibrillation/Flutter:Major Risk Factor for Stroke

Singer DE, et al. Chest 2008;133(6 Suppl):546S-592S.

Atrial Fibrillation/Flutter

• Studies are showing that there is a significantnumber of high risk patients (ESUS orcryptogenic stroke) with undetected AF/Flutterthat may be at risk for stroke

• Stroke Prevention for with patients having atrialfibrillation/flutter has been recently revisited ina flurry of recent studies regarding

• Newer methods of detecting Afib/Flutter in high riskpopulations

• Options with oral anti-coagulation medications

• Options with better success with treatments ie ablation

Canadian Journal of Cardiology Volume 30 2014

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ANTI COAGULATION:For cardio – embolic causes

• Coumadin (INR to target) (for Afib/flutter and other cardio

embolic such as mechanical valves

NEW OAC for Afib/Flutter without the presence of valvular disease

• Dabigatran (Pradaxa)(use generic name to ↓ confusion with Plavix

• Rivaroxaban ( Xarelto)

• Apixaban (Eliquis)

REFER to CHART in Canadian Best Practice

Recommendations for Stroke Care 2012

strokebestpractices.ca

• Short ½ life (12 -17 hours)• Timing is very important – same time each day• No INR monitoring required• Need to monitor kidney function tests and CBC (and liver function tests if

apixaban or xarelto)• Rivaroxaban (Xarelto) to be taken with food (protein binding)• Dabigatran (Pradaxa) should be stored in original foil package (cannot be

stored open in a blister package or dossette)• Apixaban (Eliquis) is metabolized/excreted less by kidney, more by liver,

therefore good choice in elderly with diminished kidney function• Dosing based on kidney function, age• No reversal (anti-dote) available yet• $$$ but funded with NIHB and ODB and most private plans• No bridging required if anticipating surgery/procedures

New Oral Anticoagulants

PradaxTM (Dabigatran Etexilate capsules) Product Monograph, May 2013, Boehringer Ingelheim Canada Ltd.XareltoTM (Rivaroxaban tablet) Product Monograph, February 2013, Bayer Inc.

EliquisTM (Apixaban tablets) Product Monograph, November 2012, Pfizer Canada inc. and Bristol-Myers Squibb Canada

Heavy alcohol consumption (> 3/day) has increasedincidence of stroke

(Reynolds et al, 2003; Mazzaglia et al 2001, Patra & Rehm 2009)

– Ischemic stroke “J” curve in Caucasiansalcohol affects large vessels

(not Asians as they tend to have higher risk for small vessel disease)

• Cardiac arrhythmias, especially with binge drinking(cardioembolic stroke risk)

• Can lead to cardiomyopathy, especially with heavydrinking, which also increases the likelihood ofcardioembolic stroke

– Hemorrhagic stroke• Excess alcohol increases BP

• Excess alcohol -> coagulopathy

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Obstructive Sleep Apnea

• Associated with ↑ BP, arrhythmias, stroke and heart failure

• Under recognized problem and emergingindependent risk factor for stroke

• Recommend sleep screening

Eg STOP BANG toolchung et al 2008

STOP BANG Questionnaire to screen for OSA1. SnoringDo you snore loudly (louder than talking or loud enough to be heard through closeddoors)?2. TiredDo you often feel tired, fatigued or sleepy during daytime?3. ObservedHas anyone observe you stopping breathing during your sleep?4. Blood pressureDo you have or are you being treated for high blood pressure?5. BMI -BMI more than 35kg/m2?6. Age -age over 50 years old?7. neck circumference- neck circumference greater than 40?8. gender– gender-male?—————————————————-High risk of OSA –’ yes’ to three or more itemsLow risk of OSA – ‘yes’ to less than three items chung et al 2008

First Line Therapies• avoidance of hypnotic orsedative meds and alcohol•Positional therapy•Weight loss•C-PAP•Dental appliances•Manage vascular risk factors









Public domain


Birth Controland Hormone Replacement

• Both can increase risk of ischemic stroke

• Should review the risks and benefits of thesetreatments, and management alternativesshould be considered

• CBPRSC 2012

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Stroke Types and Incidence LargeVessel Disease 20%







Public domain


Navigate ESUS Study

• Randomizing ESUS patients into one of two treatmentgroups– ASA 100 mg– Rivaroxaban 15 mg

• study is intended to show, if patients given rivaroxabanhave fewer blood clots in the brain (stroke) or in otherblood vessels.

• 3 yr study• Currently recruiting

Recreational Drug Use

• The most commonly-used illicit drugs associated withincreased stroke risk are cocaine, amphetamines, Ecstasy,heroin/opiates, phencyclidine (PCP), lysergic aciddiethylamide (LSD), and cannabis/marijuana

• These drugs may increase the risk for stroke through a varietyof mechanisms including hypertensive surges, vasospasm,enhanced platelet aggregation, vasculitis, acceleratedatherosclerosis and cardioembolism.

Canadian Stroke Best Recommendation Recommendations 2014

Stroke Prevention

• Primary and Secondary PREVENTION muststart….

– By understanding personal risk factors

– One step at a time

– Encouragement

– Positive attitude

– START by YOU – share information, role modelling,refer ……..

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• How would you explain “hypertension” to yourpatient…what is the meaning of the numbers

• If a patient asked you what the big deal is aboutblood pressure, how would you respond?

• How do you encourage medication adherence

• What practical strategies would you discuss withyour patient to lower Na intake

• What analogies can you think of to describehypertension, dyslipidemia and stroke?

Putting it all Together

• From the brain, and from the brain only, ariseour pleasures, joys, laughter and jests, as wellas our sorrows, pain, griefs and tears……

Hippocrates 400 BC

QUESTIONS

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stroke prevention talk3 feb 23 2016 · 2/19/2016 4 risk of first stroke 1 in 6 for men 1 in 5 for...

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