PHRM 864: Therapeutics IV > Stroke > Flashcards

Stroke Flashcards

(51 cards)

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1
Q

What is the epidemiology of Stroke?

A
  • 800,000 Strokes yearly
  • 5th cause of death
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2
Q

What is the defintion of a Stroke?

A
  • An acute focal injury due to lack of blood/oxygen to the CNS causing Neurological deficits
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3
Q

What are the two types of stoke?

A
  • Ischemic
  • Hemorrhagic
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4
Q

What is the definition of Ischemic Stroke?

A
  • An infarction of brain tissue resulting fom compromised blood flow
  • Atherosclerotic: Increased plaque = Decreased Blood Flow
  • Cardioembolic: Embolism from Afib
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5
Q

What is the definition of Hemorrhagic Stroke?

A
  • Bleeding in the brain due to rupture of a cerebral artery - Aneurysm
  • Intracranial Hemorrhage
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6
Q

What are some of the risk factors for Stroke?

A
  • Non-Modifiable: Age, Family History, Females > Male, Race, Birth Weight, Sickle Cell
    Modifiable: CV Diseases, Diabetes, Hyperlipidemia, HTN, Alcohol, Obesity, Smoking
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7
Q

What is are some of the clinical presentations for Stroke?

A
  • Difficulty Speaking
  • Facial Droop
  • Weakness
  • Ataxia
  • Vision Changes
  • Headache [more common in Hemorrhagic]
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8
Q

What does FAST mean within Clinical Presentation in Stroke?

A
  • F: Facial Droop
  • A: Arm Weakness
  • S: Speech Difficulty
  • T: Time to call 911
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9
Q

What are some of the assessments used to help determine a stroke?

A
  • Imaging [Head CT or MRI}
  • Vitals [BP or Oxygen Sat}
  • Lab [BG, BMP, CBC, Hematologic Markers]
  • Test [ECG or Echo]
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10
Q

What is imporant to know about Imaging in Assessment with Stroke?

A
  • Head CT or MRI
  • A quick way to see what is happening within the brain
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11
Q

What is important to know about Tests [ECG] in Assessment within Stroke?

A
  • AFib = Cardioembolic
  • Noraml = Atherosclerotic
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12
Q

What are some of the Goals of Treatment for Acute Stroke?

A
  • Limit Neurological Injury
  • Decrease Mortality
  • Prevent Future strokes [After 1st stroke, increased risk of others]
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13
Q

What is the Acute Managment Overview for Stroke?

A
  • Supportive Care
  • Glycemic Control
  • Antihypertensives
  • Thrombolytics
  • Antiplatelets
  • Anticoagulation
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14
Q

What is important to know for Glycemic Control in Acute Managment of Stroke?

A
  • Hypoglycemia: causes neuro changes that “mimics” stroke –> GIVE CARBS
  • Hyperglycemia: BG > 180mg/mL has Increased Morbidity & mortality –> GIVE INSULIN until BG < 180mg/mL
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15
Q

What should you do if a patient is Hyperglycemic and in Acidosis within Stroke?

A
  • Insulin Drip
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16
Q

What is important to know about arguing FOR or AGAINST Acute Blood Pressure Management in Stroke?

A
  • FOR: Minimize neuro deficits, Decreased cerebral edema & hemorrhage, Prevention
  • AGAINST: decreased BP to quickly can limit the brain perfusion = worse ischemia & neuro function
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17
Q

What are some fo the blood pressure goals for Acute Management of Blood Pressure in Stroke

A
  • Check BP every hour
  • GOAL within 48h: NO tPA = <220/110 & WITH tPA = <180/105
  • After 48h: <140/90 or <130/80
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18
Q

What are some of the Acute Hypertension Treatment options for Acute Management of Blood Pressure in Stroke?

A
  • Labetalol, Nicardipine, Sodium Nitroprusside
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19
Q

What are the Thrombolytics that are used in Acute Ischemic Stroke Management?

A
  • Alteplase, Tenecteplase
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20
Q

Based on the mechanism of action for Thrombolytics, what type of Stroke would you use a Thrombolytic in?

A
  • Activates plasminogen which helps break apart the clot
  • Ischemic [both atherosclerotic and cardioembolic]
  • NOT in Hemorrhagic [increases bleed risk]
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21
Q

What is important about using Thrombolytics in Ischemic Stroke?

Types? What does it help?

Study These Flashcards
A
  • BOTH TYPES - Athero and Cardio
  • NO impact on mortailty but could improve neuro function
  • ONLY IN PATIENTS THAT MEET CRITERIA
22
Q

What is the tPA Eligibility criteria for Stroke?

Study These Flashcards
A
  • Inclusion: Ishchemic Stroke ONLY & symptom onset <4.5 hours
  • Exclusion: increased bleeding, BP > 185/110 & BG<50mg/dL
23
Q

What are the two tPA agents that are used ?

Study These Flashcards
A
  • Alteplase 0.9 mg/kg IV [MAX 90 mg]
  • Tenecteplase 0.25 mg/kg IV [MAX 25mg]
24
Q

What are some side effects from tPA agents in Stroke?

Study These Flashcards
A
  • Bleeding [increases hemorrhage risk] - KEEP BP < 180/105 & avoid ALL antiplatelet and Anticoag for 24h
  • Cerebral Edema
25
What are the Antiplatelet options for Acute Ishemic Stroke Management?
- **Aspirin** - Aspirin + Clopidogrel - Ticagrelor - Aspirin + Ticagrelor
26
What is important to know about Aspirin in Acute Ischemic Stroke Management? | MOA? When?
- MOA: **Irreversible** inhibitor of COX enzyme; reducing fromation of TXA2 = decreased platelet aggregation - **FIRST LINE** - **325 mg daily** for 2-4 weeks
27
Who gets aspirin for a stroke?
- **ALL** ischemic stroke [both **Embolic and Atherosclerotic**] - Contraindications: **Bleeding** - >24h **if** tPA given [**NO tPA** then immediately]
28
What important to know about Aspirin + Clopidogrel in Acute Management of Stroke?
- MOA: Clopidogrel = P2Y12 inhibitor that decreases platelet aggregation by blocking ADP - **ONLY** for minor strokes [NIHSS < 4] - **Second Line**
29
What is important to know about Ticagrelor in Actue Management of Stroke?
- P2Y12 inhibitor that decreases platelet aggregation by blocking ADP - **ONLY** for minor strokes [NIHSS < 5] - **Second Line** - Used when **True** aspirin allergy
30
When should you use therapeutic Anticoag be used within Acute Management of Stroke?
- **LACKs** research - no improvement of neuro & **Increased Bleeding** - **USE ASPIRIN**
31
What do you do if the patient comes in on an anticoagulant?
- **D/C** anticoag --> **START** aspirin - **NO** alteplase if on Anticoag
32
If the Patient is Cardioembolic what should you do with anticoagulant?
- **Start > 2-14 days after stroke**
33
What is the Acute Management overview of Hemorrhagic Stroke/
- Reversal Agents - Surgery - Prevention of Cerebral Vasospasm - Anticonvulsants
34
What are some of the Reversing Causative Medications that could be used in Acute Management of Hemorrhagic Stroke?
- **Vitamin K** = Warfarin - **Protamie** = Heparin - **Idarucizumab** = Dabigatran [DOAC] - **Andexxa** = Other DOAC - **NOTHING** = Antiplatelets
35
What are some fo the surgical options for Acute Management for Hemorrhagic Stroke?
- Craiotomy, Endoscopic Coiling, Endoscopic Evacuation
36
When should Antihypertensives be used in Acute Hemorrhagic Stroke?
- **Prevent** rebleeding by **controlling BP** - GOAL: **first 24h** = <180/110 - GOAL: **after 24h** = <160/90 - GOAL: **after 48h** = < 130/80 or <140/90
37
What is the way that we are able to prevent Vasospasm in Acute Management of Hemorrhagic Stroke/
- Vasospasms after **Subarachnoid** Hemorrhagic Stroke [4-21d after] - **Nimodipine** decreases vasospasms [60mg q4h x 21d]
38
When should Anticonvulsants be used in the Acute Management of Hemorrhagic Stroke?
- **Increased** risk of seizure after stroke - Prophylactic **NOT** recommended - Use **ONLY** is history of seizure
39
What is the goal of Antiplatelets in Secondary Stroke Prevention?
- **Prevent** future strokes by **inhibition of platelets** - **INDEFINITE TREATMENT**
40
What is the goal of Aspirin in Secondary Stroke Prevention?
- **FIRST LINE** - Start with **325mg** then switch to **81mg** - SE: **Bleeding, Nausea**
41
What is the goal of Dipyridamole/Aspirin [**Aggrenox**] in Secondary Stroke Prevention?
- MOA: Both inhibit the aggregation fo platelets - **FIRST LINE** - SE: **Headache & GI Bleeds**
42
What is the goal of Clopidogrel in Secondary Stroke Prevention?
- **SECOND LINE** - mainly used in **Atherosclerois** - SE: **Bleeding**
43
What is the goal of Clopidogrel + Aspirin in Secondary Stroke Prevention?
- For **Minor Stroke** [NIHSS < 3] = 1st line & **Mod-Severe** = 2nd Line - SE: Bleeding [increased in combo]
44
What are some fo the Other Antiplatelets in Secondary Stroke Prevention?
- Ticagrelor + Aspirin - Prasugrel - **NOT RECOMMENDED in guideline as treatment**
45
When should anticoagulants be used in Secondary Stroke Prevention?
- In **Cardioembolic** stroke caused by **AFIB** --> start > 2-14d after stroke
46
What are some of the anticoagulants that are used in Secondary Stroke Prevention?
- DOAC [Apixaban, Dabigatran, Edoxaban, Rivaroxaban] - Warfarin - **MECH VALVE = Warfarin/Rivaroxaban**
47
What is the Hypertension Management goal for Secondary Stroke Prevention?
- GOAL BP **<130/80** for **ALL** stroke types
48
What is the Hypertensive medications for Secondary Stroke Prevention?
- Black: **CCB, Thiazide** - CKD: **ACEi, ARBs** - CAD: **BB+ACEi [or ARBs]** - DM: **ACEi, ARBs** - HFrEF: **ARNI, ACEi, or ARBs + BB + Aldosterone Antagonist [+SGLT2]** - AFib: **BB or Non-DHP CCB**
49
When should Dyslipidemia be used in Secondary Stroke Prevention?
- After **atherosclerotic ischemic** should be given a **High Intensity Statin** [Ator 40-80mg or Rosuv 20-40mg] - GOAL: **LDL < 70** - **DO NOT** use statin in **Cardioembolic or Hemorrhagic**
50
What are some other Additional Risk Factors to reduce in Secondary Stroke Prevention?
- Cessation of Illicit Drugs [Cocaine] - Decrease Alcohol - Diabetes Control [**A1c < 7**] - Physical Acitivity - Dieting - Weight Loss - Smoking Cessation
51
When should Antidepressants be started in those that have had a stroke?
- **AFTER STROKE** - SSRIs [**Sertraline, Escitalopram, Citalopram**]
PHRM 864: Therapeutics IV
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