and Post-Rehabilitation Care G. Bryan Young, MD, FRCPC Acute Stroke - - PowerPoint PPT Presentation

Primary Stroke Prevention and Post-Rehabilitation Care

• G. Bryan Young, MD, FRCPC

Acute Stroke Risk Factors Interstroke Study: Lancet 2016;388:761-775

• Hypertension: OR 2.98

(2.72-3.2)

• Regular physical activity:

OR 0.60 (0.52-0.70)

• Apolipoprotein B/A1:

OR1.84 (1.65-2.06)

• Diet (mAHEI): OR 0.60

(0.54-0.67)

• Waist-hip ratio: OR 1.44

(1.27-1.64)

• Psychosocial stress: OR

2.20 (1.78-2.72)

• Smoking: OR 1.67 (1.49-

1.87)

• Cardiac illness: OR 3.17

(2.68-3.72)

• Excessive alcohol: 2.09

(1.64-2.67)

• Diabetes m: OR 1.16

(1.05-1.30)

• Consistent across 32

countries, sexes and age groups.

Lessons

• 1. Stroke is largely preventable.
• 2. The number of risk factors reduced gives a

cumulative reduced risk of stroke:

• 1 risk factor: lowers risk by about 40%
• 5 risk factors: lowers risk by about 80%
• 3. Check all patients for stroke risk factors: at

least do BP, check pulse (for a fib), ask re: smoking.

Reducing Systolic BP

• 10 kg weight loss if
• verweight: 5-10 mm Hg
• DASH or Mediterranian

diet: 8-14 mm Hg

• Physical exercise: 4-9 mm

Hg

• Sodium reduction: 2-8

mm Hg

• Moderation of alcohol

intake: 2-4 mm Hg

Antihypertensive Drugs

• Each 10 mmHg drop in SBP  30%  stroke

risk.

• There is no consensus on the best

antihypertensive drug for stroke prevention.

• The greater the variability in SBP the greater

the stroke risk.

• CCBs produce the least variability; BB the

most variability

BP variability and Antihypertensive Drugs

CCB = Ca channel blockers, CCBND = nonpyridine CCB, DD = nonloop diuretic, ARB = angiotensin-2 receptor blocker, ACEI = ACE inhibitor, BB=beta blocker, AB = alpha-1 blocker.

Diuretics: Chlorthalidone vs. HCT

Category Relative Risk Significance

All cause mortality 0.94 (0.82-1.09) NS Stroke 0.96 (0.76-1.21) NS CHF 0.77 (0.61-0.98) 0.037 Cardiovascular events 0.79 (0.72-0.88) <0.001

NOACs vs Warfarin (Hicks et al. Open Heart 2016)

NOACs vs Warfarin and Ischemic Stroke (Hicks et al. Openheart 2016)

NOACs vs Warfarin

Yao et al. JAHA 2016

NOACs vs Warfarin: Bleeding Risk (Yao et al. JAHA 2016)

More Bleeding and Stroke Risk in Switch from NOAC to warfarin (Hicks et al. Openheart 2016)

NOACS and Nonvalvular Atrial Fibrillation: Conclusions

• Apixaban is superior to warfarin for stroke and

systemic embolism.

• All NOACs are superior to warfarin for ICH and

general bleeding complications (except for rivaroxaban for GI bleeding) –major source of reduced mortality.

• Risk of bleeding and stroke with switch from

NOAC to warfarin.

• Does not translate to other stroke pts with

mechanical heart valves.

Carotid endarterectomy for Asymptomatic Stenosis > 70%

• With medical

therapy there is a decline in stroke over time:

• 2.3-4.2 %

decline from 1996-2005 for any stroke.

CEA vs. Stenting vs. Medical Therapy for Asymptomatic CS

• Risk of stroke is 2.5% with CAS, 1.4% with CEA
• Risk with medical therapy is now <1.5 %.
• Probably no reason to consider stenting or

endarterectomy for asymptomatic carotid stenosis when optimal medical therapy is available.

ASA and primary stroke prevention AHA Guidelines – Meschia et al. Stroke 2014

ASA is recommended for:

• Pts with high risk for

cardiovascular events

• Women with high risk of

stroke (outweighing treatment risks).

• Low risk a fib patients (ASA

and clopidogrel better than ASA alone

• Patients with chronic renal

failure

• First 3 months after

bioprosthetic aortic valve ASA not recommended for:

• Diabetics, whether or not

they have PVD

• Patients at low stroke risk.

Questions?

Post-Rehab Follow-Up Issues

• Assess recurrent stroke risk.
• Function at home: fall risk, depression, safety

issues, caregiver burden, medication compliance, behavioural issues, sleep, re- integration into community.

• Driving?!
• Interaction with stroke outreach team

Post-Stroke Checklist (available on-line)

Reducing Risk of Another Stroke

• Control and monitor risk factors: BP (<140/90;

130/85 for diabetics or pts with kidney disease – PROGRESS trial), statin, antiplatelet drug for primary arterial cause, anticoagulant for cardioembolic stroke, salt intake, stop smoking, OSA Rx.

• Depending of recovery and presence of arterial

stenosis consider vascular surgery (usually after a month) for arterial cause of stroke.

Follow-up Questions

• Speak to patient and care-giver.
• Falls? Other safety issues.
• Depression (can use Geriatric Depression

Scale, also appetite, sleep).

• Behavioural issues?
• Medication – how administered?
• Caregiver burden? DayAway, help.

Driving

Highway Traffic Act Section 203(1)

• “Every legally qualified practitioner shall report to

the Registrar the name, address and clinical condition of every person sixteen years of age or

• ver attending upon the medical practitioner for

medical services who, in the opinion of the medical practitioner, is suffering from a condition that may make it dangerous for the person to

• perate a motor vehicle.”

Factors to Consider

• Visual-Perceptual Deficits: Visual field defects,

diplopia, neglect (extinction), visuospatial deficits, reading (?).

• Motor: hemiparesis, ataxia, reduced speed or

reaction time/initiation of movement.

• Cognitive: dementia, impaired judgment,

impulsivity, neglect, slow processing.

• Stability: fluctuations, seizures, drug side

effects.

Some Suggestions

• Speak to relatives privately: “I won’t let my

kids ride with him.” “He is too impulsive.”

• Do MoCA: assess visuospatial and executive

function especially; adjust for educational level.

• No driving for 1 month from discharge,

pending medical review.

• When in doubt, get OT assessment.

Interaction with Stroke Outreach Team

• Allow for two-way communication.
• Get reports from in-home assessments.
• Follow-up on concerns: re: driving,

swallowing, behaviour, depression, home situation.

Post-Stroke Events – Pt NLOL

• An 87 year old woman had a

cardioembolic stroke to her right hemisphere in March of 2016.

• She made a good recovery, but was

left with mild hand dysfunction and impaired cortical sensation.

• She was subsequently placed on

Apixaban 2.5 mg twice daily for nonvalvular atrial fibrillation.

• She presented in September 2016

with sudden pain in the left upper limb followed by “tremors” in the left hand and arm. Following this her left are was weak and dysfunctional.

• Pt. NLOL
• Follow-up CT was negative.
• She went on to have further clonic events in

the left upper limb, one of which became secondarily generalized.

• What would you do?

• Pt. NLOL
• Management with levetiractam 1000 mg

twice daily (after an initial load) was followed by cessation of seizures.

• Why levetiracetam?
• No interaction with apixaban.
• Recommendations: follow-up, no driving,

notifiy if side effects or further seizures.

Thank you!

Q and A