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 • Smoking: OR 1.67 (1.49- (2.72-3.2) 1.87) • Regular physical activity: • Cardiac illness: OR 3.17 OR 0.60 (0.52-0.70) (2.68-3.72) • Apolipoprotein B/A1: • Excessive alcohol: 2.09 OR1.84 (1.65-2.06) (1.64-2.67) • Diet (mAHEI): OR 0.60 • Diabetes m: OR 1.16 (0.54-0.67) (1.05-1.30) • Waist-hip ratio: OR 1.44 ----------------------- (1.27-1.64) - Consistent across 32 • Psychosocial stress: OR countries, sexes and age 2.20 (1.78-2.72) 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 overweight: 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 0.94 (0.82-1.09) NS mortality Stroke 0.96 (0.76-1.21) NS CHF 0.77 (0.61-0.98) 0.037 Cardiovascular 0.79 (0.72-0.88) <0.001 events
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: ASA not recommended for: • Pts with high risk for • Diabetics, whether or not cardiovascular events they have PVD • Women with high risk of • Patients at low stroke risk. 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
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 over 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 operate 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
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