New AHA Guidelines New AHA Guidelines What is the blood pressure - PowerPoint PPT Presentation

UC SF NEUROCRITICAL CARE PROGRAM New AHA Guidelines New AHA Guidelines What is the blood pressure management after acute What is recommended in standard diagnostic ischemic stroke? All of the following are correct workup after acute ischemic stroke? except… 29% 27% A. Echocardiogram A. Treat BP to goal of < 180/105 mmHg 48% B. Extended cardiac monitor after IV tPA 18% C. Fasting lipids 13% 13% 27% B. Treat BP acutely if < 220/120 mmHg if no intervention D. Intracranial vessel imaging 13% 11% E. None of the above C. Treat BP to goal < 180/105 mmHg after embolectomy m s r d g e o n v a i o r t p g i g n i i b D. Treat BP acutely if > 220/120 mmHg if . . . . l a . . . . . . . o o g m a 0 0 / . 0 i 2 0 2 d m n e 8 i i h 1 2 8 2 r t l 1 a c s e t < < > c a a s < o i f f i f i f d F s o o a l h e l y y r v e patient has CHF, other co-morbidities a l o l c a n o e g e E c l t t a o g u o u d i c c n N o a t a e t P d a P B P r P n c B B t B e a a t t t t r a a e a x t e e r e E n r T r r T T I T Page 1

PFO Patient Case - Question PFO Patient Case - Question Would you close a In patients with PFO and large PFO in a 35 stroke, do you routinely year old with an screen for lower embolic stroke and extremity DVT? 60% atrial fibrillation? 54% A. Yes 46% 40% A. Yes B. No B. No Yes No s o e N Y ICH Patient Case - Question ICH Patient Case - Question 55 yo man with a 40 cc right basal ganglia 49 yo man with a small caudate ICH and significant intraventricular hemorrhage with ICH, chronic hypertension with refusal to hydrocephalus. His Glasgow Coma Scale take outpatient medications, and an score is 10. admission BP of 225/130 (MAP 162). His Glasgow Coma Scale score is 7. You decide to: 39% A. Perform neurological exams every What is your goal blood pressure after 6 2 hours to watch for worsening hours? B. Place a ventriculostomy and drain CSF at a 68% 16% 16% 15% 14% level of 10 cmH2O above the tragus A. SBP < 160 mmHg C. Place a ventriculostomy and measure ICP, B. MAP < 110 mmHg draining CSF to keep below 20 mmHg C. SBP < 140 mmHg D. Place a ventriculostomy and instill 2 mg of t- . . . . . . . u . . . a a x . . o 14% e y y y m m m t D. SBP < 180 mmHg l n 11% a o o o o c t t t PA into the ventricles i s s s e g o o o g o r l u l u l u l u 4% o 3% c c c s u r r i r i r i o t t t r e n n n u E. MAP < 140 mmHg n e e e e m v v v n E. Call a neurosurgeon to use an endovascular r a a a a o f e e e l l r c c c a e a a a C P l l l SBP < 160 mmHg MAP < 110 mmHg SBP < 140 mmHg SBP < 180 mmHg MAP < 140 mmHg P P P scope to remove the intraventricular clot Page 2

Highlights of New AHA Acute Highlights of New AHA Acute Ischemic Stroke Guidelines Ischemic Stroke Guidelines • IV Alteplase should be administered • Carotid imaging within 24 hours, within 4.5 hours to eligible patients, with revascularization between 48h and 7 faster door to needle times days in eligible patients recommended (goal 45-60 min) • Dual antiplatelet therapy with aspirin • Use of telestroke and teleradiology to and clopidogrel within 24 hours and faciltate acute stroke management and continued for 21 days in mild stroke triage, prioritize CT and CTA. patients not treated with IV tPA • Expanded mechanical thrombectomy • Start oral anticoagulants in patients with indications within 6 hours and 6-24 atrial fibrillation within 4-14 days hours in selected patients • High-intensity statin in patients with atherosclerosis < 75 years old Other ISC Trial Highlights • Tenecteplase non-inferior to alteplase. Showed improve outcomes wht embolectomy (EXTEND-IA TNK) • Rivaroxiban (2.5 mg) + aspirin decreased secondary stroke by half (COMPASS trial) • First stroke reduced by 44 percent with candesartan/HCTZ, rosuvastatin 10 mg (HOPE-3 trial) Page 3