Stroke is caused by a reduction in blood flow to the brain, usually from a blood clot or burst blood vessel. Signs include weakness on one side of the body, speech problems, and vision loss. Stroke is a leading cause of disability in the US. Secondary prevention involves antiplatelet drugs like aspirin, statins to lower cholesterol, controlling hypertension, smoking cessation, physical activity and diet. Patients should have regular medical follow up after discharge from the hospital.
2. Stroke
• A neurological deficit (usually loss of function) caused by reduction in blood
supply to the brain. This is usually because a blood vessel bursts or is blocked
by a clot. This affects the supply of oxygen and nutrients, causing damage to
the brain tissue.
• Signs and symptoms: inability to move or feel on one side of the
body, problems understanding or speaking, dizziness, or loss of vision to one
side.
• Signs and symptoms appear soon after the stroke has occurrence.
• Stroke is the No. 5 cause of death in the United States. Someone in the
United States has a stroke every 40 seconds. Every four minutes, someone
dies of stroke.
• Stroke is a leading cause of long-term disability and the
leading preventable cause of disability.
• More women than men have strokes each year, in part because women
live longer.
3. What is FAST?
• F acial weakness - can the
person smile? Has their mouth
or eye drooped?
• A rm weakness - can the person
raise both arms?
• S peech problems - can the
person speak clearly and
understand what you say?
• T est – all 3
4. Types of Stroke
• Transient Ischaemic Attack (TIA) – a stroke which resolves within 24
hours
(10% risk of stroke within 7 days)
• Minor Stroke – a stroke resulting in persisting symptoms but not causing
significant disability
• Major Stroke – a stroke resulting in persistent deficit
5. Risk factors
Risk Factors For Stroke: Treatable
•Diabetes
•Hypertension
•Smoking
•Lifestyle
•Diet
•Cholesterol
•Heart disease, esp. atrial
fibrillation
•Transient ischaemic attacks
Less Well Documented
• Excessive alcohol intake / drug
abuse
• Acute infection
Risk Factors for Stroke That
Cannot Be Changed
• Increased age
• Being male
• Race (e.g., African-Americans)
• Family history of stroke
7. Physical activity
•Young should exercise daily for about 3 km a day.
•Older should do 30 mins walk atleast everyday.
Diet
•Dietary interventions center around fruits, vegetables, whole grains, and
long-chain omega-3- polyunsaturated fatty acids (fish and fish oils).
•Counsel and educate individuals with stroke about following a
Mediterranean-type diet, which is high in vegetables, fruits, whole grains,
fish, nuts and olive oil.
• Counsel and educate individuals with stroke and high blood pressure to
have a daily sodium intake from all sources to less than 2000 mg per day.
8. Smoking
• Smoking more than 20 cigarettes a day increases the risk of ischemic
and hemorrhagic strokes by 2-4 folds.
• The three classes of pharmacological agents that should be considered
as first-line therapy for smoking cessation are:-
-Nicotine replacement therapy
- Bupropion
- Varenicline
Alcohol
• Women are encouraged to restrict intake of alcohol to 10 drinks per
week (≤2 drinks per day) and men to no more than 15 drinks per week
(≤3 drinks per day).
• Counsel and educate individuals with stroke to avoid heavy alcohol use
(>5 drinks per day)
9. Antiplatelets
•Recommendations
•Clopidogrel 75mg daily OR Aspirin 75mg daily for 90 days and
Dipyridamole 200mg twice daily should be prescribed after
ischaemic stroke for secondary prevention of vascular events
•Aspirin alone – if dipyridamole intolerance
-(headache 26% withdrawal )
- or if carotid stenosis 70% or unstable angina
•The combination of aspirin and clopidogrel is not recommended for
prevention of ischaemic stroke or TIA
10. Statins
Statins are the drugs to lower the cholesterol in the
blood
• Statins significantly reduce relative risk of ischaemic
stroke by 21% but stroke death is not reduced
• Effect occurs without an increase in haemorrhagic
stroke
• Statins reduce coronary events and all cause mortality
• Effect occurs irrespective of baseline cholesterol level
(proportional to LDL lowering)
11. Statins
Recommendations
•A statin should be prescribed to patients who have had an ischaemic
stroke irrespective of cholesterol level
•Simvastatin 40mg per day – high risk coronary event
•Atorvastatin 80mg per day – TIA / ischaemic stroke
•Should not be used in patients with a prior history of intracerebral
haemorrhage
12. Anticoagulants
Non-cardioembolic ischaemic stroke
• Anticoagulants no more effective than aspirin
• No difference in all cause mortality between antiplatelets and
low or medium anticoagulation
• Higher mortality and major bleeding at intensive anticoagulation
Recommendation
Anticoagulation not recommended
13. Anticoagulants
Atrial fibrillation and ischaemic stroke
•Warfarin MORE effective for prevention of all vascular events and
recurrent stroke
•No significant increase in intracranial bleed
•Not within 2 weeks
Recommendation
•Warfarin should be offered with target INR of 2.0-3.0
OR
•Dabigatran (direct thrombin inhibitor) 110mg or 150mg twice a day may
become an alternative to warfarin
14. Antihypertensives
Well established link between BP reduction and stroke primary prevention
• Lowering BP reduced recurrent stroke and major vascular events
• No effect on vascular or all cause mortality
• Reduction in stroke related to difference in systolic BP between groups
15. Antihypertensives
Recommendation
•BP should be assessed in all patients and therapy with an ACE inhibitor
and thiazide diuretic should be considered regardless of BP
furosemide 20-400mg daily dose twice a day.
•Target blood pressure is <140/85 – diabetics <130/80 mmHg
16. Summary
Secondary Prevention of Ischaemic Stroke
• Aspirin 75mg + Dipyridamole 200mg twice daily
(or Clopidogrel 75mg if ACS)
• Simvastatin 40mg / Atorvastatin 80mg
• Thiazide diuretic –furosemide 20-400mg daily dose twice a day
• Warfarin or dabigatran if AF. Dabigatran (direct thrombin inhibitor)
110mg or 150mg twice a day
17. Follow up services
• A) If services such as the multidisciplinary community rehabilitation
services and carer support services are available, then early supported
discharge should be offered for all stroke patients with mild to moderate
disability.
• b) Rehabilitation delivered in the home setting should be offered to all
stroke survivors as needed.
Where home rehabilitation is unavailable, patients requiring rehabilitation
should receive centrebased
care.
• c) Contact with and education by trained staff should be offered to all
stroke survivors and families/
carers after discharge.
18. • d) Stroke survivors can be managed using a case management model
after discharge. If used, case
managers should be able to recognise and manage depression and help to
coordinate appropriate
interventions via a medical practitioner.
• e) Stroke survivors should have regular and ongoing review by a
member of a stroke team, including at
least one specialist medical review. The first review should occur within
three months, then again at
six and 12 months post discharge.
• f) Stroke survivors and their carers/families should be provided with
contact information for the
specialist stroke service and a contact person (in the hospital or
community) for any post-discharge
queries for at least the first year following discharge.
Editor's Notes
Stroke is a devastating disease
Scottish Executive has made a national priority
F face facial paresis
Arm arm drift
Speech abnormal speech
Test - requires an assessment of three specific symptoms of stroke
Simple accurate diagnostic tool anyone can do to improve speed and accuracy of diagnosis in patients with suspected stroke
If a person has failed any of these, it is crucial to call 999. Stroke is a medical emergency and by calling 999 you can help someone reach hospital quickly and receive the early treatment they need. Prompt action can prevent further damage to the brain and help someone make a full recovery. Delay can result in death or major long-term disabilities, such as paralysis, severe memory loss and communication problems.
2nd key message – Think FAST
These are other terms you may hear – all are treated with same medicines
10% risk of stroke within 7 days of TIA
There are a number of scales that measure extent of disability post stroke that help define these terms that I will mention later in relation to care issues
Risk factors can be divided into treatable and untreatable
Diabetes – can be treated but cannot change fact that have it
Smoking habit and Lifestyle – can change but socioeconomic status difficult to change
TIA or previous stroke – secondary prevention treatment
Smoking can double the risk of stroke and stopping can reduce risk by up to 50%
Concentrate on secondary prevention of ischaemic stroke which is where all evidence exists
SPARCL pts with no history of ischaemic heart disease – only TIA/stroke
HPS - pts with TIA/stroke simvs reduced risk of cardiac events but not recurrent stroke
Ie as long as ischaemic stroke not caused by a thrombus in the heart – no benefit of warfarin
Risk of recurrent stroke is 5% within 2 weeks in patients with AF post stroke
Increased incidence of AF and higher stroke risk in elderly so no cut off age for prescribing warfarin – risk/benefit in individual
