Latest trends in Care of the Stroke Patient - PowerPoint ...


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  • AIAN gap between highest and lowest quintiles is 5fold, but only 2fold for us as a whole. Greatest of all groups
    North-south trend.
    If wanted to plan a program aimed at NA, would miss this trend if looked only at the map for all persons.
  • Latest trends in Care of the Stroke Patient - PowerPoint ...

    1. 1. Latest Trends in CareLatest Trends in Care of the Stroke Patientof the Stroke Patient William J. Meurer, MDWilliam J. Meurer, MD Clinical Lecturer and Stroke FellowClinical Lecturer and Stroke Fellow University of Michigan Stroke ProgramUniversity of Michigan Stroke Program Departments of Emergency MedicineDepartments of Emergency Medicine and Neurologyand Neurology
    2. 2. ObjectivesObjectives  Review concise clinical pearls inReview concise clinical pearls in caring for the acute stroke patientcaring for the acute stroke patient  Review results of past research thatReview results of past research that may influence your practicemay influence your practice  Discuss recently announced acuteDiscuss recently announced acute stroke researchstroke research  Provide overview of ongoing researchProvide overview of ongoing research which may influence your practice inwhich may influence your practice in futurefuture
    3. 3. DisclosuresDisclosures  My salary is provided by theMy salary is provided by the University of MichiganUniversity of Michigan  No other financial supportNo other financial support  I WILL discuss some off label uses ofI WILL discuss some off label uses of medicationsmedications
    4. 4. OverviewOverview  Review scope and disease process ofReview scope and disease process of strokestroke  Review clinical guidelines and pearlsReview clinical guidelines and pearls  Discuss recent advancesDiscuss recent advances  Discuss ongoing national and localDiscuss ongoing national and local researchresearch
    5. 5. Stroke Facts • Third leading cause of death – Over 160,000 deaths per year • 750,000 strokes per year • Over 4 million stroke survivors • Leading cause of adult disability – Of those who survive, 90% have deficit 1. Williams GR, Jiang JG, Matchar DB, et al. Stroke 1999; 30:2523-28. 2. Hoyert DL, Kochanek KD, Murphy SL. National Vital Statistics Report 1999; 47:19.
    6. 6. Annual rate of first cerebral infarction by age, sex and raceAnnual rate of first cerebral infarction by age, sex and race (Greater Cincinnati/Northern Kentucky Stroke Study: 1993-94).(Greater Cincinnati/Northern Kentucky Stroke Study: 1993-94). Source: Unpublished data from the GC/NKSS; Kissela et al., Stroke. 2004;35:426-31.Source: Unpublished data from the GC/NKSS; Kissela et al., Stroke. 2004;35:426-31.
    7. 7. Smoothed County Stroke Death Rates:Smoothed County Stroke Death Rates: Adults 35 and Older, 1991-98Adults 35 and Older, 1991-98 Source: CDC. Atlas of Stroke Mortality: Racial, Ethnic and Geographic Disparities in the United States, Jan. 2003
    8. 8. Michigan’s Stroke BeltMichigan’s Stroke Belt Source : The Atlas of Stroke Mortality
    9. 9. Acute Stroke / ASA GuidelinesAcute Stroke / ASA Guidelines  tPA if indicated and exclusionstPA if indicated and exclusions absentabsent  Anti-platelet within 48 hours (do notAnti-platelet within 48 hours (do not give with tPA)give with tPA)  Permissive hypertensionPermissive hypertension  No IV anticoagulants (i.e. heparin) –No IV anticoagulants (i.e. heparin) – DVT prophylaxis okay (after 48 hr ifDVT prophylaxis okay (after 48 hr if tPA given)tPA given)  CT remains standard acute imagingCT remains standard acute imaging
    10. 10. ASA guidelines – ischemic strokeASA guidelines – ischemic stroke  If not receiving thrombolyticsIf not receiving thrombolytics – Do not treat unless SBP > 220 or DBP >Do not treat unless SBP > 220 or DBP > 120120  If receiving thrombolytics treat ifIf receiving thrombolytics treat if – PreRx SBP > 185 DBP > 110PreRx SBP > 185 DBP > 110 – PostRx SBP > 180 DBP > 105PostRx SBP > 180 DBP > 105
    11. 11. Doesn’t ACEP also have aDoesn’t ACEP also have a guideline?guideline?  Has practice guidelineHas practice guideline  – type acute – type acute stroke into search boxinto search box  I recommend you read it yourselvesI recommend you read it yourselves if interestedif interested
    12. 12. Copied from ACEP websiteCopied from ACEP website verbatimverbatim  EDs and hospitals should work withEDs and hospitals should work with emergency medical services and theemergency medical services and the community so that all parties knowcommunity so that all parties know what the hospital's capabilities arewhat the hospital's capabilities are regarding acute stroke care.regarding acute stroke care.  Further studies are needed to defineFurther studies are needed to define more clearly those patients mostmore clearly those patients most likely to benefit from fibrinolyticlikely to benefit from fibrinolytic therapy in acute ischemic stroke.therapy in acute ischemic stroke.
    13. 13. Copied from ACEP websiteCopied from ACEP website verbatimverbatim  Intravenous tPA may be anIntravenous tPA may be an efficacious therapy for theefficacious therapy for the management of acute ischemicmanagement of acute ischemic stroke if properly used incorporatingstroke if properly used incorporating the guidelines established by thethe guidelines established by the National Institute of NeurologicalNational Institute of Neurological Disorders and Stroke (NINDS).Disorders and Stroke (NINDS).
    14. 14. Copied from ACEP websiteCopied from ACEP website verbatim (bolding mine)verbatim (bolding mine)  There is insufficient evidence at this time toThere is insufficient evidence at this time to endorse the use of intravenous tPA in clinicalendorse the use of intravenous tPA in clinical practicepractice when systems are not in place towhen systems are not in place to ensure that the inclusion/exclusion criteriaensure that the inclusion/exclusion criteria established by the NINDS guidelines for tPAestablished by the NINDS guidelines for tPA use in acute stroke are followeduse in acute stroke are followed. Therefore,. Therefore, the decision for an ED to use intravenous tPA forthe decision for an ED to use intravenous tPA for acute stroke should begin at the institutional levelacute stroke should begin at the institutional level with commitments from hospital administration,with commitments from hospital administration, the ED, neurology, neurosurgery, radiology, andthe ED, neurology, neurosurgery, radiology, and laboratory services to ensure that the systemslaboratory services to ensure that the systems necessary for the safe use of fibrinolytic agentsnecessary for the safe use of fibrinolytic agents are in place.are in place.
    15. 15. tPAtPA
    16. 16. A. Hernandez, M.I. Rochera, R. Angles, M. Farre, J. Caballero: Hemorrhagic Transformation And A New Ischemic Accident During Thrombolysis Treatment With rtPA. The Internet Journal of Emergency and Intensive Care Medicine. 2006. Volume 9 Number 1
    17. 17. Acute stroke - summaryAcute stroke - summary  Time is brain (notify, notify, notify)Time is brain (notify, notify, notify)  tPA is your friendtPA is your friend  Watch for fluctuationWatch for fluctuation  Treat feverTreat fever  Consider treating hyperglycemiaConsider treating hyperglycemia  Use crystalloid (think perfusion)Use crystalloid (think perfusion)  Avoid dropping BP in ischemic strokeAvoid dropping BP in ischemic stroke  Acute Stroke Protocol in place andAcute Stroke Protocol in place and ready to go!ready to go!
    18. 18. Important advance – primary strokeImportant advance – primary stroke centerscenters  Acute Stroke TeamsAcute Stroke Teams  Written Care ProtocolsWritten Care Protocols  Emergency Medical ServicesEmergency Medical Services  Emergency DepartmentEmergency Department  Stroke UnitStroke Unit  Neurosurgical ServicesNeurosurgical Services  Support of Medical OrganizationSupport of Medical Organization  NeuroimagingNeuroimaging  Laboratory ServicesLaboratory Services  Outcomes/Quality ImprovementOutcomes/Quality Improvement  Education ProgramsEducation Programs
    19. 19. Primary Stroke Centers (JCAHO)Primary Stroke Centers (JCAHO) Bixby Medical Center Borgess Medical Center Bronson Methodist Hospital Detroit Receiving Hospital/University Health Center Henry Ford Hospital and Health Network Herrick Memorial Hospital Metro Health Hospital Northern Michigan Hospital Providence Hospital and Medical Centers Saint Mary’s Health Care - Grand Rapids, Mich. Sparrow Hospital Spectrum Health - Blodgett Campus Spectrum Health-Butterworth Campus St. Joseph Mercy Oakland St. Mary’s of Michigan Medical Center University of Michigan Health System – MMC William Beaumont Hospital
    20. 20. Florida Stroke ActFlorida Stroke Act  Required EMS to take patients toRequired EMS to take patients to primary stroke centers (JCAHO orprimary stroke centers (JCAHO or state certified)state certified)  Resulted in significantly increasedResulted in significantly increased utilization of tPA at certified centersutilization of tPA at certified centers  Resulted in increased stroke volumeResulted in increased stroke volume at certified centersat certified centers
    21. 21. Important Advance – Stroke UnitsImportant Advance – Stroke Units  Outcomes improved (trends)Outcomes improved (trends) – Decreased disabilityDecreased disability – Reduced discharges to nursing homesReduced discharges to nursing homes – Reduced mortalityReduced mortality  Behavior changedBehavior changed – Increased use of tPAIncreased use of tPA
    22. 22. Important advance –Important advance – telemedicinetelemedicine
    23. 23. DisclaimerDisclaimer  Discussion from this point (otherDiscussion from this point (other than summary) is regardingthan summary) is regarding experimental therapiesexperimental therapies  Some of these may be offered toSome of these may be offered to patients at centers in Michiganpatients at centers in Michigan currentlycurrently  Some may notSome may not  Some may turn out not to work…Some may turn out not to work…
    24. 24. Options other than tPAOptions other than tPA  Intra-arterial tPA (upIntra-arterial tPA (up to 6 hours)to 6 hours)  MERCI retrieval (up toMERCI retrieval (up to 6-8 hours)6-8 hours)  Either could beEither could be considered in selectedconsidered in selected cases when systemiccases when systemic tPA contra-indicatedtPA contra-indicated or outside 3 hror outside 3 hr windowwindow  Severity requirementSeverity requirement Source: Imaging Economics, November 2005
    25. 25. MERCI DeviceMERCI Device Source: St. Petersburg Times, October 2003
    26. 26. Recent Negative ResearchRecent Negative Research  NXY-059 (SAINT II)NXY-059 (SAINT II) – Neuro-protective agentNeuro-protective agent – Primary outcome not reachedPrimary outcome not reached  NovoSevenNovoSeven – Recombinant Factor VIIaRecombinant Factor VIIa – Hemostatic agent (ICH)Hemostatic agent (ICH) – Primary Outcome Not ReachedPrimary Outcome Not Reached – No longer seeking FDA approvalNo longer seeking FDA approval
    27. 27. Activated Factor VIIaActivated Factor VIIa
    28. 28. NXY-059 (SAINT-II)NXY-059 (SAINT-II)
    29. 29. Ongoing Acute Stroke Research atOngoing Acute Stroke Research at UMHSUMHS  Multi-centerMulti-center – CLEARCLEAR – TNKTNK – INSTINCTINSTINCT – NETTNETT
    30. 30. TNK / CLEARTNK / CLEAR  Studying alternate thrombolyticStudying alternate thrombolytic regimens to tPAregimens to tPA  Similar inclusionSimilar inclusion  Similar outcome measuresSimilar outcome measures  Proposed as potentially safer agentsProposed as potentially safer agents
    31. 31. INSTINCTINSTINCT  Multi-center trialMulti-center trial  Targeted educational interventionTargeted educational intervention  Involves 24 hospitals in MichiganInvolves 24 hospitals in Michigan  Primary endpoint is appropriate usePrimary endpoint is appropriate use of tPAof tPA
    32. 32. NETTNETT  A multi-centerA multi-center network to engage innetwork to engage in acute treatment trialsacute treatment trials in Neurologicin Neurologic EmergenciesEmergencies  System of hubs andSystem of hubs and spokesspokes  U of M is clinicalU of M is clinical coordinating centercoordinating center  Henry Ford andHenry Ford and Wayne State are hubsWayne State are hubs
    33. 33. What is being studiedWhat is being studied elsewhereelsewhere  Encouraging pilot / safety studiesEncouraging pilot / safety studies  Highlighting therapies which mayHighlighting therapies which may have impact on acute care in futurehave impact on acute care in future
    34. 34. IMS-2IMS-2  2/3 of standard dose tPA given (0.62/3 of standard dose tPA given (0.6 mg/kg)mg/kg)  Cerebral angiogramCerebral angiogram  Additional bolus and infusion atAdditional bolus and infusion at embolism siteembolism site
    36. 36. Therapeutic hypothermiaTherapeutic hypothermia  Recommended therapy for comatoseRecommended therapy for comatose survivors of out of hospital cardiac arrestsurvivors of out of hospital cardiac arrest  Feasibility study done in stroke – furtherFeasibility study done in stroke – further work ongoingwork ongoing
    37. 37. Prehospital MagnesiumPrehospital Magnesium  Novel system in LA countyNovel system in LA county  IV magnesium sulfate given to patientsIV magnesium sulfate given to patients identified in the field with severe acuteidentified in the field with severe acute ischemic strokeischemic stroke 
    38. 38. Summary – take home pointsSummary – take home points  Time to treatment is keyTime to treatment is key  Treat fever / hyperglycemiaTreat fever / hyperglycemia  Permissive HTN in acute ischemicPermissive HTN in acute ischemic strokestroke  There are options beyond 3 hoursThere are options beyond 3 hours  A great deal of exciting research isA great deal of exciting research is going on in Michigan and around thegoing on in Michigan and around the worldworld
    39. 39. Neurology Lewis B. Morgenstern, MD Director Devin L. Brown MD, MS Michael M. Wang MD PhD Kate Maddox, RN Darin Zahuranec, MD Jennifer Majersik, MD William Meurer, MD Neurosurgery Julian T. Hoff, MD B. Gregory Thompson, MD Emergency Medicine William G. Barsan, MD Phillip A. Scott, MD Robert Silbergleit, MD Shirley Frederiksen, MS, BSN Annette Sandretto, MSN William Meurer, MD Cardiology Kim A. Eagle, MD Epidemiology Lynda D. Lisabeth PhD Mary N. Haan, PhD Radiology Ellen Hoeffner, MD Dheeraj Gandhi, MD Joe Gemette, MD The University of Michigan Comprehensive Stroke Program Physical Medicine & Rehabilitation Lisa DiPonio, MD
    40. 40. University of Michigan StrokeUniversity of Michigan Stroke ProgramProgram  Website –Website –  My email –My email –  Please feel free to contact me if youPlease feel free to contact me if you would like an educational program atwould like an educational program at your site!your site!