Victor C. Urrutia, MD, FAHA Assistant Professor Director, The Johns Hopkins Hospital Stroke Center

1. Stroke Prevention, a New Approach Victor C. Urrutia, MD, FAHA Assistant Professor Director, The Johns Hopkins Hospital Stroke Center Department of Neurology Johns Hopkins University School of Medicine vurruti1@jhmi.edu

2. Objectives • New TIA concept • Review stroke risk factors • Update on evidence based preventive interventions for intracranial stenosis • Present a new model for stroke prevention

3. Disclosures • Atrial fibrillation advisory board (1/30/12). Janssen Pharmaceuticals • Johns Hopkins Hospital site PI for DIAS 4 (Lundbeck) and POINT (NINDS) • PI for SAIL ON, funded by Genentech • I will mention off label use of approved medications

4. Introduction • WHO estimates that stroke is the 2nd leading cause of death in the world • 5.7 million affected each year • Stroke is the 4th leading cause of death in the US • 610, 000 1st time strokes • 65.5 billion in costs Roger VL, Go AS, Lloyd-Jones DM, et al. Circulation 2011 123:e18-e209

5. Stroke or TIA? • “Transient ischemic attack (TIA): a transient episode of neurological dysfunction caused by a focal brain, spinal cord, or retinal ischemia, without acute infarction” Easton JD, Saver JL, Albers, GW, et al. Stroke 2009;40;2276-2293

6. Transient Ischemic Attack • Class I recommendations • Patients with TIA should be evaluated as soon as possible (Level B) • Imaging within 24 hrs, MRI with DWI preferred (Level B) • Non invasive vascular imaging, head and neck (Level A) • EKG as soon as possible (Level B) Easton JD, Saver JL, Albers, GW, et al. Stroke 2009;40;2276-2293

7. Transient Ischemic Attack • Class II recommendations • Echocardiogram (Class IIa, Level B) • Laboratory evaluation (Chemistry, CBC, PT, PTT, Lipid profile) • Hospitalization if within 72 hrs (Class IIa, Level C) • ABCD2>3 • ABCD2 0-2 uncertainty of speedy work up • ABCD2 0-2 and suspicion for brain ischemia Easton JD, Saver JL, Albers, GW, et al. Stroke 2009;40;2276-2293

8. ABCD2 • Age ≥ 60 1 point if yes • BP ≥ 140/90 mmHg at initial evaluation? 1 point if yes • Clinical Features of the TIA: • Unilateral Weakness 2 points if yes • Speech Disturbance without Weakness 1 point if yes • Duration of Symptoms? • 10-59 minutes 1 point • ≥ 60 minutes 2 points • Diabetes Mellitus in Patient's History? 1 point if yes

9. ABCD2 48hr Risk of Stroke • Score 0-1 = 0% • Score 2-3 = 1.3% • Score 4-5 = 4.1% • Score 6-7 = 8.1% Other predictors: • Acute stroke in MRI doubles the risk of short term stroke • A vessel occlusion in MRA increases it 4 times

10. Risk factors Non-modifiable Modifiable Hypertension Smoking Diabetes Highblood cholesterol Atrial Fibrillation Large artery atherosclerosis Inactivity Obesity • Age • Gender • Race • Family History

11. CHADS2 score http://www.healthsystem.virginia.edu/Internet/afibcenter/treatment.cfm

12. Intracranial Stenosis

13. SAMMPRIS • Enrolment stopped 4/11/11 • High grade (70-99%) stenosis of Intracranial ICA, vertebral, Basilar and M1 • Enrolled within 30 days of TIA or non-disabling stroke • Aggressive medical management: • Aspirin 325mg • Plavix 75mg for 90 days • Systolic <140 mmHg, <130mmHg if diabetic • LDL<70mg/dL • Lifestyle modification program

14. SAMMPRIS • 451 patients out of 764 planned (59%) • 50 participating sites • Gateway-Wingspan system • 14% of patients in the angioplasty and stent died or had a stroke within 30 days vs 5.8% of those randomized to the medical arm Chimowitz MI, Lynn MJ, Derdeyn CP, et al. N Engl J Med 2011;365:993-1003

16. How Are We Doing?

17. Risk Factors • Approximately 34% of adults over age 20 have hypertension • 78% are aware of the diagnosis • 68% are using medications to control hypertension • 44 % are adequately controlled • Approximately 23% of men and 18% of women over age 18 are smokers • Approximately 8% of the adult population is diagnosed with Diabetes Mellitus NHANES 2005-2008

18. Epidemiology of Risk Factors • 36.8% have pre-diabetes with abnormal fasting blood sugar • It is estimated that 33,600,000 adults older than 20 years of age have a total cholesterol > 240mg/dL • 33.7% of adults in the US are obese (BMI >30)

19. Stroke in African Americans • Incidence of 1st ever stroke in AA is twice that of whites • AA younger than age 55 have 2 to 5X higher risk of death from stroke • In Maryland, black males have the highest rates of hospitalization for strokes, especially at younger ages • Approximately 44% of AA over age 20 have hypertension • In Maryland, rate of tobacco use is highest among black males

20. North East Market Project

22. Hypertension (NEMP 2008)

23. Comparison of Risk Factors Market/Maryland (NEMP 2008)

24. NEMP 2011

25. Prevalence of Risk Factors * BRFSS – Behavior Risk Factor Surveillance Screen. 2009 - CDC

26. Hypertension

29. New Approach to Stroke Care • The multi disciplinary, guideline driven approach that has been successful in acute stroke care, has the potential for success in secondary and primary prevention

30. N Engl J Med. 2010. 362;17:1555-1557

31. AAN on Patient Centered Medical Home model “Yet there may still be a place for specialists who provide the majority of care (not primary care) to be the “home” for a patient, while the primary care physician still fills the rest of the role of the primary care provider.” http://www.aan.com/go/practice/models/pcmh

33. Stroke Prevention and Recovery Center Stroke prevention education Provider Visit RN Visit Navigating the system/follow up call Database Screened for clinical trials Rehabilitation

34. Integration of the Stroke System

35. 48 hours post discharge Patient ready for discharge Day before clinic appointment Appointment • Nutritionist • Follow up results • Follow up visit • Tests • Follow up calls • Other specialties • PT/OT/SLT

36. Accomplishments • Patient care coordination from hospital to clinic • Active BP management • Post clinic rounds • Nutritionist consult • Stroke Prevention Connection Newsletter • High risk patients from NEMP • Screened/follow up for Clinical trials (POINT, IRIS, P. Celnik) • Blood pressure, weight, BMI recorded in each visit http://www.hopkinsmedicine.org/news/e-newsletters/stroke_prevention/index.html

40. Next Steps… • Truly integrate: • Prevention • Recovery • Research • One stop shop Tracking and altering the time course of spontaneous biological recovery after stroke PaBLO CELNIK (Johns Hopkins), ANDREAS LUFT (Zurich), JOEL Stein, ToMOKOKitago (Columbia) (Funding: McDonnell Foundation)

41. How Does Recovery Work? Murphy TH, Corbett D. Nature Reviews/Neuroscience. 2009 10:861-872

42. Recovery Duncan, et al. Measurement of Motor Recovery After Stroke. Stroke. 1992;23:1084-1089

43. Interventions with a Possible Effect in Recovery • PT/OT/SLT • Transcranial Magnetic Stimulation • Transcranial Direct Current Stimulation • Peripheral stimulation or inhibition • Electric Stimulation • Robots • Constraint-Induced Therapy • Neurotransmitter modulation • SSRIs • Dopaminergic drugs, cholinesterase inhibitors

44. Conclusions • The Stroke Prevention Clinic as a Specialty Medical Home is feasible. We have successfully established a system of care coordination and active risk factor management for stroke/TIA patients • Replication of the model at other hospitals will make analysis of clinical outcomes (recurrence rates) possible • This is a new platform for care, education and research