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Stroke and TIA guidelines; New evidence beyond?

Stroke and TIA guidelines; New evidence beyond?. Monika Hollander, MD, PhD Julius Center University Medical Center. Sources. AHA/ASA guidelines 2014 with special for women NICE: revision of 2008 guideline in 2014 NHG Dutch guideline for GPs 2013 Recent literature. Topics. Diagnosis

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Stroke and TIA guidelines; New evidence beyond?

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  1. Stroke and TIA guidelines;New evidence beyond? Monika Hollander, MD, PhD Julius Center University Medical Center

  2. Sources • AHA/ASA guidelines 2014 with special for women • NICE: revision of 2008 guideline in 2014 • NHG Dutch guideline for GPs 2013 • Recent literature

  3. Topics • Diagnosis • Etiology • Therapy • ‘new’risk factors

  4. Topics • Diagnosis • Etiology • Therapy • ‘new’risk factors

  5. “ new”tissue-based definition TIA: A transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia without acute infarction Cerebral infarction: Brain, spinal cord or retinal cell death attributable to ischemia based on neuropathological, neuroimaging and/or clinical evidence of permanent injury Ischemic stroke: symptoms+ Silent infarction: symptoms- Kernan et al. Stroke 2014;45:2160-2236

  6. Time is brain! Recognition of stroke by FAST test: Face, Arms, Speech, Time Thrombolysis possible <4.5 hours Prognosis in TIA: Age BP Clin symptoms Duration DM (ABCD2) score

  7. Topics • Diagnosis • Etiology • Therapy • ‘new’risk factors

  8. TOAST classification of stroke 20% hemorrhage 80% ischemic 50% large vessel disease 25% small vessel disease (lacunar infarction) 20% cardio-embolic 5% other Estimation: 54-68% preventable by influencing modifiable risk factors

  9. Topics • Diagnosis • Etiology • Therapy • ‘new’risk factors

  10. Large artery atherosclerosis Intra- orextracranial Treatment options: • antiplatelettherapy (OAC in AF), BP control, statins, stop smoking , lifestyle • Carotidendarterectomy (CE) • Carotidangioplasty & stenting (CAS)

  11. Carotid entarterectomy (CEA) and Carotid artery angioplasty/stenting (CAS) CEA: ~6-7% 30 day death rate Preferably < 2 weeks after stroke Data from large trials: NASCET, ECST, VACS CAS: Less invasive than CEA More patient comfort/shorter recuperation period Preferable in all patients?

  12. ASA guideline carotid stenosis Treatmentrelated to factors age, severity of stenosis, periprocedural risk >70% stenosis: CEA + medicaltherapyifperioperativemorbidity risk < 6% CAS alternativeif average/low complication risk and < 70 years 50-69% stenosis: CEA basedonpatientcharacteristics <50% stenosis: CEA and CAS notrecommended Routine follow up of carotidarterywith duplex is notrecommended Kernan et al. Stroke 2014:45:2160-2236

  13. Should we screen for asymptomatic carotid stenosis? Jonas et al. Ann Intern Med. 2014;161:336-346

  14. Should we screen for asymptomatic carotid stenosis? NO! Jonas et al. Ann Intern Med. 2014;161:336-346

  15. Antiplatelet therapy AHA/ASA: Selection of antiplatelet therapy should be individualised on basis of RF profile, tolerance, efficacy and clinical characteristics Options: Aspirin (50-325) mg daily Aspirin + dipyridamole 200 mg 2dd Clopidogrel 75 mg is reasonable option instead Kernan et al. Stroke 2014;45:2160-2236

  16. Aspirin + dipyridamole More effective than aspirin alone Prevents 1 exta event per 100 pts py But: dipyridamole less well tolerated Clopidogrel is as effective Kernan et al. Stroke 2014;45:2160-2236

  17. Timing of antiplatelet therapy in acute ischemic stroke Yongjun Wang et al N Engl J Med 2013;369:11-19

  18. Cardioembolic stroke AF Acute MI and LV thrombus Cardiomyopathy Valvular heart disease Prosthetic heart valve Kernan et al. Stroke 2014;45:2160-2236

  19. Cryptogenic stroke and AF Gladstone et al. NEJM 2014 370;26 2467-77

  20. Cryptogenic stroke and AF Sanna et al. NEJM 2014;370:2478-86

  21. Topics • Diagnosis • Etiology • Therapy • ‘new’risk factors

  22. Stroke risk in women Bushnell et al. Stroke. 2014;45:000-000

  23. Pregnancy outcomes and stroke Bushnell et al. Stroke. 2014;45:000-000

  24. Migraine with aura Risk of ischemic stroke HR 2.51 (1.52-4.14) Association is stronger in women vs men + OC use: risk 7x higher + smoking: risk 9x higher AHA: Treat to reduce frequency of migraine High risk in combination with smoking-> stop smoking therapy Bushnell et al. Stroke. 2014;45:000-000

  25. Obstructive sleep apnea General population: 5-10% Elderly: 20% TIA/Stroke pt: 50-70% 70-80% of all not diagnosed and treated Associated with poor stroke outcomes AHA: Sleep apnea might be considered in stroke/TIA patients If diagnosed, treatment with CPAP might be considered Kernan et al. Stroke 2014;45:2160-2236

  26. Obstructive sleep apnea; cause or consequence of stroke? Effects OSAS: Negativethoracicpressure Influenceonsympaticaltone & BP Oxidative stress Inflammation Endothelialdysfunction Hypercoagulable state Causalitynot proven Marker of comorbidity ? Kasai et al. Circulation 2012 126 1495 1510

  27. Topics • Diagnosis • Etiology • Therapy • ‘new’risk factors

  28. Conclusions Time is brain Cause of stroke determines therapy More focus individual patient characteristics Farmacological and lifestyle therapy remains cornerstone Beware of undetected AF, migraine with aura, “female” riskfactors and OSAS

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