STROKE

1. STROKE Anne Kinnear Lead Pharmacist NHS Lothian

2. Aim • To update pharmacists on Stroke: the disease and its management and explore ways to implement pharmaceutical care for this patient group as part of normal working practice.

3. Objectives • Describe the disease, identify risk factors and signs and symptoms associated with Stroke. • Define the current therapeutic management of acute Stroke and secondary prevention measures. • Identify pharmaceutical care issues and respond to symptoms in patient scenarios and identify appropriate management solutions. • Explore how to implement the principles of a pharmaceutical care needs assessment tool in practice.

4. Stroke • Third commonest cause of death in Scotland • 15,000 stroke patients in Scotland annually • One of leading causes of disability in adults

5. “Time is Brain”

6. Stroke • 2 million neurones per minute

7. How do you know if someone is having a stroke?

8. 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

9. Stroke WHO Definition • 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.

10. Chest Heart and Stroke Definition • A stroke is a brain attack. • It happens when the blood supply to the brain is disrupted. • Most strokes occur when a blood clot blocks the flow of blood to the brain. • Some strokes are caused by bleeding in or around the brain from a burst blood vessel.

11. 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

12. Diagnosis • Computed Tomography scan • (CT scan) • `Immediate`

13. STROKE Diagnosis – stroke type Cerebral infarct CT scan Cerebral haemorrhage

14. Stroke

15. Atherosclerotic thrombosis

16. Stroke 1 - Anterior cerebral artery 2 - Anterior communicating artery 3 - Internal carotid artery 4 - Posterior communicating artery 5 - Middle cerebral artery 6 - Posterior cerebral artery 7 - Superior cerebellar artery 8 - Basilar artery 9 - Anterior inferior cerebellar artery

18. Cerebrum – intellect, speech, emotion, sensory, movementCerebellum – balance, co-ordinationBrain stem – respiration, heart rate, blood pressure, wakefulnessCerebrum - left hemisphere – speech and language

19. Risk Factors For Stroke: Treatable Major 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

20. Risk factors • Risk Factors for Stroke That Cannot Be Changed • Increased age • Being male • Race (e.g., African-Americans) • Family history of stroke

21. Evidence Base for Treatment • ACTIVE • PROGRESS • CHARISMA • SPARCL • ESPRIT • MATCH • PROFESS • RE-LY

22. Acute Secondary Prevention

23. Acute treatment • Thrombolysis • Antiplatelets • Blood pressure • Hydration • Oxygen • Blood glucose • Temperature

24. Thrombolysis • Lyses clot by digesting fibrinogen • Intravenous recombinant tissue plasminogen activator (tPA - Alteplase) 0.9mg/kg after test dose • Within 4.5 hours (6hrs if IST-3 clinical trial) • Reduces death and disability at 90 days • 2% incidence of symptomatic haemorrhage at 24 hrs • 8% incidence of symptomatic haemorrhage at 7 days

25. Antiplatelets • Aspirin 300mg within 48 hours continued for 14 days • reduces 14 day mortality and morbidity • No evidence for: • Anticoagulants • Combinations of antiplatelets or antiplatelets with anticoagulants • Neuroprotectants

26. Blood pressure - not actively managed in acute phase • Hydration – IV Sodium Chloride 0.9% is preferred to glucose 5% • Blood glucose - treat if blood glucose is >11mmol/L • Oxygen - supplemental Oxygen if saturation <95% • Temperature – prescribe antipyretics

27. Secondary Prevention Treatment

28. Antiplatelets

29. Antiplatelets Evidence Cochrane Reviews Dipyridamole MR Clopidogrel vs Aspirin Randomised Clinical Trials MATCH Aspirin + Clopidogrel vs Clopidogrel CHARISMA Aspirin + Clopidogrel vs Aspirin ESPRIT Aspirin + Dipyridamole MR vs either alone PROFESS Aspirin + Dipyridamole MR vs Clopidogrel

30. Antiplatelets • Aspirin and Dipyridamole MR in combination significantly reduces risk of vascular events compared to aspirin alone (approx 25% risk reduction) • without an increase in bleeding • The combination of Aspirin and Clopidogrel is no more effective than either alone • is associated with an increase in moderate/life threatening bleeding • only 25% patients in studies had a history of previous stroke • used in acute coronary syndrome (NSTEMI) or carotid stenosis

31. Antiplatelets • The combination of Aspirin and Dipyridamole MR vs Clopidogrel showed no difference in efficacy

32. Antiplatelets • Recommendations • Clopidogrel 75mg daily OR Aspirin 75mg daily and Dipyridamole 200mg MR twice daily should be prescribed after ischaemic stroke for secondary prevention of vascular events • Aspirin alone – if dipyridamole intolerance • (headache 26% withdrawal ESPRIT trial) • - or if carotid stenosis 70% or unstable angina • The combination of aspirin and clopidogrel is not recommended for prevention of ischaemic stroke or TIA

33. Statins • Evidence • 2 x Systematic reviews (170000 pts) • Randomised Clinical Trial – SPARCL (4700 pts) • 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)

34. Statins • Recommendations • A statin should be prescribed to patients who have had an ischaemic stroke irrespective of cholesterol level • Which statin? • Simvastatin 40mg – high risk coronary event • Atorvastatin 80mg – TIA / ischaemic stroke • Should not be used in patients with a prior history of intracerebral haemorrhage

35. Anticoagulants • Non-cardioembolic ischaemic stroke • Evidence • Systematic review Anticoagulant vs antiplatelet • Randomised clinical trial – ESPRIT • 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

36. Anticoagulants • Atrial fibrillation and ischaemic stroke • Evidence • RE-LY trial • 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

37. Anticoagulants • Atrial fibrillation and ischaemic stroke • Evidence • RE –LY trial (NEJM 2009) • Warfarin versus Dabigatran in AF with primary outcome of stroke • Recommendation • Equal efficacy for warfarin and dabigatran with no worse safety profile for the dabigatran

38. Antihypertensives • Evidence • Well established link between BP reduction and stroke primary prevention • Systematic review (7 trials) • Randomised Clinical Trial - PROGRESS Perindopril/Indapamide • 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

39. Antihypertensives • Recommendation • BP should be assessed in all patients and therapy with an ACE inhibitor and thiazide diuretic should be considered regardless of BP • Target blood pressure is <140/85 – diabetics <130/80 mmHg

40. Summary Secondary Prevention of Ischaemic Stroke • Aspirin 75mg + Dipyridamole 200mg twice daily • (or Clopidogrel 75mg if ACS) • Simvastatin 40mg / Atorvastatin 80mg • Thiazide diuretic • ACE inhibitor • Warfarin or dabigatran if AF

41. Pharmacist Role • Public health, education and information • Pharmaceutical care • Research • Multidisciplinary team membership

42. Public Health, education and information • Awareness and promotion of: • Public Health campaigns • CHSS campaigns and resources • Risk factors – action to take • Stroke Identification – FAST test • Lifestyle advice – smoking, weight loss/diet, vitamins

43. Pharmacist Role • Public health, education and information • Pharmaceutical care • Research • Multidisciplinary team membership

44. Pharmaceutical Care • Transfer of patient information primary/secondary care interface • continuity of care • reduction of medication errors/discrepancies • Identification and resolution of pharmaceutical care issues • - level and type of resultant disability

45. Modified Rankin Score (mRS) Disability Score

46. Dysphasia Aphasia Dysphagia Aphagia Hemiparesis Hemiplegic Hemianopia Speech Swallow Weakness Paralysis Visual difficulties Disability

47. Speech Comprehension Swallow Communication/counselling carers Ability to take medicines aspiration risk and liquids formulations bioavailability eg phenytoin NG and PEG tube feeding Pharmaceutical Care Issues

48. Weakness or paralysis Visual problems Ability to operate devices inhalers, insulin Ability to open containers Ability to read instructions labels, leaflets, charts Stroke

49. Pharmacist Role • Public health, education and information • Pharmaceutical care • Research • Multidisciplinary team membership

50. Research • Practice development project – MSc Strathclyde University • Standardised pharmaceutical care plan validation • Validation of care issues for transfer – needs assessment tool • Pharmacist Research Fellow • Design and validate transfer document for stroke