Stroke Care: Focus on guidelines

1. Stroke Care:Focus on guidelines Sara C. Huffer, MD 11/17/2011

2. Outline Background tPA for acute ischemic stroke Stroke mechanisms Guidelines for anticoagulation Summary

3. Background Quality measures are increasingly used Quality, and not quantity, of care will drive reimbursement Multiple stakeholders interested in highest quality of care in setting of limited resources

4. Background EIGHT CORE MEASURES 1. IV tPA 2. Stroke Education 3. Discharge on statin 4. DVT prophylaxis 5. Rehabilitation assessment 6. Anticoagulation for atrial fibrillation 7. Antithrombotics by hospital day #2 8. Antithrombotics at discharge

5. Case 90 year old woman admitted with hip fracture found by her daughter at 9am to have aphasia and decreased movement of right side.

6. Case What is the next step? ICU transfer Head CT now Call pharmacy and have them mix tPA Hope that everything will get better Have a snack; gather thoughts

7. Case Head CT is without blood Neurology consult for acute stroke Thrombolysis decision: Assess for contraindications to therapy Discussion with family Risks/benefits

8. NINDS Study 1995 Double-blinded Placebo controlled NIH-sponsored 0.9mg/kg IV t-PA 624 patients Treatment within 3 hours 1/2 within 90 minutes 1/2 within 91-180 minutes

9. IV-tPA Efficacy - mRS 0-1 2-3 4-5 Death Placebo 25 27 21 26% t-PA 39% 21 23 17 NEJM 1995; 333:1581-7.

10. modified Rankin Score (mRS) • 0: No symptoms at all • 1: No significant disability despite symptoms; able to carry out all usual duties and activities _____________ • 2: Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance • 3: Moderate disability; requiring some help, but able to walk without assistance _____________ • 4: Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance • 5: Severe disability; bedridden, incontinent and requiring constant nursing care and attention ____________ • 6: Dead

11. NNT = 8 (for minimal/no disability by mRS)

12. NINDS Trial Placebo Group tPA Group

13. The True Time of Onset • “When was the last time you saw him/her totally normal?” • How “normal” were they? • Who saw them this morning? • Clearly no symptoms? • Times of reference • “When the Colts game started”

14. Sooner is Better! Lancet 2004; 363: 768–74

15. Time is Brain Lancet2004; 363: 768–74

16. N Engl J Med 2008;359:1317-1329.

17. AHA/ASA Position An American Heart Association/American Stroke Association science advisory group has recommended the use of t-PA in the 3 to 4.5 hour window. The advisory committee emphasizes the importance of treating acute strokes as rapidly as possible. The extended time window should not lead to any delay in treating eligible patients.

18. Case patient • 90 year old woman admitted with hip fracture found by her daughter at 9am to have aphasia and decreased movement of right side. • Nursing notes indicate patient was last seen normal 15 minutes earlier when the neurologist was called (60 minutes ago now).

19. Absolute Contraindications BP >185/110 or aggressive BP lowering measures Any history of intracranial hemorrhage Symptoms of SAH Active bleeding or known bleeding disorder Plt<100, high PTT, INR >1.7 H/o ischemic stroke, neurosurgery or serious head trauma within 3 months

20. Relative Contraindications • Major surgery/trauma within 14 days • Gastrointestinal/urinary hemorrhage within 21 days • Arterial puncture at a noncompressible site within 7 days • LP within 7 days • Recent MI (with sx/signs of pericarditis) • Seizure at onset • Known AVM or aneurysm • Glucose < 50 or >400 • Rapidly improving or minor symptoms

21. Hemorrhagic Transformation (HT) Khatri, Stroke, 2007 • Common and natural consequence of infarction • 43% HT rate at 4 weeks in natural hx studies • Risk of severe HT increases with rt-PA (and all revascularization therapies) • 6.4% risk in NINDS (compared to 0.6% in placebo) • Increased risk with older age and large strokes, but still overall benefit

22. Case patient • 90 year old woman admitted with hip fracture found by her daughter at 9am to have aphasia and decreased movement of right side. • Nursing notes indicate patient was last seen normal 15 minutes earlier when the neurologist was called (60 minutes ago now). • Accucheck was 85, blood pressure was 170/96. • She has no history of major bleeding • Relative contraindication of trauma/surgery and age. Orthopedic surgeon felt it an acceptable risk to proceed with tPA. • Prior to today she was independent at home and a church pianist. Family felt that patient would have wanted to take the risk to avoid severe debility.

23. Emergent management • Nursing at bedside, may need to contact clinical supervisor • Do NOT wait for ICU transfer • Accucheck • STAT labs • BMP, CBC, Coags, Cardiac markers • No need to wait for results unless clinical concern • If BP>185/110 • Start gentle: Labetolol 10mg IV, may repeat x 1 • Discuss w/family • no consent needed for standard IV rt-PA • Foley catheter (if need anticipated after tPA) • Call pharmacy to order t-PA; 0.9 mg/kg, 10% bolus • If not used, Genentech will reimburse

24. Post tPA care Transfer to ICU for at least 24 hours No anticoagulants, antiplatelets, etc BPs less than 180/105 Blood sugars less than 200 Generally NPO ‘Safety’ HCT at 24 hours IVF: NS (no D5) HCT for headache, N/V, drowsiness, abrupt neurological decline

25. NINDS National Symposium: Time Recommendations Marler, NINDS/NIH, 1997. TIME ZERO = ARRIVAL TO ED • Seen by physician < 10 minutes • Tx’ing physician notified <15 min • CT scan <25 min • Interpretation <45 min • IV rt-PA started <60 min • Earlier=better

26. Outline Background tPA for acute ischemic stroke Stroke mechanisms Guidelines for anticoagulation Summary

27. Ischemic stroke mechanisms • Embolic • Cardio-embolic • Artery-artery embolic • Thrombotic • Atherosclerotic • Small vessel disease • Hemodynamic failure, “watershed”

28. Cardioembolic • Atrial fibrillation • Acute MI and LV thrombus • Cardiomyopathy • Native valvular heart disease • Prosthetic heart valves

29. Artery to Artery Embolism • 15-20% of all ischemic strokes • Carotid stenosis • Vertebral, intracranial arteries, aorta

30. Outline Background tPA for acute ischemic stroke Stroke mechanisms Guidelines for anticoagulation Summary

31. Common misconceptions • All patchy or wedge shape infarcts are embolic • All “embolic” infarcts require anticoagulation • Anticoagulation should be performed urgently after ischemic stroke to prevent worsening or further strokes

32. AHA/ASA guidelines on urgent anticoagulation • Urgent anticoagulation, with the goal of preventing early recurrent stroke, halting neurological worsening or improving outcomes after acute ischemic stroke is not recommended for treatment of patients with acute ischemic stroke, (Class III, Level of Evidence A) • Urgent anticoagulation is not recommended for patients with moderate to severe strokes because of an increased risk of serious intracranial hemorrhagic complications (Class III, Level of Evidence A).

33. Common misconceptions • Anticoagulation should be performed urgently after ischemic stroke to prevent worsening or further strokes • NO • Heparin is a common source of medication error in stroke patients • Due to unpredictable pharmacokinetics, need for frequent lab testing and dose changes, and continuous infusion. • Michaels et al, “Medication errors in acute cardiovascular and stroke patients: A scientific statement from the American Heart Association”. Circulation, 2010.

34. Cardioembolic StrokeSecondary prevention • Atrial fibrillation • Vitamin K antagonist • If unable, use aspirin alone • Aspirin-Plavix combo causes bleeding risk similar to warfarin • Acute MI and LV thrombus • Cardiomyopathy • Native valvular heart disease • Prosthetic heart valves

35. Artery-artery embolism • Carotid stenosis • Antiplatelet therapy • Statin therapy and risk factor modification • CEA if indicated • Intracranial atherosclerosis • Aspirin instead of warfarin (Class I, level B) • Angioplasty or stent placement is investigational

36. PFO • Present in 15-25% of population • AHA guidelines: Insufficient data whether anticoagulation is equivalent to or superior to aspirin in secondary stroke prevention • Metaanalysis of retrospective studies: PFO was associated with increased risk of stroke in age group <55 years • Odds ratio 3.1 for PFO alone, 15.5 with atrial septal aneurysm Overell. Neurology. 2000

37. PFO studies • PFO in cryptogenic stroke study • 34% had PFO • No difference in 2 year outcome in PFO vs. no PFO • No difference in 2 year outcome asprin vs. warfarin • European PFO study • 2.3% recurrence with PFO • 15% recurrence with PFO +atrial septal aneurysm • 4.2% recurrence with neither • Homma et al. Circulation, 2002 • Mas et al. NEJM, 2001

38. Outline Background tPA for acute ischemic stroke Stroke mechanisms Guidelines for anticoagulation Summary

39. Summary Quality measures are becoming more prevalent tPA for acute stroke is the standard of care Guidelines exist for decision to anticoagulate, based on risk factors More trials are needed on PFO and stroke

40. Reference • Furie, et al. Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2011;42:227-276. • Or google “AHA stroke guidelines”

41. Questions? Sara Huffer, MD IU Health Arnett shuffer@iuhealth.org