Dr Karim Mahawish. Consultant in General Geriatric & Stroke Medicine Rotorua Hospital

Transcription

1 Dr Karim Mahawish Consultant in General Geriatric & Stroke Medicine Rotorua Hospital 8:30-9:25 WS #195: Prevention and Treatment of Stroke 9:35-10:30 WS #207: Prevention and Treatment of Stroke (Repeated)

2 The Prevention & Treatment of Stroke Dr Karim Mahawish Consultant in Geriatric, General & Stroke Medicine Rotorua Hospital 10th June 2018

3 Scope Hyperacute stroke treatment TIA Atrial fibrillation Medication Post stroke complications Driving The future

4 Burden of Stroke 4 th leading cause of death Leading cause of disability Personal cost independence, employment Impact on family & relationships Economic burden - $450 million/year (2009)

5 Stroke CVA Ischaemic strokes account for 85% Remainder haemorrhage hypertensive/amyloid angiopathy/sah, etc.

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7 Definitions WHO: Rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function with no apparent cause other than a vascular origin TIA < 24 hours Stroke 24 hours In reality, most TIAs last < 30 minutes

8 Mr TW Finished breakfast with his wife at 8:30 A loud noise is heard upstairs found on floor with aphasia and a right hemiparesis at 9:30 What is the stroke onset time? Either patient tells you or last seen well

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11 Each minute, the brain loses: 2 million neurones 14 billion synapses 12km of fibres Time is brain Saver JL. Stroke 2006; 263: 263-6

12 Effect of alteplase on good stroke outcome (mrs 0 1) by onset to needle 90 mins - NNT mins - NNT mins - NNT 14

13 USA Data Modern treatments are working: Between Death rate from stroke has reduced by 34% Stroke changed from 4 th to 5 th leading cause of death last year

14 Stroke Assessment Patients with recent stroke symptoms: Spend 1-2 minutes on history & exam FAST positive or disabling stroke and onset time <4 hours Priority 2 transfer to hospital Brief note detailing symptoms, PMH & medication All stroke patients require admission to hospital

15 Stroke Unit Admission Lower mortality More patients returning home Shorter admission length

16 Dysphagia Affects ~ 50% ~50% will recover within 2 weeks. 15% persistent dysphagia at 1 month Dysphagia care associated with: pneumonia & death institutionalisation regaining swallowing function

17 Mrs F, 73 years old PMH - hypertension Reports episode of expressive dysphasia this morning lasting 15 minutes Examination: 150/80 mmhg No focal neurological deficit Diagnosis? What next?

18 High Risk (Admission): ABCD 4 Atrial fibrillation > 1 TIA in 1 week Known carotid stenosis Use of anticoagulants

19 Pitfalls in TIA diagnosis Very rarely get > 2 episodes of TIA with stereotyped symptoms: Migraine Seizure Other causes of dizziness Not syncope (unless with disabling stroke)

20 Carotid imaging Anterior circulation or PCA territory (i.e. not brainstem/cerebellum) TIA or non-disabling stroke only Is the patient fit for GA? (MoH target: surgery within 2 weeks)

21 Carotid Stenosis CEA if stenosis 70% (not occluded) CEA in high risk patients 50% Carotid angioplasty & stenting (Higher rates of complications in those >70 years) P.M. Rothwell et al. Stroke. 2004;35:

22 76 year old Presents with productive cough OE, Temp 38.5, R basal crackles and found have an irregularly irregular pulse ECG HR 90bpm atrial fibrillation Treated for RTI. Anything else? Reviewed in GP surgery one week later Feeling well, back in SR What next?

23 Annual risk of stroke (%) Stroke risk persists even in asymptomatic/paroxysmal AF The risk of stroke with asymptomatic or paroxysmal AF is comparable to that with permanent AF 1,2 Observed rate of ischaemic stroke 1 14 Intermittent AF Sustained AF 0 Low Moderate High Stroke risk category 1. Hart RG et al. J Am Coll Cardiol 2000;35:183 7; 2. Flaker GC et al. Am Heart J 2005;149:

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25 66 year old female Diabetes & AF 1 st July 2014

26 4 th July 2014

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29 Low-Dose Aspirin for Prevention of Stroke in Low-Risk Patients With AF Japan AF Stroke Trial Sato et al Stroke. 2006;37: Kaplan Meier survival curves for primary end points (a) and for primary plus secondary end points (b). Treatment with aspirin mg/day was not superior to treatment without aspirin for primary end points (log-rank; P=0.310) and secondary end points (log-rank; P=0.109)

30 BAFTA Trial Aspirn Vs Warfarin in 75 year olds N=973 The primary endpoint was fatal or disabling stroke (ischaemic or haemorrhagic), intracranial haemorrhage, or clinically significant arterial embolism Findings Warfarin superior to aspirin in stroke prevention. Similar rates of bleeding Lancet 2007; 370 (9586):

31 The HAS-BLED bleeding risk score European Heart Journal (2010) 31,

32 Definitions Hypertension >160 mmhg systolic Abnormal renal function tests: Chronic dialysis Renal transplantation Cr 200 μmol/l Abnormal liver function tests: Chronic hepatic disease (e.g. cirrhosis) Bilirubin > 2 x ULN & AST/ALT/Alk P > 3 x ULN European Heart Journal (2010) 31,

33 Definitions Bleeding Requiring hospitalisation Hb by >20 g/dl Requiring blood transfusion (Not haemorrhagic stroke) European Heart Journal (2010) 31,

34 Warfarin INR checking at least once a month in all Annual review of control Poor control: 2 INR values > 5 or 1 INR value > 8 in past 6 months 2 INR values less than 1.5 within the past 6 months TTR < 65%

35 Cumulative survival Why time in therapeutic range (TTR) matters Warfarin group % 61 70% 51 60% 41 50% 31 40% <30% Non warfarin Survival to stroke (days) Morgan CL et al. Thrombosis Research 2009;124:37 41

36 DOACs

37 SPAF trials versus Warfarin Dabigatran Rivaroxaban Rivaroxaban Apixaban Apixaban Study RELY Rocket Aristotle Design PROBE Double Blind Double Blind Follow up 2 yrs 1.5yrs 1.5yrs Population size >18,000 >14,000 >18,000 Inclusion Inclusion (CHADs) Primary Endpoint Non valvular AF + 1 risk factor Non valvular AF + 2 risk factor (i.e. moderate to high risk) Stroke and systemic embolism Stroke and systemic embolism Non valvular AF + 1 risk factor Stroke and systemic embolism Warfarin comparator INR control (mean TTR) 64% 55% 62% Ezekowitz et al. Am Heart J 2009;157 and Connolly et al, N Eng J Med 2009; 361 Rocket investigators, Am Heart J 2010; 159 and Patel et al, N Eng J Med 2011; 365 Lopes et al. Am Heart J 2010; 159 and Granger et al, N Eng J Med 2011; 365

38 DOACs versus warfarin Stroke, Systemic Embolism SSE* vs. Warfarin (ITT population) ARR HR D ( ) D ( ) Rivaroxaban ( ) Apixaban ( ) Haemorrhagic stroke Haemorrhagic stroke vs. Warfarin ARR HR D ( ) D ( ) Rivaroxaban ( ) Apixaban ( ) Connolly et al, N Eng J Med 2009; 361 and Vol. 363 No.19 Patel et al, N Eng J Med 2011; 365 Granger et al, N Eng J Med 2011; 365

39 DOACs versus warfarin Major Bleeds Major Bleeding ARR HR D ( ) D ( ) Rivaroxaban ( ) Apixaban ( ) Intracranial bleeding Intracranial Bleeding ARR HR D ( ) D ( ) Rivaroxaban ( ) Apixaban ( ) Connolly et al, N Eng J Med 2009; 361 and Vol. 363 No.19 Patel et al, N Eng J Med 2011; 365 Granger et al, N Eng J Med 2011; 365

40 Long term Data - DOACs RELY-ABLE trial Median 4.6 year follow-up Stroke/systemic embolisation risk 1.25% Rate of haemorrhage 3.34% XANTUS 1 year follow-up Stroke/systemic embolisation 0.8% Major bleeding 2.1%

41 DOACs & warfarin Intracranial haemorrhage in patients on DOACs: Less frequent Smaller Patients are less disabled In phase III RCTs, mortality is lower in patients on DOACs compared with warfarin Dabigatran 150 mg BD, RRR 12% p=0.05 Dabigatran 110 mg BD, RRR 9% p=0.13

42 Dabigatran Vs Rivaroxaban No clear winner Neither approved in patients with CrCl <30 Consider: Pill burden Size of tablets Systematic review - more major bleeding with rivaroxaban (but = warfarin) 1 Antidote availability 1. Bai Y, et al. Stroke 2017; 48: 970-6

43 45 year old Comes to see you 4 weeks after admission with a stroke Seeks medical clearance to return to work/driving

44 NZTA guidance - TIA Class 1 & 6 license No driving for 1 month after a single event > 1 TIA no driving until condition under satisfactory control, and symptom free for 3 months Class 2,3,4 & 5 licence No driving for 6 months after a single TIA No driving unless free of symptoms for 12 months following multiple TIAs

45 Stroke Class 1 & 6 No driving for 1 month Driving may resume when: Satisfactory clinical recovery No residual limb disability that cannot be accommodated by vehicle modifications No cerebral damage resulting in: cognitive defects reduced reaction times perceptual difficulties visual problems such as homonymous field defects and/or hemispatial neglect

46 Stroke Class 2, 3, 4 & 5 Lifetime ban! License may be granted if: Full and complete recovery with no suggestion of recurrence over a period of three years A supporting specialist physician or neurologist s report will be required

47 Interesting cases

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49 MRI area of restricted diffusion in left thalamus

50 Referral to TIA clinic: Please see this Indian lady who reports a one year history of left sided numbness lasting seconds precipitated by coughing and sneezing. Could these be TIAs?

51 Medication in Stroke/TIA

52 Antiplatelets in Stroke/TIA IST, ESPIRIT, ESPS2, PROFESS, MATCH, CHANCE Stroke: Aspirin 300mg OD for up to two weeks, switch to clopidogrel 75mg OD after TIA: Aspirin 100mg OD or Clopidogrel 75mg OD. Clopidogrel long term

53 Secondary Prevention Stop smoking Target BP (140/80mmHg younger individuals /80) Target LDL <1.8 mmol/l Treat DM Alcohol < 14units/week males, < 7/week females Members of the audience: Up to 10 portions of fruit/vegetables per day Mediterranean diet rich in nuts

54 84 year old female PMHx of dementia & pressure sores Dependent for ADLs Found collapsed L hemiparesis & hemianopia NIHSS 18

55 Trajectories of chronic illness Claire J Creutzfeldt et al. BMJ 2015;351:bmj.h3904

56 Fig 2 Trajectory for severe acute brain injury patients present with a crisis that may result in early death (often after a decision to withdraw life sustaining treatments) or survival with a high degree of disability. DNAR High risk of neurogenic induced MI & cardiac arrhythmias 2015 by British Medical Journal Publishing Group

57 Post stroke complications Central post-stroke pain Gabapentin Amitriptyline, Lamotrigine, Venlafaxine Hemiplegic shoulder pain Ice, heat, massage, NSAIDs (short term) Intra-articular steroids Depression/anxiety/emotional lability Psychology referral SSRI

58 Post stroke complications Urinary incontinence Overactive bladder most common cause Spasticity Not baclofen Physiotherapy referral If potential for complications e.g. pressure sores/hygiene issues - botox

59 THE FUTURE

60 Proximal Thrombus & IV alteplase Significant mortality/dependency despite treatment Stent Retriever Device MR Clean Trial, 1 st Jan 2015 N=500 Within 6 hours & proximal thrombus Mean age 65 (23-96 years) 13.5% absolute increase in functional independence

61 Mechanical Thrombectomy

62 Thank you