Mike Previti, MD UW Valley Medical Center, Stroke Program Medical Director UW, Dept of Neurology, Clinical Instructor

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1 Mike Previti, MD UW Valley Medical Center, Stroke Program Medical Director UW, Dept of Neurology, Clinical Instructor

2 What is TIA? TIA vs CVA, does it matter? Who needs the hospital? What is the ABCD 2 Score? Is ABCD 2 enough? What to evaluate in order to lower risk of future stroke History Imaging Labs How to lower risk for future stroke AntiPLTs, HTN, HLD, DM, tobacco, symptomatic carotid disease, afib, OSA, obesity, diet

3 Conventional clinical (old) definition: focal neurological deficit lasting <24 hours Modern-ish clinical trial (newer) definition: symptoms lasting <24 hours AND no imaging of an acute clinically relevant brain lesion AHA/ASA 2006 proposed definition: brief episode of neurological dysfunction caused by a focal disturbance of brain or retinal ischemia, with clinical symptoms typically lasting <1 hour, and without evidence of infarction. Stroke 2006;37:

4 Since it s been shown that <1/3 rd of patients with symptoms lasting <24 hours are found to have an infarction, we ve adopted these new definitions: Tissue-based definition of TIA A transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. Tissue-based definition of CVA Brain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/or clinical evidence of permanent injury. Subtypes Ischemic stroke central nervous system infarction accompanied by overt symptoms Silent infarction No known symptoms Stroke 2014;?... Epub ahead of print May 1

6 They are the same disease process They share pathophysiological mechanisms; prognosis may vary depending on their severity and cause; and definitions are dependent on the timing and extent of the diagnostic evaluation. (Stroke 2014;? Epub TIA Guidelines) We treat them the same way The distinction between TIA and ischemic stroke has become less important in recent years because many of the preventative approaches are applicable to both. (Stroke. 2009;40: ) TIA angina

7 Age BP >60 = 1 point >140/90 = 1 point Clinical Features Speech disturbance w/o weakness = 1 point Unilateral weakness = 2 points Duration of Symptoms mins = 1 point 60+ mins = 2 points Diabetes = 1 point Lancet Jan 27;369(9558):283-92

8 South Western Sydney TIA study (Intern Med J Aug;42(8):913-8) ~800 TIAs followed for 1 year No significant difference in stroke at 30, 90, or 365 days if ABCD2 was < or >4 UK cost meta-analysis (Health Technol Assess Apr;18(27):1-368) ~ 50 studies & ~30,000 TIAs ~1/3 rd of specialist-diagnosed true TIAs & ~ 1/3 rd of mimics had an ABCD2 score of 4 ~1/5 th of true TIAs with ABCD2 score of < 4 had key risk factors (carotid stenosis, afib)

9 The following increases your risk of a TIA leading to stroke: 2 TIAs in <7 days >50% stenosis of an artery leading to the brain area affected Stroke 2014;45:

10 ABCD 2 >4 unless a specialist feels there may be another etiology Patients with stroke risk factors even if they have a low score HTN DM Tobacco HLD Atrial fibrillation CAD PVD

11 Symptoms Should start suddenly (may leave more slowly) Usually painless in the body (some patients will get headache, though) Rarely involves more than one side of the body (half the brain, half the body) May wax & wane (stuttering TIA) Ever had numbness, weakness, speaking problems that came & went before?

12 Past Medical History High blood pressure, white coat HTN, BP Rx s 60% of strokes from HTN Diabetes, pre-diabetes, almost-diabetes, the sugar 2x as likely to have stroke Any tobacco use 2.5x as likely to have stroke Hyperlipidemia, cholesterol Rx s Carotid disease/stenosis/occlusion/plaque, neck blockages Atrial fibrillation, arrhythmia, irregular heart beats 20% of strokes, ~1/3 rd with afib will have stroke Obstructive sleep apnea, next room snoring, use a CPAP?

13 Look at the brain CT head vs MRI brain Look at the vessels Carotid ultrasound and transcranial Doppler (dynamic, emboli, shunts) CTA MRA Look at the heart Transthoracic echocardiogram +/- bubble study Transesophageal echocardiogram? +/- bubble study Transcranial Doppler, R->L shunt series Telemetry

14 Vitals BP, trend over hrs if possible HR & rhythm, ECG Orthostatics if symptoms are positional Labs Fasting lipids (LDL) Hemoglobin A1C Diabetes > ~6.5 Prediabetes > ~6.0

15 Dissection Head/neck trauma recently Cerebral venous thrombosis Pregnancy, peripartum, OCP, dehydration, smoking Endocarditis Dental problems/infection, IVDU Vasospasm Cocaine, methamphetamine, thunderclap headache

16 Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

17 Meta-analysis of 21 trials, ~18k pts (BMJ 2002;324:71-86) ASA mg has most evidence No evidence for dual anti-plt Rx Updated meta-analysis of 14 trials, ~9k pts (Circulation. 2013;128: ) For noncardioembolic small CVA/TIA, dual anti-plt may offer early benefit of decreased stroke recurrence

18 For Noncardioembolic CVA, antiplt Rx > OAC (Class I; Level of Evidence A). ASA mg (Class I; Level of Evidence A) or Aggrenox (Class I; Level of Evidence B) for initial Tx - revised Clopidogrel 75mg is reasonable in place of the above (Class IIa; Level of Evidence B). Combination of ASA & Plavix considered to start w/in 24 hrs TIA/minor CVA for 90 days (Class IIb; Level of Evidence B) - new Combination of ASA & Plavix when started days to years after TIA/minor CVA for 2-3 yrs, risk & not recommended (Class III; Level of Evidence A). When CVA/TIA on ASA, dose has no benefit. (Class IIb; Level of Evidence C) Hx of CVA/TIA, afib, CAD usefulness of adding antiplt Rx to VKA is of unclear benefit (Class IIb; Level of Evidence C), unstable angina & coronary stenting may warrant DAPT/VKA - new

19 Control of BP can lead to ~35% reduction in stroke risk Eur J Vas Endovasc Surg 2008;35: Low dose thiazides may be the best at all cause mortality Cochrane Database Syst Rev 2009;(3):CD Meta-analysis of 13 RCTs, ~106k pts, suggested that beta blockers were associated with more stroke Lancet 2005;366: Widely accepted goals of <140/90 (Ø DM) & <130 systolic (+DM) Eur J Vas Endovasc Surg 2008;35:139-44

20 Resume BP therapy after the first several days after CVA/TIA (Class I; Level of Evidence A) revised The optimal drug regimen is uncertain The available data indicate that diuretics or the combination of diuretics and an angiotensin-converting enzyme inhibitor is useful (Class I; Level of Evidence A). Initiate BP therapy after the first several days after CVA/TIA if BP >140/90 (Class I; Level of Evidence B) - revised Goals for target BP are uncertain it is reasonable to [aim for <140/90] (Class IIa; Level of Evidence B) - revised For patients with a recent lacunar stroke, it might be reasonable to target a systolic BP of <130 mm Hg (Class IIb; Level of Evidence B) - revised Stroke 2014;?... Epub ahead of print May 1

21 2011 AHA/ASA Guidelines recommend LDL <100 mg/dl (everyone), and LDL <70 mg/dl (Hx TIA/CVA). (Stroke 2011;42:e464-e540) Systematic Review of statins on carotid plaque morphology suggests benefit in reducing IMT. (Atherosclerosis 2010;213:8-20) Post-hoc analysis of SPARCL subgroup with carotid stenosis suggested a significant 33% reduction in stroke risk. (Stroke 2008;39: )

22 ACC/AHA 2013 guideline adherence, lifestyle modification and Rx recommendations (Class I; Level of Evidence A) - revised Statin therapy is recommended among patients with ischemic stroke or TIA presumed to be of atherosclerotic origin and an LDL-C level 100 mg/dl (Class I; Level of Evidence B) - revised Statin therapy with intensive lipid-lowering effects is recommended to reduce risk of stroke and cardiovascular events among patients with ischemic stroke or TIA presumed to be of atherosclerotic origin, an LDL-C level <100 mg/dl, and no evidence for other clinical ASCVD (Class I; Level of Evidence C) - new

23 6 studies ~28k pts Cardiovasc Ther Jun;31(3):

24 Post TIA/CVA, all patients should be screened for DM HbA1c may be more accurate than other screening tests in the immediate postevent period (Class IIa; Level of Evidence C). - new Follow ADA guidelines for CVA/TIA pts with DM or pre-dm (Class I; Level of Evidence B).

25 20 studies ~900k pts J Public Health (Oxf) Dec;33(4): Research conducted by the Framingham Heart Study on smoking and stroke incidence found that stroke risk decreased significantly by two years and was at the level of non-smokers by five years after cessation of cigarette smoking.

26 Counseling, nicotine products, and oral smoking cessation medications are effective in helping smokers to quit (Class I; Level of Evidence A). Healthcare providers should strongly advise every patient with stroke or TIA who has smoked in the past year to quit (Class I; Level of Evidence C). It is reasonable to advise patients after TIA or ischemic stroke to avoid environmental (passive) tobacco smoke (Class IIa; Level of Evidence B).

27 Symptomatic stenosis implicated in 15-30% of all ischemic strokes Minerva Cardioangiol 2007;55:19-56 Stroke 2001;32: Asymptomatic carotid stenosis of >50% / <70 yo: 4.8%/2.2% / >70 yo: 12.5%/6.9% Stroke 2010;41: Asymptomatic carotid stenosis of >70% / >80 yo: 3.1%/0.9% Stroke 2010;41:1294-7

28 NNT = 3 NNT = 8 NNT = 5 Moderate Severe Near Occlusion

29 TIA/CVA within the past 6 months and ipsilateral severe (70% 99%) carotid artery stenosis, CEA is recommended if the perioperative morbidity and mortality risk is estimated to be <6% (Class I; Level of Evidence A). TIA/CVA and ipsilateral moderate (50% 69%) carotid stenosis..., CEA is recommended depending on patient-specific factors, such as age, sex, and comorbidities, if the perioperative morbidity and mortality risk is estimated to be <6% (Class I; Level of Evidence B). When the degree of stenosis is <50%, CEA and CAS are not recommended (Class III; Level of Evidence A). CAS and CEA in the above settings should be performed by operators with established periprocedural stroke and mortality rates of <6% for symptomatic patients, similar to that observed in trials comparing CEA to medical therapy and more recent observational studies (Class I; Level of Evidence B) - revised Routine, long term follow-up imaging of the extracranial carotid circulation with carotid duplex ultrasonography is not recommended (Class III; Level of Evidence B) - new

What is the current status of invasive treatment of extracranial carotid artery disease?

30 Figure 1 Annual rates of stroke in medically treated patients with asymptomatic carotid stenosis stratified for year of publication and baseline severity of stenosis Adapted from Naylor, A. R. What is the current status of invasive treatment of extracranial carotid artery disease? Stroke 42, (2011) Lippincott Williams & Wilkins Naylor, A. R. (2011) Time to rethink management strategies in asymptomatic carotid artery disease Nat. Rev. Cardiol. doi: /nrcardio

31 CRYSTAL AF Trial, results not yet published ~450 cryptogenic CVA pts with < 3yr implantable monitor

32 For patients who have experienced an acute ischemic stroke or TIA with no other apparent cause, prolonged rhythm monitoring ( 30 days) for AF is reasonable within 6 months of the index event (Class IIa; Level of Evidence C) - new VKA therapy (Class I; Level of Evidence A), apixaban (Class I; Level of Evidence A), and dabigatran (Class I; Level of Evidence B) are all indicated for the prevention of recurrent stroke in patients with nonvalvular AF - new Rivaroxaban is reasonable for the prevention of recurrent stroke in patients with nonvalvular AF (Class IIa; Level of Evidence B) - new For most patients with a stroke or TIA in the setting of AF, it is reasonable to initiate oral anticoagulation within 14 days after the onset of neurological symptoms (Class IIa; Level of Evidence B) - new In the presence of high risk for hemorrhagic conversion (ie, large infarct, hemorrhagic transformation on initial imaging, uncontrolled hypertension, or hemorrhage tendency), it is reasonable to delay initiation of oral anticoagulation beyond 14 days (Class IIa; Level of Evidence B) - new The combination of oral anticoagulation (ie, warfarin or one of the newer agents) with antiplatelet therapy is not recommended for all patients after ischemic stroke or TIA but is reasonable in patients with clinically apparent CAD, particularly an acute coronary syndrome or stent placement (Class IIb; Level of Evidence C) - new

33 12 studies, ~26k pts Severe OSA & risk of CHD, CVA, all cause mortality Int J Cardiol Nov 5;169(3):

34 A sleep study might be considered for patients with an ischemic stroke or TIA on the basis of the very high prevalence of sleep apnea in this population and the strength of the evidence that the treatment of sleep apnea improves outcomes in the general population (Class IIb; Level of Evidence B) - new Treatment with CPAP might be considered for patients with ischemic stroke or TIA and sleep apnea given the emerging evidence in support of improved outcomes (Class IIb; Level of Evidence B) - new

35 97 prospective cohort studies that collectively enrolled 1 8 million participants between 1948 and 2005 Lancet Mar 15;383(9921):970-83

36 All CVA/TIA patients should be screened for obesity with BMI (Class I; Level of Evidence C) - new Despite the demonstrated beneficial effects of weight loss on cardiovascular risk factors, the usefulness of weight loss among patients with a recent TIA or ischemic stroke and obesity is uncertain (Class IIb; Level of Evidence C) - new For patients who are able and willing to initiate increased physical activity, referral to a comprehensive, behaviorally oriented program is reasonable (Class IIa; Level of Evidence C) - new

37 <300 pts high CVD risk in 3 arm RCT In high-risk individuals, most with treated hypertension, MedDiets supplemented with extravirgin olive oil or nuts reduced 24-hour ambulatory BP, total cholesterol, and fasting glucose. Hypertension May 5. [Epub ahead of print]

38 Patients with a history of ischemic stroke or TIA and signs of undernutrition should be referred for individualized nutritional counseling (Class I; Level of Evidence B) - new Routine supplementation with a single vitamin or combination of vitamins is not recommended (Class III; Level of Evidence A) - new It is reasonable to recommend that patients with a history of stroke or TIA reduce their sodium intake to less than 2.4 g/d. Further reduction to <1.5 g/d is also reasonable and is associated with even greater BP reduction (Class IIa; Level of Evidence C) - new It is reasonable to counsel patients with a history of stroke or TIA to follow a Mediterranean-type diet instead of a low-fat diet. The Mediterranean-type diet emphasizes vegetables, fruits, and whole grains and includes low-fat dairy products, poultry, fish, legumes, olive oil, and nuts. It limits intake of sweets and red meats (Class IIa; Level of Evidence C) - new

39 TIA & CVA are the same Dx When you see it Good Hx, vessel imaging, MRI brain, echo, A1C, lipids, BP, call neuro What to fix to prevent TIA from becoming CVA AntiPLTs ASA +/- plavix HTN - <140/90 HLD - statin DM A1C < 6.5? Tobacco - quit symptomatic carotid disease CEA, maybe CAS Afib VKA, NOAC OSA - CPAP Obesity wt loss program Diet - nutritionist

Long-Term Care Updates

Long-Term Care Updates October/November 2015 By Daniel Kerner, PharmD A stroke occurs when blood flow to the brain is stopped or slowed, resulting in death or damage to brain cells. There are three main