5/2/2016. Outpatient Stroke Management Sheila Smith MD May 5, 2016

Transcription

1 Outpatient Stroke Management Sheila Smith MD May 5,

2 Management of Outpatient Stroke Objectives Review blood pressure management post stroke Review antithrombotic therapy Review statin therapy Discuss interruption of anti-thrombotic therapy for surgery 2 2

3 Blood Pressure Management for Secondary Stroke Prevention Does lowering blood pressure in patients with recent stroke and BP 140 systolic and/or 90 diastolic decrease risk of secondary stroke? 3 3

4 Blood Pressure Management for Secondary Stroke Prevention Several Trials have shown efficacy of blood pressure treatment for secondary prevention of Stroke and TIA PATs Trial in China Published in Chin Med J 1995; 108: Randomized 5665 patients to indapamide vs. placebo regardless of baseline BP Indapamide had relative risk reduction of secondary stroke of 30% compared to placebo PROGRESS Trial published in J Hypertension 1999; 17: Randomized 6105 patients to perindopril vs. perindopril + indapamide vs. placebo Perindopril had a relative risk reduction of stroke of 28% compared to placebo Perindopril + indapamide had a RRR of stroke of 43% compared to placebo Stroke 2014; 45:

5 Meta Analysis in Stroke 2003 Included 7 RCTs Patients had a h/o recent ischemic stroke, hemorrhagic stroke, or TIA 3 trials only included patients with elevated blood pressure 4 included patients who may or may not have had elevated BP Stroke 2003; 34:

6 Meta Analysis in Stroke 2003 There was a statistically significant reduction in all stroke, all non fatal stroke, MI, and all vascular events Stroke 2003; 34:

7 Blood Pressure Management for Secondary Stroke Prevention Latest AHA guidelines for secondary stroke prevention were published in 2014 About 70% of patients with a recent stroke have hypertension, defined as elevated blood pressure > 140/90 HTN is the major modifiable risk factor for secondary stroke prevention Stroke 2014; 45:

8 Blood Pressure Management for Secondary Stroke Prevention What should the choice of antihypertensive be? The optimal drug regimen to achieve the recommended level of reductions is uncertain because direct comparisons between regimens are limited. The available data indicate that diuretics or the combination of diuretics and an angiotensin-converting enzyme inhibitor is useful. Class I, Level A evidence What should the goal Blood Pressure be? Stroke 2014; 45:

9 Blood Pressure Management for Secondary Stroke Prevention AHA 2014 Secondary Stroke Prevention Guidelines Initiation of blood pressure therapy is indicated in the patients who have elevated blood pressure 140 systolic or 90 diastolic after several days after their stroke Resumption of BP therapy is indicated for previously treated patients with known hypertension for both prevention of recurrent stroke and prevention of other vascular events in those who have had an ischemic stroke or TIA and are beyond the first several days What should the target be? it is reasonable to achieve a systolic pressure <140 mm Hg and a diastolic pressure <90 mm Hg (Class IIa; Level of Evidence B). For patients with a recent lacunar stroke, it might be reasonable to target an SBP of <130 mm Hg (Class Iib, Level of evidence B). [Latter shown in the SPS trial] Stroke 2014; 45:

10 NHLBI asked an appointed JNC 8 council to update HTN guidelines In 2013, NHLBI announced their decision to discontinue the development of these guidelines. Instead of the JNC 8 Council producing the guidelines, the plan was to partner with organizations like ACC and AHA in the development of such guidelines However, the JNC 8 appointed council decided on their own to move forward with publishing guidelines above, and these are not endorsed by NHLBI JAMA 2014; 311(5):

11 Management of Blood Pressure in Adults Published in 2014 by members appointed to the JNC 8 These are not specific to Secondary Stroke Prevention JAMA 2014; 311(5):

12 AHA does not endorse BP goal of LESS THAN 150/90 for patients aged 60 years and older and a history of stroke or TIA Goal of LESS THAN 140/90 is endorsed by AHA There is concern that more patients will have increased risk of heart disease and stroke with higher blood pressures 12 12

13 Blood Pressure Management for Secondary Stroke Prevention What about patients with steno-occlusive disease? 13 13

14 Blood Pressure Management for Secondary Stroke Prevention Carotid Occlusion Surgery Study (COSS Trial) This was a trial where carotid occlusion patients were randomized to cerebral bypass vs. medical management There was a subgroup analysis published looking at the difference in outcomes amongst non-surgical patients (#91) based on blood pressures Patients with lower BPs < 130/85 had a decreased risk of secondary stroke Neurology 2014; 82: Symptomatic Intracranial Stenosis trial (SAMMPRIS Trial) Patients were randomized to optimal medical management alone vs. optimal medical mangement plus intracranial stenting Medical Management = 3 months of dual antiplatelet therapy, statin therapy for goal LDL < 70, and normotension (<140 systolic but <130 systolic if DM was present) The rate of stroke was much lower ( ~ 12%) than had been demonstrated in a previous trial looking at intracranial stenosis NEJM 2011; 365:

15 Statin Use for Secondary Stroke Prevention 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 and an LDL-C level 100 mg/dl with or without evidence for other clinical ASCVD (Class I; Level of Evidence B). 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). Stroke 2014; 45:

16 SPARCL Trial 4, 731 patients randomized Atorvastatin 80mg vs. placebo Patients had h/o stroke or TIA & LDL Results: significant decreased risk of stroke & cardiovascular events NEJM 2006; 355(6):

17 2009 Meta Analysis of Statins for Primary & Secondary Stroke Prevention 165, 792 patients Statins reduce risk of primary & secondary stroke For every 39 mg/dl decrease in LDL, there is a 21% Relative Risk Reduction (RRR) in stroke Statins reduce risk of cardiovascular events There is no increase risk of hemorrhagic stroke Lancet Neurology 2009; 8(5):

18 Antiplatelet Therapy for Secondary Stroke Prevention Not much has changed! Circulation 2010; 121:

19 Antiplatelet Drugs FDA Approval Class of Evidence Generic Advantage Disadvantage ASA X IIa, Level of Evidence A Yes -Inexpensive -OTC -indications for CAD, PVD Clopidogrel (Plavix) X IIa, Level of Evidence A Yes -Indications for CAD, PVD in addition to stroke -option for patients with true ASA allergy -Indications for CAD, PVD ASA + dipyridamole (Aggrenox) X 1, Level of Evidence A Yes -Only indication is for stroke. No indication for CAD or PVD -Headaches 19 19

20 Antiplatelet Therapy for Secondary Stroke Prevention Ticagrelor Use in Stroke: SOCRATES TRIAL ASA vs. ticagrelor for secondary stroke prevention in patients with mild stroke Recently finished Not published. Will be released soon Ticagrelor was not superior to aspirin Amer Heart J 2011; 161(3):

21 Antiplatelet Therapy for Secondary Stroke Prevention Dual Antiplatelet Therapy Use in Secondary Stroke Prevention Why do we sometimes still prescribe ASA + clopidogrel after stroke or TIA? 21 21

22 MATCH TRIAL in 2004 Randomized, placebo controlled trial 7599 patients radomized Clopidogrel & placebo vs. Clopidogrel & ASA 81mg daily Patients had a h/o ischemic stroke or TIA plus an additional high risk vascular risk factor No Benefit in reduction in stroke or MI Increased Risk of Bleeding Lancet 2004; 364:

23 Dual Antiplatelet Therapy Circumstances where short term Dual Antiplatelet Therapy may be considered Symptomatic intracranial atherosclerotic disease SAMMPRIS Trial: Maximal medical management vs. Maximal medical management + Intracranial Stenting Medical Management in the included ASA 325mg + Clopidogrel 75mg daily, high dose statin therapy, & normotension x 90 days Patients in medical arm did better than patients in previous intracranial stenosis trials 23 23

24 Dual Antiplatelet Therapy Circumstances where short term Dual Antiplatelet Therapy may be considered High risk stroke or TIA patients CHANCE Trial: 5170 patients in China were randomized within 24 hours of stroke or TIA to ASA + clopidogrel (loaded initially) vs. clopidogrel alone Patients who received clopidogrel + aspirin x 21 days had a statistically significant decreased risk of stroke at 90 days vs. patients who received clopidogrel alone NEJM 2013; 369(1):

25 Interruption of Antithrombotic Therapy 25 25

26 Bridging with LMWH prior to Elective Surgery in patients with history of coronary stent who were taking antiplatelet therapy Retrospective study 515 patients were included 251/515 bridged with LMWH prior to surgery vs. 264/515 continued on antiplatelet therapy Primary Endpoints: major cardiac & cerebrovascular endpoint Safety endpoint of major bleeding Thromb Haemost 2015; 114:

27 Bridging with LMWH prior to Elective Surgery in patients with history of coronary stent who were taking antiplatelet therapy Patients bridged with LMWH had increased risk of: Major Cardiac and Cerebrovascular Events AND increased risk of bleeding (Bleeding Academic Research Consortium [BARC] 2) Thromb Haemost 2015; 114:

28 Interruption of Antithrombotic Therapy for Surgery Bridge Study Published in 2015 in NEJM Randomized, placebo controlled study Compared bridging patients with Afib with LMWH (Dalteparin) vs. placebo pre and post surgery Patients had a history of Afib plus at least one point on CHAD2 score Patients with mechanical heart valves were excluded Patients were undergoing elective surgery. Cardiac, spinal, and intracranial surgeries were excluded NEJM 2015; 373:

29 BRIDGE Trial Study Design 1884 patients were enrolled and randomized Placebo arm: 950 Dalteparin arm: 934 NEJM 2015; 373:

30 BRIDGE Trial There was no significant increase risk of arterial embolism in the placebo group (no bridge) There was a higher risk of major & minor bleeding in the dalteparin (bridging) group NEJM 2015; 373:

31 Conclusion Blood Pressure Post Stroke Goal is < 140/90. Patients with steno-occlusive disease will require more careful titration of their blood pressure while watching for signs of neurological deterioration, but studies of patients with steno-occlusive disease have shown a normal blood pressure is associated with lower risk of secondary stroke Statin Use In general, patients with stroke/tia of atherosclerotic origin should be prescribed statin for secondary stroke prevention Patients with stroke/tia not attributable to atherosclerotic origin (an example is arterial dissection), do not have a clear indication for statin from a stroke standpoint and should be managed per the 2013 AHA/ACC cholesterol guidelines 31 31

32 Conclusion Antiplatelet Therapy All patients post stroke or TIA should be prescribed some antithrombotic therapy unless it is contraindicated Dual antiplatelet therapy can be considered for a short period of time post stroke/tia, but should not be continued long term (> 3months) due to the increased risk of hemorrhagic complications Interruption of Antithrombotic Therapy post Stroke Bridging high risk cardiac patients with LMWH pre and post surgery has been shown to increase the peri-operative risk of bleeding & HAS NOT been shown to decrease the risk of thromboembolic events 32 32