Long Term Management of the Stroke Pa2ent

Transcription

1 Long Term Management of the Stroke Pa2ent Theodore Wein MD,FRCPC Assistant Professor of Neurology & Neurosurgery Stroke Preven2on Clinic Montreal General Hospital

2 Disclosure Disclosure Grants/Research Support: Honoraria: Steering Commi9ees: Consul:ng Fees: Investments: Guideline Commi9ees: Board of Directors: NIH, Allergan Inc., Alder Pharmaceu2cals, Bayer, Boehringer Ingelheim, Acorda Therapeu2cs Inc. Boehringer Ingelheim, Bayer, Allergan. REFLEX, MOBILITY, Allergan 116 Allergan Inc., Boehringer Ingelheim., Bayer, Novar2s None L Global Stroke Community Advisory Panel Canadian Cardiovascular Society Canadian Best Prac2ce Recommenda2ons for Stroke Care o Co Chair Preven2on Guidelines o Commi\ee Member Canadian Stroke Consor2um

3 Statement I am here to answer your ques2on on stroke. Please ask you ques2ons on any topic whenever you wish as I would rather address your needs than do a didac2c lecture. This is a workshop your par2cipa2on is needed

4 Ques2on Once Stroke survivors leave rehab, do they con2nue to have ongoing problems that require medical a\en2on? If so what percentage? How long do stroke survivors need to be followed for and how oaen?

5 Post-Stroke Disabili:es Are Common & Varied Many pa2ents have several disabili2es Up to 83% severe impairment Percentage of survivors % Up to 50% 45% Up to 36% moderate impairment 20% 0 Motor impairments Cogni:ve impairments Urinary incon:nence Dysphagia Language impairments Psychological disturbances Paul SL, et al. Curr Drug Targets. 2007;8(7):

6 Post-Stroke Disabili2es Persist A recent study evaluated levels of disability and handicap at 5 years (n = 418) after stroke using several different measures Regardless of the instrument used to evaluate disability, approximately one-third of survivors had moderate or severe impairment at 5 years post stroke Percentage of patients Barthel Index score "Two simple ques:ons" Neurologic impairment Modified Rankin score Severe impairment Moderate impairment Feigin VL, et al. Neurology. 2010;75(18):

7 Requirement for Long-term Assistance With Primary Ac:vi:es of Daily Living 2 Years A`er Stroke Riks-Stroke Ambulation Dressing Daily hygiene Toilet visits Eating Percentage of patients requiring assistance Adapted from Glader Glader EL, et al. Läkartidningen. 2001;98(41):

8 Selected Symptoms 2 Years Aaer Stroke Riks-Stroke Almost never Sometimes Often Always Fatigue Depression Anxiety Pain Percentage of patients reporting symptom Adapted from Glader Glader EL, et al. Läkar3dningen. 2001;98(41):

9 Pa:ent Survey at 2 Years A`er Stroke: Are You Currently Receiving Rehabilita:on? Riks-Stroke Adapted from Glader Glader EL, et al. Läkar3dningen. 2001;98(41):

10 Caregiver Surveys Indicate a Need for More Informa:on and Be9er Support 2 Years A`er Stroke Riks-Stroke Percentage of caregivers Did not know who to contact for advice or support Wanted more knowledge on stroke Actively in contact with community and hospital care Had contact with local patient organizations Had any formal support Adapted from Asberg Asberg KH, et al. Läkar3dningen. 2005;102(4):

11 UK Stroke Survivor Unmet Needs Survey: Highlights the Need at 5 Years A`er Stroke Cross-sec2onal survey 1 to 5 years aaer stroke 2 samples: Na2onal/Local Register (South London) 60% na2onal sample/78% local popula2on responses 1251/799 ques2onnaires returned 49% reported unmet needs Median number of unmet needs = 3 (range, 1-13) 59% unmet pain needs 54% unmet need for stroke informa2on 42% reported nega2ve change in their rela2onship with spouse 39% unmet emo2onal need McKevi\ C, et al. Stroke. 2011;42(5):

12 South London Stroke Register: Ongoing Disability and Need for Rehabilita2on at 10 Years 10% to 20% of pa2ents had moderate-to-severe disability at 10 years 20% to 30% of pa2ents at any one 2me point require ongoing assessment and rehabilita2on interven2on By Barthel Index (mean, 95% confidence interval) Incidence of moderate/severe disability per d Time since stroke (years) Wolfe CD, et al. PLoS Med. 2011;8(5):e

13 Ques2on What ques2ons do you typically ask a stroke survivor when you see them in follow up?

14 Wein CSC 2016 Quebec City 14

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16 Ques2on How many of you encourage Stroke Survivors to exercise? Does Exercise help in Stroke Preven2on? If yes how frequent and for what dura2on do you suggest to your pa2ents?

17 Physical Ac2vity Important modifiable lifestyle factor that can play a protec2ve role in both primary and secondary preven2on of stroke Global Burden of Disease Study, Feigin et al. (2016) data from 188 countries 7.7% stroke burden a\ributed to low physical ac2vity. Canada, the es2mate was 10.9%.

18 Excercise and Stroke Metanalysis of 23 trials (Lee et al. Stroke 2003;34: ) High physcial ac2vity vs low physical ac2vity: Total Stroke: 27% RR, P<0.001 Moderate vs Low phsyical ac2vity Total Stroke: 20% RR p<0.001

19 Cohort Studies:protec2ve effect of physical ac2vity Million Women Study Armstrong et al. (2015) Inves2gated how reproduc2ve and lifestyle factors affect women s health. Women who engaged in strenuous physical ac2vity 1-3x/week had a lower risk of both ICH & ischemic stroke vs women who rarely or never engaged in such ac2vity. The effect was U-shaped such that the risk of stroke was not reduced significantly for women who engaged in strenuous ac2vity more than three 2mes per week

20 Excercise and Stroke Physical ac2vity is improtant modifiable risk factor that influences both Primary and Secondary Stroke Preven2on Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study (n=30 239) (Stroke 2013;44: ) Prospec2ve cohort study, aged 45 years, the study No physical ac2vity vs persons exercising 4x/week, Risk of stroke was HR= 1.20, 95% CI, INTERSTROKE (3000 case matched controls) -(Lancet 2010;376:223-23) Regular physical ac2vity reduced Total stroke by 32% Women s Health Study (n=39 315) (Stroke 2010;41: ) Walking > 2 hours per week 30% lower risk of stroke than women whom did not walk Those whom walked at 4.8 km/hr 37% reduc2on in stroke

21 2.3 Exercise: I. Pa2ents should be counseled to reduce sedentary behaviours and to work towards increased ac2vity goals as tolerated throughout their stroke recovery [Evidence Level B]. II. Pa2ents should be counseled to par2cipate in moderate intense dynamic exercise (such as brisk walking, jogging, swimming, cycling) 4 to 7 days per week, in episodes of 10 minutes or more, in addi2on to rou2ne ac2vi2es of daily living (Refer to the CSEP Canadian Physical Ac3vity Guidelines 2011 and CHEP 2015 for addi3onal informa3on) [Evidence Level B]. New Guideline pending final approval and publica:on

22 RRs and 95% CIs for total (A) and ischemic (B) stroke by low-risk lifestyle score Chiuve, S. E. et al. Circulation 2008;118:

23 Ques2on Mr. Jones recently suffered a stroke and spent 3 months in rehab. He has significant paresis on his lea hemibody. He is now under your care. 1. Do pa2ents develop spas2city 3 months aaer their stroke? 2. What is the mean 2me from neurological event to spas2city treatment here in canada

24 Ques2on Which is the best an2-platelet to have your pa2ents on?

25 Ques2on Your pa2ent was placed on ASA and PLAVIX in the hospital for their stroke. Should they be on it long term?

26 An2coagula2on and Stroke When do you an2 coagulate a pa2ent for stroke preven2on? What is the best agent to an2 coagulate with? How do you dis2nguish between the different an2coagulants and what factors do you use to select an agent What if any monitoring is needed for these agents?

27 Ques2on Stroke pa2ent is going for cataract surgery and is on an2-coagula2on. How many days prior to surgery do you stop an2coagula2on

28 Other Clinical Tools, Guides and Apps Are Available at Thrombosis Canada DOACs: Peri-opera2ve Management DOACs: Coagula2on Tests DOACs: Bleeding Management DOACs: Comparison and FAQs 28

29 Thrombosis Canada: Bleeding Risks for Invasive / Surgical Procedures HIGH OR VERY HIGH RISK LOW RISK VERY LOW RISK Any procedure involving neuraxial anesthesia Neurosurgery (intracranial or spinal surgery) Cardiac surgery (e.g. CABG, heart valve replacement) Major vascular surgery (e.g. aortic aneurysm repair, aortofemoral bypass) Major urological surgery (e.g. prostatectomy, bladder tumour resection) Major lower limb orthopaedic surgery (e.g. hip/knee joint replacement surgery) Lung resection surgery Intestinal anastomosis surgery Selected procedures (e.g. kidney biopsy, prostate biopsy, cervical cone biopsy, pericardiocentesis, colonic polypectomy) Other intra-abdominal surgery Other intrathoracic surgery Other orthopaedic surgery Other vascular surgery Laparoscopic cholecystectomy Laparoscopic inguinal hernia repair Dental procedures Dermatologic procedures Ophthalmologic procedures Coronary angiography Cardiac implantable electronic device (pacemaker, implantable defibrillator) Gastroscopy without biopsy, colonoscopy without polypectomy Selected procedures (e.g. bone marrow biopsy, lymph node biopsy, thoracentesis, paracentesis, arthrocentesis) Tooth extraction (1 or 2 teeth) or teeth cleaning Skin biopsy or skin cancer removal Cataract removal *MAY CONTINUE WARFARIN AT THERAPEUTIC INR OR OTHER ANTICOAGULANTS DURING PROCEDURE An2thrombo2c therapy with ASA or warfarin (INR ) may con2nue for implanta2on of cardiac implantable devices. In addi2on to the bleeding risk of a procedure, physicians should consider co-morbid condi2ons that might exacerbate the bleeding risk (e.g. advanced age, renal or liver impairment). Adapted from: Verma et al. Can J Cardiol 2014; ; Thrombosis Canada 29

30 Thrombosis Canada: Suggested Guide for Pre-opera:ve Management of Pa:ents Receiving a DOAC** DRUG (DOSE REGIMEN) RENAL FUNCTION MINOR SURGERY/PROCEDURE (LOW BLEEDING RISK)* 12-25% residual an3coagulant effect at 3me of surgery acceptable MAJOR SURGERY/PROCEDURE INCLUDING NEURAXIAL PROCEDURES* (HIGH BLEEDING RISK) <10% residual an3coagulant effect at 3me of surgery acceptable Dabigatran (twice daily) Normal renal func2on or mild impairment (CrCl >50 ml/min) Give last dose 2 days before surgery/ procedure* (i.e. skip 2 doses) Give last dose 3-4 days before surgery/procedure* (i.e. skip 4-6 doses) Moderate renal impairment (CrCl ml/min) Give last dose 3 days before surgery/procedure* (i.e. skip 4 doses) Give last dose 5 to 7 days before surgery/procedure* (i.e. skip 8-12 doses) Rivaroxaban (once daily) Normal renal func2on, mild or moderate impairment (CrCl >30mL/min) Give last dose 2 days before surgery/procedure* (i.e. skip 1 dose) Give last dose 3 days before surgery/procedure* (i.e. skip 2 doses) Apixaban (twice daily) Normal renal func2on, mild or moderate impairment (CrCl >30 ml/min) Give last dose 2 days before surgery/procedure* (i.e. skip 2 doses) Give last dose 3 days before surgery/procedure* (i.e. skip 4 doses) **These recommenda:ons may differ from the product monographs/approved recommenda:ons as per Health Canada. *No an:coagulant taken on the day of surgery/procedure. Neuraxial procedures include spinal anesthesia, epidural inser:on and epidural catheter removal. CrCl: crea2nine clearance Adapted from Thrombosis Canada. 30

31 Thrombosis Canada: Suggested Guide for Post-Opera2ve Management of Pa2ents Receiving a DOAC* DRUG MINOR SURGERY/ PROCEDURE (LOW BLEEDING RISK) MAJOR SURGERY/PROCEDURE (HIGH BLEEDING RISK) Dabigatran Resume on day aaer surgery (~24 hours post-opera2ve) Resume 2 days aaer surgery (~48 hours post-opera2ve) Rivaroxaban Resume on day aaer surgery (~24 hours post-opera2ve) Resume 2 days aaer surgery (~48 hours post-opera2ve) Apixaban Resume on day aaer surgery (~24 hours post-opera2ve) Resume 2 days aaer surgery (~48 hours post-opera2ve) *These recommenda:ons may differ from the product monographs/approved recommenda:ons as per Health Canada. Adapted from Thrombosis Canada. 31

32 Ques2on Pa2ent seen in follow up with a history of stroke. LDL is 2.5 mmol/l. Should this person be on a sta2n. If so what dose?

33 Ques2on Mr. Smith is 75 years old. He has 70% caro2d Artery stenosis on a caro2d doppler. 1) Do other tests need to be done? 2) Is this person at higher risk for stroke or MI? 3) If an interven2on is to be done. What is be\er, cartoid artery sten2ng or caro2d endarterectomy?

34 Ques2on Mr. Jones is being seen in you office for stroke follow up. His BP is 139.9/90. How is long term BP managed? What are you goals or targets? What agents should we use?

35 Ques2on Oh my god doctor I have a hole in my heart. Does it need to be closed. What do you do with pa2ent with a PFO,

36 Ques2on Mrs Smith had a stroke. She is found to have sleep apnea. 1. Is obstruc2ve sleep apnea a risk factor for stroke? 2. Does trea2ng OSA decrease your risk for stroke?

37 Ques2on What is the prevalence of cogni2ve changes aaer stroke? What tests should be done to iden2fy cogni2ve impairment?

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