Dawn Matherne Meyer PhD,RN,FNP-C. Assistant Professor University of California San Diego

Transcription

1 Dawn Matherne Meyer PhD,RN,FNP-C Assistant Professor University of California San Diego Evidence Based Care of the Stroke Patient: A Focus on Acute Treatment, BP Management, & Antiplatelets TIME IS BRAIN Dawn M Meyer RN, FNP-C,PhD

2 OBJECTIVES 1. Neuro-anatomy and function 2. Updated rt-pa prescribing 3. Evidence based blood pressure management 4. Evidence based antiplatelet use Dawn M Meyer RN, FNP-C,PhD

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4 Functional Neuroanatomy

5 Functional Anatomy of Brain

6 Sensory Pathways

7 Motor Pathways

8 Vascular Neuroanatomy

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12 Circle of Willis- Blood Supply of the Brain Dawn M Meyer RN, FNP-C,PhD

13 Dawn M Meyer RN, FNP-C,PhD

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15 TREATMENT OF ISCHEMIC STROKE Dawn M Meyer RN, FNP-C,PhD

16 t-pa (Activase ) THROMBOLYTIC THERAPY t-pa is the ONLY FDA approved treatment for ischemic stroke (based on the NINDS trial). Nationally 2-3% of ischemic stroke patients receive TPA. Some reasons that patients do not receive t-pa: Arrive at hospital too late Inability for hospitals to triage pts Concerns about bleeding complications Dawn M Meyer RN, FNP-C,PhD

17 NINDS t-pa STROKE TRIAL Randomized, double blind, placebo-controlled trial Treatment with 0.9mg/kg t-pa (Activase ) vs placebo within 3 hours of stroke symptom onset 624 patients treated within 3 hours 32% more t-pa patients had minimal or no disability at 90 days 6.4% of patients had a symptomatic intracranial hemorrhage by 36 hours after treatment Mortality at 90 days was 17% in t-pa group and 21% in placebo group (The NINDS Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. NEJM, 1995) Dawn M Meyer RN, FNP-C,PhD

18 CAUTIONS WITH t-pa THROMBOLYTIC THERAPY The t-pa for stroke and MI are DIFFERENT. Double check to ensure you are administering Activase (alteplase) for ischemic stroke. A CT scan must be performed before administering Activase (alteplase). Major complication of t-pa: 6.4% symptomatic intracranial hemorrhage (ICH) Dawn M Meyer RN, FNP-C,PhD

19 ADMINISTERING t-pa DOSING: 0.9 mg/kg * pt weight in kg= TOTAL DOSE 10% as IV Bolus over 1 minute Remaining 90% 1 hr IV infusion MAX DOSE= 90mg MONITORING: Vital signs and neuro checks every 15 minutes x2 hours from time of t-pa, every 30 minutes x6 hours, every 1 hour x 16 hours, then per unit protocol. Dawn M Meyer RN, FNP-C,PhD

20 CARE OF THE ISCHEMIC STROKE PATIENT Dawn M Meyer RN, FNP-C,PhD

21 COMMON MEDICATIONS ORDERED FOR THE ISCHEMIC STROKE PATIENT Anti-platelets or anticoagulants Blood pressure management DVT prophylaxis Lipid lowering medications Smoking Cessation Dawn M Meyer RN, FNP-C,PhD

22 Blood Pressure Management Emergency Department Goal BP for patients treated with rt-pa is SBP <185 and DBP <110 Goal for ischemic stroke patients not treated with rt-pa is SBP <220 and DBP <120 Dawn M Meyer RN, FNP-C,PhD

23 Blood Pressure Management ICU/Stroke Unit rt-pa treated Patients Goal SBP <185 and DBP <110 (or MAP ) for 1 st 24 hours After 24 hours, the BP goal should be 120/80* The MAP should not be decreased more than 15% per day * Patients with hemodynamically significant stenosis of the large arteries (e.g. internal carotid arteries) should not have the BP lowered without further workup. Dawn M Meyer RN, FNP-C,PhD

24 Blood Pressure Management ICU/Stroke Unit Non-rt-PA treated Patients Goal SBP <220 and DBP <120 (or MAP <130) for 1 st 24 hours After 24 hours, the BP goal should be 120/80* The MAP should not be decreased more than 15% per day * Patients with hemodynamically significant stenosis of the large arteries (e.g. internal carotid arteries) should not have the BP lowered without further workup. Dawn M Meyer RN, FNP-C,PhD

25 Nitroglycerin

26 Labetolol

27 Dawn M Meyer RN, FNP-C,PhD Enalaprilat

28 Hydralazine

29 Nitroprusside

30 Clevidipine

31 Nicardipine

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33 Current Antiplatelet Therapy in Stroke Aspirin Clopidogrel Aspirin + ER Dipyradamole

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35 Aspirin Aspirin Mechanism: (inhibits PG synthesis) - Inhibits arachidonic acid metabolism necessary for thromboxane production - Covalently acetylates Cyclooxygenase (irr.) - Inhibits platelet function within 1 hour - Lasts entire platelet lifetime (~10d) Efficacy & Dosage: - Efficacy is not in question - Ideal dosage still debated

36 Aspirin-Efficacy CAST& IST- SALT- UK-TIA- Metaanalysis ~40,000 pts. Reduction of 7/1000 ischemic stroke (CVA+all death) ASA 75mg 18.0% RRR (major cva/ MI/ vascular death) ASA 300 vs 1200mg = effective. 15% OR (-3 29%) DUTCH-TIA- (CVA/MI/vasc. death) ASA 30 vs. 283mg both effective Hazards Ratio

37 ASA Meta-analyses: APTC (1994): 46 ASA trials 25% OR (cva/mi/vasc.death) Algre & van Gijn (1996): 10 trials. 6,171 pts. 16% OR (cva/mi/vasc.death) 13% Relative RR (CI=4-21%) Same for any dose ASA ( mg/d) Johnson et al. (1999): 11 trials. 5,228 pts. 15% Relative RR for cva (CI=6-23%) Same for any dose ASA ( mg/d) ~15-18% RRR for Stroke, NNT 100 APTC Algre & van Gijn Johnson et al Aspirin

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39 Clopidogrel Thienopyridine derivative: Same chemical family as Ticlopidine. Inhibits ADP induced plt aggregation. Pharmacodynamics are similar to ASA. 400mg x 1 => max 40% inhibition mg QD => 50-60% inhibition may take 4-7 days for max effect. Patrono et al. Chest. 1998; 114:

40 Clopidogrel CAPRIE: (Clopidogrel vs ASA) Clopidogrel(75mg) ASA(325mg) 19,185 pts c h/o CVA/ MI/ PVD Incidence 5.83% (ASA) 5.32% (Clopidogrel) 8.7% (p=0.043) RRR overall, 7 stroke (p=0.26) CAPRIE. Lancet. 1996;378: NNT 60

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42 Dipyridamole Pyrimidopyrimidine derivative: Vasodilator & antiplatelet properties. Mechanism: Inhibits Phosphodiesterase increased c-gmp Result is platelet inhibition. *Blocks Adenosine uptake into cell increased intra- plt c-amp Result is platelet inhibition. Patrono et al. Chest. 1998; 114:

43 ASA+ERDP ESPS-2: (E.R.Dipyridamole 200mg bid vs. ASA 25mg bid) 6,602 pts with prior stroke/tia 4 treatment groups (including placebo) RRR (for cva) vs Placebo Low ASA ERDP ASA+ERDP 18.0% (p=0.013) 16.3% (p=0.039) 37.0% (p<0.001) Diener et al. ESPS-2. J. Neuro Sci. 1996l143:1-13. NNT 18 (placebo)/34 (ASA)

44 ASA+ERDP ESPRIT/ESPRIT-2 Trial ASA+ERDP (n=1363) ASA (n=1376) Primary outcome (death from all vascular causes, nonfatal stroke, non-fatal MI, or major bleeding complication) 173 (13%) ASA+ERDP 216 (16%) ASA alone HR 0.80; ARR 1.0% per year 24% RRR when compared to OAC (INR 2-3)

45 ASA+Clopidogrel +

46 ASA+Clopidogrel MATCH: (Clopidogrel+ASA) vs. Clopidogrel Clopidogrel(75mg)+ASA(75mg) vs Clopidogrel(75mg) 7,599 high risk pts (CVA/TIA + 1 Risk Factor) 18 month follow up Results: Event Rate = 15.7% vs. 16.7% RRR 6.4% (p=0.244) **nss Hemorrhage Rate = 2.6% vs. 1.3% RRE 100% (p=0.029) **ss Diener et al. MATCH. Lancet.2004;364:

47 PRoFESS VERSUS with OR without

48 Primary Outcome First Recurrence of stroke, ITT Analysis Total number of recurrent strokes was 1,814 ASA+ERDP n=916 (9.0%) Clopidogrel n=898 (8.8%) HR 1.01, CI Because CI extends beyond did not meet the pre-specified non-inferiority endpoint 87.4% of recurrent strokes were ischemic There was no significant difference in 3 month mrs 3 between the groups (4.1% ASA+ERDP, 3.9% clopidogrel) Per protocol analysis recurrence rate was 7.6% ASA+ERDP, 7.7% clopidogrel

49 Effect on Clinical Practice ASA+ERDP is not inferior to clopidogrel Patient selection is key to choice of antiplatelet for secondary stroke prevention ASA financial barriers ASA+ERDP Ischemic stroke, no significant cardiac history, CHF* Clopidogrel Cardiac history, PAD, risk for ICH, migrainours, hx GI bleed

50 When We Combine Things We Don t Always Get What We Expect

51 Summary Understanding neuro-anatomy and function allows you to anticipate the needs of your patient and understand their neurologic deficit rt-pa is the only FDA approved treatment for ischemic stroke Blood pressure management is vital to maintaining cerebral perfusion after stroke while minimizing the risk of hemorrhagic transformation or expansion The choice of antiplatelet therapy is guided by the patient profile Dawn M Meyer RN, FNP-C,PhD

52 Dawn M Meyer RN, FNP-C,PhD THE END