Stroke Care: Focus on guidelines Sara C. Huffer, MD 11/17/2011.

Stroke Care:Focus on guidelines

Sara C. Huffer, MD

11/17/2011

Background tPA for acute ischemic stroke Stroke mechanisms Guidelines for anticoagulation Summary

Quality measures are increasingly used

Quality, and not quantity, of care will drive reimbursement

Multiple stakeholders interested in highest quality of care in setting of limited resources

EIGHT CORE MEASURES 1. IV tPA 2. Stroke Education 3. Discharge on statin 4. DVT prophylaxis 5. Rehabilitation assessment 6. Anticoagulation for atrial fibrillation 7. Antithrombotics by hospital day #2 8. Antithrombotics at discharge

90 year old woman admitted with hip fracture found by her daughter at 9am to have aphasia and decreased movement of right side.

What is the next step? ICU transfer Head CT now Call pharmacy and have them mix tPA Hope that everything will get better Have a snack; gather thoughts

Head CT is without blood Neurology consult for acute stroke

Thrombolysis decision: Assess for contraindications to therapy Discussion with family

Risks/benefits

Double-blinded Placebo controlled NIH-sponsored 0.9mg/kg IV t-PA 624 patients Treatment within 3

hours 1/2 within 90 minutes 1/2 within 91-180 minutes

NEJM 1995; 333:1581-7.

27PlaceboPlacebo

t-PAt-PA

26% 25 21

4-50-1 2-3 Death

2339% 21 17

• 0: No symptoms at all• 1: No significant disability despite symptoms; able to carry out all usual duties

and activities_____________• 2: Slight disability; unable to carry out all previous activities, but able to look after

own affairs without assistance• 3: Moderate disability; requiring some help, but able to walk without assistance_____________• 4: Moderately severe disability; unable to walk without assistance and unable to

attend to own bodily needs without assistance• 5: Severe disability; bedridden, incontinent and requiring constant nursing care and

attention____________• 6: Dead

tPA Group

Placebo Group

“When was the last time you saw him/her totally normal?”

How “normal” were they? Who saw them this morning? Clearly no symptoms?

Times of reference “When the Colts game started”

Time (min)Time (min) Odds Ratio Odds Ratio (Favorable (Favorable Outcome)Outcome)

95% CI95% CI

0-900-90 2.82.8 1.8-4.51.8-4.5

91-18091-180 1.51.5 1.1-2.11.1-2.1

181-270181-270 1.41.4 1.1-1.91.1-1.9

271-360271-360 1.21.2 0.9-1.50.9-1.5

Lancet 2004; 363: 768–74

Lancet 2004; 363: 768–74

N Engl J Med 2008;359:1317-1329.

An American Heart Association/American Stroke Association science advisory group has recommended the use of t-PA in the 3 to 4.5 hour window.

The advisory committee emphasizes the importance of treating acute strokes as rapidly as possible. The extended time window should not lead to any delay in treating eligible patients.

Case patient 90 year old woman admitted with hip

fracture found by her daughter at 9am to have aphasia and decreased movement of right side.

Nursing notes indicate patient was last seen normal 15 minutes earlier when the neurologist was called (60 minutes ago now).

BP >185/110 or aggressive BP lowering measures

Any history of intracranial hemorrhage Symptoms of SAH Active bleeding or known bleeding disorder Plt<100, high PTT, INR >1.7 H/o ischemic stroke, neurosurgery or serious

head trauma within 3 months

• Major surgery/trauma within 14 days• Gastrointestinal/urinary hemorrhage within 21 days• Arterial puncture at a noncompressible site within 7 days• LP within 7 days• Recent MI (with sx/signs of pericarditis)• Seizure at onset• Known AVM or aneurysm• Glucose < 50 or >400• Rapidly improving or minor symptoms

Common and natural consequence of infarction 43% HT rate at 4 weeks in natural hx studies

Risk of severe HT increases with rt-PA (and all revascularization therapies) 6.4% risk in NINDS (compared to 0.6% in placebo) Increased risk with older age and large strokes, but still

overall benefit

Khatri, Stroke, 2007

Case patient 90 year old woman admitted with hip fracture found by her daughter

at 9am to have aphasia and decreased movement of right side. Nursing notes indicate patient was last seen normal 15 minutes

earlier when the neurologist was called (60 minutes ago now). Accucheck was 85, blood pressure was 170/96. She has no history of major bleeding Relative contraindication of trauma/surgery and age. Orthopedic

surgeon felt it an acceptable risk to proceed with tPA. Prior to today she was independent at home and a church pianist.

Family felt that patient would have wanted to take the risk to avoid severe debility.

Emergent management• Nursing at bedside, may need to contact clinical supervisor

Do NOT wait for ICU transfer• Accucheck• STAT labs

– BMP, CBC, Coags, Cardiac markers– No need to wait for results unless clinical concern

• If BP>185/110– Start gentle: Labetolol 10mg IV, may repeat x 1

• Discuss w/family– no consent needed for standard IV rt-PA

• Foley catheter (if need anticipated after tPA)• Call pharmacy to order t-PA; 0.9 mg/kg, 10% bolus

– If not used, Genentech will reimburse

Transfer to ICU for at least 24 hours No anticoagulants, antiplatelets, etc BPs less than 180/105 Blood sugars less than 200 Generally NPO ‘Safety’ HCT at 24 hours IVF: NS (no D5) HCT for headache, N/V, drowsiness, abrupt neurological

decline

TIME ZERO = ARRIVAL TO ED Seen by physician < 10 minutes Tx’ing physician notified <15 min CT scan <25 min

Interpretation <45 min

IV rt-PA started <60 min Earlier=better

Marler, NINDS/NIH, 1997.

Ischemic stroke mechanisms Embolic

Cardio-embolic Artery-artery embolic

Thrombotic Atherosclerotic Small vessel disease

Hemodynamic failure, “watershed”

Cardioembolic Atrial fibrillation Acute MI and LV thrombus Cardiomyopathy Native valvular heart disease Prosthetic heart valves

Artery to Artery Embolism 15-20% of all ischemic strokes Carotid stenosis Vertebral, intracranial arteries, aorta

Common misconceptions All patchy or wedge shape infarcts are

embolic All “embolic” infarcts require anticoagulation Anticoagulation should be performed

urgently after ischemic stroke to prevent worsening or further strokes

AHA/ASA guidelines on urgent anticoagulation• Urgent anticoagulation, with the goal of preventing early

recurrent stroke, halting neurological worsening or improving outcomes after acute ischemic stroke is not recommended for treatment of patients with acute ischemic stroke, (Class III, Level of Evidence A)

• Urgent anticoagulation is not recommended for patients with moderate to severe strokes because of an increased risk of serious intracranial hemorrhagic complications (Class III, Level of Evidence A).

Common misconceptions Anticoagulation should be performed urgently after

ischemic stroke to prevent worsening or further strokes NO

Heparin is a common source of medication error in stroke patients

Due to unpredictable pharmacokinetics, need for frequent lab testing and dose changes, and continuous infusion.

Michaels et al, “Medication errors in acute cardiovascular and stroke patients: A scientific statement from the American Heart Association”. Circulation, 2010.

Cardioembolic StrokeSecondary prevention

Atrial fibrillation Vitamin K antagonist

If unable, use aspirin alone Aspirin-Plavix combo causes bleeding risk similar to warfarin

Acute MI and LV thrombus Cardiomyopathy Native valvular heart disease Prosthetic heart valves

Artery-artery embolism Carotid stenosis

Antiplatelet therapy Statin therapy and risk factor modification CEA if indicated

Intracranial atherosclerosis Aspirin instead of warfarin (Class I, level B) Angioplasty or stent placement is investigational

PFO Present in 15-25% of population AHA guidelines: Insufficient data whether

anticoagulation is equivalent to or superior to aspirin in secondary stroke prevention

Metaanalysis of retrospective studies: PFO was associated with increased risk of stroke in age group <55 years Odds ratio 3.1 for PFO alone, 15.5 with atrial septal

aneurysmOverell. Neurology. 2000

PFO studies PFO in cryptogenic stroke study

34% had PFO No difference in 2 year outcome in PFO vs. no PFO No difference in 2 year outcome asprin vs. warfarin

European PFO study 2.3% recurrence with PFO 15% recurrence with PFO +atrial septal aneurysm 4.2% recurrence with neither

Homma et al. Circulation, 2002

Mas et al. NEJM, 2001

Quality measures are becoming more prevalent

tPA for acute stroke is the standard of care Guidelines exist for decision to

anticoagulate, based on risk factors More trials are needed on PFO and stroke

Reference Furie, et al. Guidelines for the Prevention of Stroke in Patients

With Stroke or Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2011;42:227-276.

Or google “AHA stroke guidelines”

Sara Huffer, MD

IU Health Arnett

[email protected]

Stroke Care: Focus on guidelines Sara C. Huffer, MD 11/17/2011.

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