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Preventing Stroke in Primary Care Clinical recommendations from the Alberta Provincial Stroke Strategy

Preventing Stroke in Primary Care Clinical recommendations from the Alberta Provincial Stroke Strategy. Learning Objectives. Upon completion of this program, participants will be able to: Discuss the incidence of stroke and the risk of recurrent stroke

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Preventing Stroke in Primary Care Clinical recommendations from the Alberta Provincial Stroke Strategy

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  1. Preventing Stroke in Primary CareClinical recommendations from the Alberta Provincial Stroke Strategy

  2. Learning Objectives Upon completion of this program, participants will be able to: • Discuss the incidence of stroke and the risk of recurrent stroke • Describe four components of secondary stroke prevention • Identify high risk TIA/stroke patients along with the appropriate care and investigations • Explain strategies to reduce the risk of recurrent stroke

  3. Stroke: The Canadian Perspective • 50,000 new stroke patients/year in Canada† • 1 stroke every 10 minutes • 5000 new strokes / year in Alberta • 200,000–300,000 stroke survivors in Canada† • 35-40,000 stroke survivors in Alberta • Cost to Alberta Health over $300 million / year

  4. Stroke: The Canadian Perspective • 4th leading cause of death in Canada • The leading cause of adult disability • 28% of stroke patients are under age 65*

  5. Stroke Subtypes Hemorrhagic 20% Ischemic 80%

  6. Athero-thrombosis: a progressive process Plaquerupture/fissure &thrombosis Athero-scleroticplaque Fattystreak Fibrousplaque Normal Myocardial infarction Ischaemic stroke Critical leg ischaemia Angina Transient ischaemic attack Claudication/PAD Clinically silent Cardiovasculardeath Increasing age

  7. Recurrence of Ischemic Stroke Outcomes for Patients With a First Ischemic Stroke (by subtype) †Not significant; all other categories statistically different across subtype of stroke. From Petty GW et al. Stroke 2000;31:1062-68

  8. Second Strokes • Stroke or TIA survivors have an increased risk of a subsequent stroke • Recurrent strokes are more likely than initial strokes to result in disability and death • ~ 20%-40% of strokes are preceded by a TIA or non disabling stroke (Rothwell et al. Lancet Neurol 2006; 5: 323-331) Golden Opportunity for Stroke Prevention!

  9. TIA Stroke Risk Risk of stroke following TIA is high: • 10-20% within 90 days • 50% of these within the first 2 days (48 hours) Johnston et al. JAMA 2000; 284: 2901-06 EARLY PREVENTION STRATEGIES can make a difference! ACT FAST!

  10. Modifiable Hypertension Dyslipidemia Diabetes Metabolic syndrome Atrial fibrillation Cardiovascular Disease TIA/prior stroke Carotid stenosis Cigarette smoking Alcohol abuse Obesity Physical inactivity Obstructive sleep apnea Nonmodifiable Age Gender Race/ethnicity Heredity Risk Factors for Stroke Goldstein L, et al. Circulation. 2001;103:163-182. Broderick J, et al. Stroke. 1998;29:415-421. Brown WV. Clin Cornerstone. 2004;6(suppl 3):S30-S34.

  11. Approach to Secondary Stroke Prevention Components: • Evaluate the Event • Implement Interventions • Initiate Medications • Modify Stroke Risk Factor: Continuous Monitoring

  12. Evaluate the Event

  13. ABCD2 ScoreRothwell et al. Lancet; 2007; 369: 283-292

  14. Evaluate the Event: TIA / Minor Stroke Risk Assessment TIA Stroke Risk Assessment High Risk 1. Symptom onset within the last 48 hours with any one of the following : • Motor deficit lasting more than 5 minutes • Speech deficit lasting more than 5 minutes • ABCD2 score ≥ 4 2. Atrial fibrillation with TIA

  15. Evaluate the Event: TIA / Minor Stroke Risk Assessment TIA Stroke Risk Assessment Medium Risk Symptom onset between 48 hours and 7 days with any one of the following : • Motor deficit lasting more than 5 minutes • Speech deficit lasting more than 5 minutes • ABCD2 score ≥ 4 Low Risk 1. Symptom onset > 7 days 2. Symptom onset ≤ 7 days without the presence of high risk symptoms • Speech deficit, motor deficit, ABCD2 score ≥ 4, atrial fibrillation with TIA ** Isolated syncope or dizziness is rarely a TIA and may not require Stroke Prevention Clinic Referral

  16. Evaluate the Event: Investigations • Labs - CBC, lytes, Cr, gluc, PTT, INR, fasting lipids • ECG • ? Cardiac cause - afib • Holter monitor • CT or MRI • Rule out mimics, identify stroke type • Carotid Imaging (carotid dopplar, CTA or MRA) • Identify stenosis • Echocardiogram • If suspect cardiac cause

  17. IMPLEMENT INTERVENTIONS ACT FAST WITH HIGH RISK PATIENTS!

  18. SOS - TIA

  19. EXPRESS study ( UK) • PHASE 1 : daily appointment clinic , advice faxed to the FP • PHASE 2 : Emergency clinic, TIA patients seen on the same day and treatment given in clinic • ASA in all cases, ASA + clopidogrel in high risk patients, simvastatin 40mg, perindopril 4mg and indapamide 1.25 mg • Reduction in risk of early recurrent stroke by over 80% Rothwell et al. Lancet; 2007:370:1432-1442

  20. Express Study

  21. Implement Interventions: Carotid Endarterectomy If TIA due to ≥ 50% stenosis in extracranial carotid artery consider CEA Greatest benefit if surgery within 2 weeks Rothwell et al. Lancet; 2004; 363: 915-25

  22. Early Carotid Surgery Much Better >70% w/o near-occlusion Rothwell PM et al. Stroke 2004;35:2855-2861. NNT 3

  23. To order pocket card: there is a link on APSS webpage underneath Professional Education Resources: http://www.strokestrategy.ab.ca/health-care-providers-ed.html:

  24. Initiate Medications: Antithrombotic Therapy Aspirin (50-325 mg/day) is first line treatment • If aspirin naïve- load with 160mg then 81 mg OD Options: Aspirin/extended release dipyridamole • 25mg/200mg BID Clopidogrel • 75 mg OD, consider loading with 300 mg

  25. ESPS-2: The Second European Stroke Prevention Study • Tested efficacy of ASA/ER DP for secondary stroke prevention • Addressed clinical questions • Does ER DP prevent stroke? • Does low-dose ASA prevent stroke? • Is ASA/ER DP superior to ASA alone? To ER DP alone? • Is ASA/ER DP well tolerated? Diener HC, et al. J Neurol Sci 1997;151:S1-S77 Diener HC, et al. J Neurol Sci 1996;143:1-13

  26. ESPS-2 Results:Stroke-Free Survival 100 ER DP 95 ASA/ER DP Patients without stroke (%) ASA 90 Placebo 85 80 6 12 18 24 Time (months) Kaplan-Meier stroke-free survival curves

  27. ESPS-2: Conclusions • Combined treatment with ER DP + ASA reduces the risk of stroke by 37% vs. placebo (p<0.001) • Combined treatment with ER DP + ASA is significantly superior to ASA alone (RRR 23.1%, p<0.006) • ER DP and ASA have an additive effect in secondary prevention of stroke Diener HC, et al. J Neurol Sci 1997;151:S1-S77 Diener HC, et al. J Neurol Sci 1996;143:1-13

  28. MATCH: ASA+Clopidogrel showed a non significant trend for the reductionin major vascular events in specific high risk cerebrovascular patients* Primary Endpoint (ITT) IS, MI, VD, rehospitalisation for acute ischaemic event 0.20 Clopidogrel ASA+Clopidogrel 0.16 RRR: 6.4% (p=0.244) 0.12 Cumulative event rate 0.08 0.04 0.00 0 3 6 9 12 15 18 Months of follow-up * All patients received clopidogrel

  29. Initiate Medications: Antithrombotic Therapy If cardioembolic source: • Long-term anticoagulation (Warfarin) • Target INR 2.0 – 3.0

  30. Atrial Fibrillation • Persistent and PAF predictors of first and recurrent strokes • Overall RR with coumadin is 68% • Optimal INR 2-3 • Estimated RR with ASA compared to placebo is 21% • About one-third with AF & IS will have another potential cause eg carotid stenosis

  31. Stroke Prediction Model: CHADS Scoring Tool Risk Classification Scheme: Components of CHADS2 CHADS2 item Points Congestive heart failure 1 Hypertension (systolic >160 mmHg) 1 Age greater than 75 years 1 Diabetes 1 Prior cerebral ischemia 2

  32. Antithrombotic Therapy for Patients With Atrial Fibrillation Weaker Risk Factors Moderate-Risk Factors High-Risk Factors Female gender Age ≥ 75 years Previous stroke /TIA or embolism Age 65 to 74 Hypertension Mitral stenosis Coronary Artery Disease Heart Failure Prosthetic heart valve Thyrotoxicosis LV ejection fraction ≤ 35% Diabetes ACC/AHA/ESC guide lines for management of AF; Circulation 2 Aug 06

  33. Antithrombotic Therapy for Patients With Atrial Fibrillation Risk Category Recommended Therapy No risk factors ( ASR 1%) Aspirin, 81 to 325 mg daily One moderate-risk factor (ASR 4%) Aspirin, or warfarin Any high-risk factor or more than 1 warfarin moderate-risk factor (ASR 8-12%) ACC/AHA/ESC guide lines for management of AF; Circulation 2 Aug 06

  34. Medical conditions Hypertension Hypercholesterolemia Obesity Diabetes mellitus Insulin resistance? Cardiac diseases Atrial fibrillation Coronary artery disease CHF Behaviours Cigarette smoking Heavy alcohol use Physical inactivity Modifiable Stroke Risk Factors

  35. 1. Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat and salt in accordance with the DASH diet 2. Regular physical activity: optimum 20-60 minutes of moderate cardiorespiratory activity 3-5/week or more 3. Reduction in alcohol consumption in those who drink excessively (<2 drinks/ day) 4. Weight loss (> 5 Kg) in those who are over weight (BMI>25) 5. Smoke free environment Lifestyle Recommendations

  36. Lifestyle: Weight Loss • Healthy BMI: 18.5-24.9 kg/m2 • Waist circumference: <102 cm for men, <88 cm for women • ? Insulin Resistance (metabolic syndrome)

  37. CAN ALL BARRIERS BE OVERCOME?

  38. Treating Hypertension to Prevent Stroke • HTN is the single most important modifiable risk factor for stroke • HTN contributes to 70% of all strokes • Atheroma in carotids, aortic arch • Friability of small cerebral end arteries • LV dysfunction and atrial fibrillation

  39. Benefits of Treating Hypertension • Younger than 60 yrs • Reduces the risk of stroke by 42% • Reduces the risk of coronary event by 14% • Older than 60yrs • Reduces overall mortality by 20% • Reduces cardiovascular mortality by 33% • Reduces incidence of stroke by 40% • Reduces coronary artery disease by 15%

  40. Treat Hypertension Aggressively • Target most patients still < 140/90 • Home Measurement < 135/85 • Diabetics < 130/80 • Lifestyle Modification: • Sodium restriction, DASH diet, physical activity, weight loss, alcohol restriction, smoking cessation • Expect to use combination therapy • ACE inhibitor, ARB, diuretic

  41. Hypertension outcome trials Stroke Myocardial infarction 7 6 5 4 3 2 1 0 Percent (%) STOP-1 STONE SYST-CHINA CAPP NICS INSIGHT SHEP SYST-EUR HOT STOP-2 NORDIL Kjeldsen et al. Blood Pressure 2001;10:190-192.

  42. PROGRESS TRIAL • Randomised placebo-controlled trial designed to determine the effects of a blood pressure-lowering regimen on the risks of stroke and other major vascular events in hypertensive and non hypertensive patients with a history of stroke or TIA Reference: Lancet 2001; 358: 1033-41

  43. PROGRESS TRIAL STROKE RISK REDUCTION 0.20 28% risk reduction 95% CI 17 - 38% p<0.0001 0.15 Placebo Active* Proportion with event 0.10 0.05 0.00 0 1 2 3 4 Follow-up time (years) *Active: perindopril 4 mg ± indapamide Reference: Lancet 2001; 358: 1033-41

  44. Hypertension: ARB Studies • LIFE (Losartan Intervention for Endpoint Reduction in Hypertension) • Randomized controlled trial • Treatment: • Losartan + Atenelol placebo vs Atenelol + Losartan placebo • Hydrochlorothiazide added at 2 months • At 4 months - Losarten or Atenelol doubled to achieve target BP < 140/90 • Results • More patients reached target BP with Losarten vs Atenelol arm • 25% decrease incidence of diabetes • Less incidence of stroke, MI and death in Losarten arm Lancet 2002;359:995-1003

  45. 8 Atenolol 7 6 5 Losartan Proportion of patients with first event (%) 4 3 2 Adjusted Risk Reduction 24·9%, p=0·001 Unadjusted Risk Reduction 25·8%, p=0.0006 1 0 0 6 12 18 24 30 36 42 48 54 60 66 LIFE: Fatal/Nonfatal Stroke Study Month B Dahlof et al. Lancet 2002;359:995-1003

  46. Treatment of HypertensionwithCerebrovascular Disease • Strongly consider blood pressure reduction in all patients after the acute phase of non disabling stroke or TIA • Recommended agents: ACE-I, diuretics ARB - ongoing studies ß-blockers, CCB

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