Monitoring: What, when and how long? George Ntaios University of Thessaly, Larissa, Greece.

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Presentation transcript:

Monitoring: What, when and how long? George Ntaios University of Thessaly, Larissa, Greece

Disclosures Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. Honoraria: Medtronic; Quintiles; Boehringer-Ingelheim. Speaker fees: Sanofi; Boehringer-Ingelheim; Galenica; Bayer. Support for educational events: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer- Ingelheim; Galenica; Elpen; Bristol Myers Squibb. Participation in trials: – NAVIGATE-ESUS / National coordinator (Greece) – PRECIOUS / National coordinator (Greece). – ENOS / National coordinator (Greece). – BIOSIGNAL / Principal Investigator (Larissa). – EBBINGHAUS / Principal Investigator (Larissa). – FOURIER / Principal investigator (Larissa). – PREVISE / Principal investigator (Larissa). – GLORIA-AF / Sub-investigator (Larissa).

Stroke is an earthquake San Francisco Bay Area, California, USA. August 24, :20 AM

Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG

Monitor for diagnostic reasons

Continuous ECG monitoring vs. Holter Rizos. Stroke 2012; 43:

Continuous monitoring vs. Holter

Sanna. N Engl J Med 2014;370: CRYSTAL-AF

CRYSTAL-AF: the more you look, the more you find Sanna. N Engl J Med 2014;370:

EMBRACE Gladstone. N Engl J Med 2014;370:

EMBRACE : the more you look, the more you find Gladstone. N Engl J Med 2014;370:

Monitor ECG – for how long?

Gladstone. Stroke 2015; 46: Atrial extrasystoles predict AF

Gladstone. Stroke 2015; 46: Atrial extrasystoles predict AF

Gladstone. Stroke 2015; 46: Atrial extrasystoles predict AF

Monitor ECG in lacunar strokes ? Sacco. Neurology 2006; 66:1335-8

Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli

Monitor for diagnostic reasons

Microemboli monitoring

Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure

Monitor Blood Pressure Jorgensen. Cerebrovasc Dis 2002;13:204-9

Monitor Blood Pressure Vemmos. Journ Intern Med 2004; 255: 257–265

Monitor Blood Pressure Sandset. Lancet 2011; 377:741-50

Monitor Blood Pressure Sandset. Lancet 2011; 377:741-50

Monitor Blood Pressure Sandset. Lancet 2011; 377:741-50

Monitor Blood Pressure ENOS. Lancet 2015; 385:617-28

Monitor Blood Pressure ENOS. Lancet 2015; 385:617-28

ESO Guidelines Cautious BP lowering is recommended in patients with extremely high BPs (>220/120mmHg) (Class IV, GCP) It is recommended that BP of >185/110mmHg lowered before thrombolysis (Class IV, GCP) ESO Guidelines. CVD 2008

Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose

Monitor glycemia Quinn. Cerebrovasc Dis 2009;27:148–155

Monitor glycemia Previously diagnosed DM Newly diagnosed DM Stress hyperglycemia Fasting Glu ≥ 126 Random Glu ≥ 200 HbA 1c ≥ 6.5% Fasting Glu ≥ 126 Random Glu ≥ 200 HbA 1c < 6.5%

Monitor glycemia Ntaios, Michel. Stroke 2010; 41:

Monitor glycemia Gray. Lancet Neurol 2007; 6: 397–406

Monitor glycemia Gray. Lancet Neurol 2007; 6: 397–406

Insulin treatment – functional outcome Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013

Insulin treatment - mortality Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013

Insulin treatment - hypoglycemia Ntaios, Papavasileiou, Makaritsis, Michel. Int J Stroke 2013

Monitor glycemia

AHA guidelines Jausch. Stroke 2013 it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL and to closely monitor to prevent hypoglycemia in patients with acute ischemic stroke (Class IIa; Level of Evidence C).

Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose Dysphagia

Monitor for dysphagia Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Videofluoroscopy

Monitor for dysphagia

ESO guidelines ESO Guidelines. CVD 2008 Swallowing assessment is recommended but there are insufficient data to recommend a specific approach for treatment (Class III, GCP)

Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose Dysphagia Temperature

Monitor temperature Kakaletsis/Ntaios/Michel. Larissa 2015

Monitor temperature

Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose Dysphagia Temperature Oxygen

ESO guidelines ESO Guidelines. CVD 2008 Intermittent monitoring of oxygen saturation is recommended for 72 h in patients with significant persisting neurological deficits (Class IV, GCP) It is recommended that oxygen should be administered if the oxygen saturation falls <95% (Class IV, GCP)

Monitor 0 2 Roffe. Nice 2014

Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose Dysphagia Temperature Oxygen Lab tests (CRP, WBC…) Clinically

Monitor clinically -Physical examination -Neurological status -NIHSS -yawning -vomit -headache -GCS

Why monitor? Monitor Diagnostic reasons Vital signs & complications Response to treatment ECG Microemboli Arterial pressure Glucose Dysphagia Temperature Oxygen Lab tests (CRP, WBC…) Clinically Repeat imaging

Stroke unit works Langhorne, Cochrane 2009; CD000197

One size does not fit all

Take-home messages

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