Preventing Strokes One at a Time Evaluating the Event 2009

Acknowledgements  The Heart and Stroke Foundation and Canadian Stroke Strategy gratefully acknowledges the collaborative contributions of healthcare professionals and stroke programs across the country in the development of this tool kit.  This resource and its components are based upon the Canadian Best Practice Recommendations for Stroke Care, updated 2008, and was developed to support the implementation of the recommendations for stroke prevention.

Canadian Stroke Strategy  Resources available at:  Acute Stroke Management Resource  Toolkit for the Canadian Best Practice Recommendations for Stroke Care, updated 2008  Pocket Reference Cards  Faaast FAQ’s for Nurses  National Professional Education Atlas  NEW!! Stroke Prevention Tool Kit

 2.0 Prevention of Stroke 2.1 Lifestyle and risk factor management 2.2 Blood pressure management 2.3 Lipid management 2.4 Diabetes management 2.5 Antiplatelet therapy 2.6 Antithrombotic therapy for atrial fibrillation 2.7 Carotid intervention  3.0 Hyperacute Stroke Management 3.2 Acute management of transient ischemic attack and minor stroke Canadian Best Practice Recommendations for Stroke Care, updated 2008: Prevention Sections CMAJ 2008;179(12 Suppl):E1-E93

Preventing Strokes One at a Time Upon completion, participants will be able to:  Discuss the incidence of TIA/minor stroke and the risk of recurrent stroke  Describe four steps of secondary stroke prevention  Implement Canadian Best Practice Recommendations for Stroke Care in the evaluation and identification of risk with TIA and minor stroke patients  Identify patients at high risk of recurrent stroke Workshop Learning Objectives

Outline  Overview of Stroke & TIA  Etiology  Stroke Risk  Diagnostic investigations

Impact of Stroke in Canada Someone has a stroke every 10 minutes ~ 50,000 strokes/year 300,000 Canadians living with stroke 20% chance of second stroke within 2 years 16,000 Canadians die from stroke each year Price Tag: $3.6 billion annually For every symptomatic stroke there are 9 ‘silent’ strokes resulting in cognitive impairment

Stroke TIA  Sudden onset  Focal neurological symptoms  Interruption in blood supply to a part of the brain  WHO >24 hours  Typical > 1 hour  Permanent damage  Sudden onset  Focal neurological symptoms  Transient lack of blood supply and focal ischemia  WHO < 24 hours  Typical < 1 hour  No permanent damage to the brain

Warning Signs: Stroke/TIA  Sudden loss of strength or sudden numbness in the face, arm or leg, even if temporary  Sudden difficulty speaking or understanding or sudden confusion, even if temporary  Sudden trouble with vision, even if temporary  Sudden severe and unusual headache  Sudden loss of balance especially with any of the above signs CALL 911 HSFC, 2006

Evaluate the Event: Investigating and Stratifying Risk  3.2 Acute management of TIA and Minor Stroke  “ Patients who present with symptoms suggestive of minor stroke or TIA must undergo a comprehensive evaluation to confirm the diagnosis and begin treatment to reduce the risk of major stroke as soon as is appropriate to the clinical situation.”. CMAJ 2008;179(12 Suppl):E1-E93 #3.2 Canadian Best Practice Recommendations for Stroke Care, 2008

ETIOLOGY “The approach to secondary stroke prevention is dependent upon the underlying cause, or mechanism of the initial event and the existing stroke risk factors.” (APSS, Feb 2009)

Ischemic (80%)Hemorrhagic (20%)

Ischemic Stroke: Etiology  Large Vessel Disease  Atherosclerosis  Small Vessel Disease  Lacunar Infarction  Cardioembolic  Cryptogenic

Stroke Mimics  Patients can present with deficits that initially can resemble stroke making TIA difficult to diagnose  History, assessment, and imaging all contribute to the assessment and identification of stroke mimics

Stroke Prevention  Primary:  an individually based clinical approach to disease prevention  directed toward preventing the initial occurrence of a disorder in otherwise healthy individuals  Recommendations related to stroke emphasize the importance of screening and monitoring those patient at high risk of a first stroke  Secondary:  An individually based clinical approach to reducing the risk of recurrent vascular events in individuals who have already experienced a stroke or TIA and in those who have one or more of the medical conditions or risk factors that place them at high “risk of stroke”  Recommendations are directed to those risk factors most relevant to stroke CMAJ 2008;179(12 Suppl):E1-E93, p. E16

The Road to Prevention Are all TIA/minor stroke patients at risk of subsequent stroke? Is early identification of those at highest risk of stroke critical?

STROKE RISK

Risk of Recurrent Stroke  People with symptoms of a TIA are at higher risk for subsequent stroke  11.5 % will have a stroke within 90 days  Of these patients 50% will have a stroke within 48 hours Johnston et al (2000) & Gladstone et al (2004)  20%-40% of strokes are preceded by a TIA or non disabling stroke (Rothwell et al. Lancet Neurol 2006; 5: )

Risk Factors  Hypertension  Obesity  Atrial Fibrillation  Diabetes  Cardiac Disease  Dyslipidemia  Excessive Alcohol Intake  Physical Inactivity  Smoking  Stress  Diet  Age  Gender  Family History  Ethnicity  Previous TIA or Stroke  Modifiable  Non-Modifiable

An Approach to Secondary Stroke Prevention Four Step Process  Evaluate the Event  Initiate Medications  Implement Interventions  Modify Stroke Risk Factors Adapted from APSS, February 2009

Step 1: Evaluate the Event  TIA/Minor Stroke Risk Assessment  Clinical Predictors  Investigations  CT or MRI, ECG, Carotid Imaging, Blood work

Evaluate the Event: Investigating and Stratifying Risk  3.2a.i “All patients with suspected TIA or Minor Stroke should have an immediate clinical evaluation and additional investigations as required to establish the diagnosis, rule out stroke mimics and develop a plan of care  3.2a.ii “Use of a standardized risk stratification tool at the initial point of health care contact- whether first seen in primary, secondary or tertiary care-should be used to guide the triage process.”. CMAJ 2008;179(12 Suppl):E1-E93 #3.2 Canadian Best Practice Recommendations for Stroke Care, 2008

Evaluate the Event: Risk Stratification  Emergent  Symptoms within previous 24 hours with 2 or more high risk clinical features  Acute/persistent or fluctuating stroke symptoms  1 positive investigation  Other factors based on individual presentation and clinical judgement  Urgent  TIA within 72 hours  Semiurgent  Does not fit in urgent or emergent CMAJ 2008;179(12 Suppl):E1-E93, #3.2

Evaluate the Event: Investigating and Stratifying Risk  3.2a.iii “Patients with suspected TIA or minor stroke should be referred to a designated stroke prevention clinic or to a physician with expertise in stroke assessment and management, or if these options are not available, to an emergency department that has access to neurovascular imaging facilities and stroke expertise.”. CMAJ 2008;179(12 Suppl):E1-E93 #3.2 Canadian Best Practice Recommendations for Stroke Care, 2008

Evaluate the Event: Timing of Tests Diagnostic TestEmergentUrgentSemiurgent Assessment by medical specialist trained in stroke 24 h7 d30 d CT or MRI24 h7 d30 d Carotid Imaging24 h7 d30 d ECG24 h7 d30 d CMAJ 2008;179(12 Suppl):E1-E93 #3.2

Evaluate the Event: Example of a Risk Stratification Tool Age1 point for age >60/1 BP1 point for BP> 140/90/1 Clinical Features 2 points for focal weakness 1 point for speech disturbance without weakness /2 Duration2 points for duration >60 minutes 1 point for duration >10min<59 minutes /2 Diabetes1 point for presence of diabetes/1 Johnston, Rothwell et al. Lancet; 2007; 368: Total score/ 7 ABCD2 Score * not endorsed by the Canadian Stroke Strategy

Evaluate the Event: Investigations Labs  CBC,  Electrolytes, Urea, Creatinine, LFT’s, CK  INR  Fasting Glucose  Hb A 1C  Fasting Lipid Profile o Total Cholesterol o HDL o LDL o Triglycerides Diagnostics  CT head, MRI  Carotid Imaging (Carotid Doppler, CTA, MRA)  CXR  ECG  Echocardiogram  Holter Monitor

Evaluate the Event: Investigations TestRationaleOutcome CT or MRI Rule out mimics, Identify stroke type MRI: Better visualization of acute stroke Diagnosis; begin appropriate interventions. All TIA minor stroke patients should receive a CT scan of the head ASAP. Carotid Imaging (Carotid Doppler, CTA, MRA) Identify carotid stenosis. Prompt carotid imaging is essential Goal to TX within 2 weeks (70- 99% stenosis:90 day risk of stroke is 25%) Neurovascular Imaging

Evaluate the Event: Investigations TestRationaleOutcome Other Labs: CK, LFTs, INR, PTT, Fasting lipids & glucose, HbA1C CK, LFT: Baseline values prior to statin ; INR: risk of hemorrhage & assessment of Coumadin efficacy: Glucose: Identify & treat early diabetes, HbA1C (if diabetic) Statins can ↓ further vascular events by 25%; Sub-therapeutic INR (<2) puts patients at High risk for further event ECGScreen for Atrial Fibrillation.Treat with Coumadin. ECHO/ TEEIf suspicion of cardiac source. TEE Assists to identify PFO, shunts Expedites proper treatment &management. Holter Monitor If you suspect atrial fibrillation Expedites proper treatment & management

An Approach to Secondary Stroke Prevention Four Step Process  Evaluate the Event √  Initiate Medications  Implement Interventions  Modify Stroke Risk Factors APSS, February 2009

Canadian Best Practice Recommendations for Stroke Care, updated