Update from education committee Train the trainercontent reviewed

Update from education committee • Train the trainer—content reviewed from Prevention of Stroke “First Tuesdays” Lecture Series

Introduction and Goal of “First Tuesdays” • Sabreena Slavin MD – Vascular Neurologist and Neurohospitalist at KU School of Medicine • Didactic lecture series as part of the Kansas Initiative for Stroke Survival • Updates in Practice and FAQ’s on Acute Stroke Care • 20 minute didactic, 10 minutes for questions/discussion.

Long Term Stroke Prevention • Primary prevention of stroke: education and patient recognition

Primary prevention in atrial fibrillation • CHADS-VASc score – CHF = 1 – Hypertension = 1 – Age < 65 = 0; Age 65 -74 = 1; Age > 74 = 2 – Diabetes = 1 – Stroke, TIA, or thromboembolism = 2 – Vascular disease = 1 – Sex (female) = 1 • Score of 0: no anticoagulation needed; give antiplatelet medication. • Score of 1: Consider anticoagulation. • Score ≥ 2: Anticoagulate. Lip et al, Chest 2010.

Primary prevention in atrial fibrillation • HAS-BLED score – – – – Hypertension = 1 Abnormal renal function = 1/Abnormal liver function = 1 Age ≥ 65 = 1 Stroke = 1 Bleeding = 1 Labile INRs = 1 ETOH use = 1 Drug use (that increase bleeding risk like ASA/NSAIDs) = 1 • Score of 0 -1: Ok to anticoagulate. • Score of 2: Can consider. • Score of ≥ 3: Try to use alternative. Pisters et al, Chest 2010.

Primary prevention in carotid stenosis • Reasonable to consider CEA or carotid stenting for patients asymptomatic (never had stroke or TIA) stenosis of 50 -99%. 1 • CREST-2 study: RCT of either CEA or stenting vs medical management in asymptomatic patients with stenosis ≥ 70%. 2 1. Abbott et al, Stroke 2015; 2. Mott et al, Stroke 2018.

Secondary prevention of stroke • Generally depends on etiology of stroke, found by inpatient workup. • Most patients should have at least antiplatelet medication, statin (despite LDL), and BP control. • Statins have non-lipid dependent effects on stroke prevention, including improving endothelial function, reducing thrombogenesis, and reducing oxidative stress, and antiinflammatory effects. 1 1. Zhao et al, Curr Neuropharmacol 2014.

TOAST Criteria • Cardioembolic – multiple vascular distributions affected • Large vessel atherosclerosis – one large vascular distribution affected • Lacunar – usually < 1. 5 cm, in deep territories, brainstem, or cerebellum • Other (e. g. : prothrombotic state, arterial dissection, vasculitis, drug induced vasospasm, MI/cardiac surgery, etc. ) • Cryptogenic Adams et al, Stroke 1993

Martini et al, Illustrated Guide to Cardiovascular Disease (Chapter 56: Stroke) 2016

Inpatient workup • Cardioembolic – Transthoracic echocardiogram; transesophageal echocardiogram or cardiac MRI is more specific if higher suspicion for valvular disease – Telemetry; extended cardiac rhythm monitor if higher suspicion for arrythmias • Large vessel atherosclerosis – CTA head, CTA neck OR carotid ultrasound – Lipid panel, Hb. A 1 c, smoking assessment, BP monitoring • Lacunar – Lipid panel, Hb. A 1 c, smoking assessment, BP monitoring • Other (e. g. : prothrombotic state, arterial dissection, vasculitis, drug induced vasospasm, MI/cardiac surgery, etc. ) – Urine toxicology screen, hypercoagulable panel, conventional arteriogram, CSF evaluation • Cryptogenic

Treatment for secondary prevention • Cardioembolic – Anticoagulation for cardiac thrombus, arrhythmias, severely depressed ejection fraction – Antibiotics for endocarditis • Large vessel atherosclerosis – Antiplatelet (Aspirin and/or Plavix), statin, BP management, smoking cessation, diet/exercise – Carotid stenting or endarterectomy for carotid stenosis • Lacunar – Antiplatelet (Aspirin and/or Plavix), statin, BP management, smoking cessation, diet/exercise • • Other (e. g. : prothrombotic state, arterial dissection, vasculitis) Cryptogenic

Lifestyle modifications • Smoking cessation • Diet and exercise

Questions? • • Call for help anytime! KU BAT phone: 913 -588 -3727 http: //www. kissnetwork. us/ sslavin 2@kumc. edu