Stroke Care:
Focus on guidelines
Sara C. Huffer, MD
11/17/2011
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Background
tPA for acute ischemic stroke
Stroke mechanisms
Guidelines for anticoagulation
Summary
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Quality measures are increasingly used
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Quality, and not quantity, of care will drive
reimbursement
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Multiple stakeholders interested in highest
quality of care in setting of limited
resources
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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
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90 year old woman admitted with hip
fracture found by her daughter at 9am to
have aphasia and decreased movement of
right side.
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What is the next step?
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ICU transfer
Head CT now
Call pharmacy and have them mix tPA
Hope that everything will get better
Have a snack; gather thoughts
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Head CT is without blood
Neurology consult for acute stroke
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Thrombolysis decision:
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Assess for contraindications to therapy
Discussion with family
 Risks/benefits
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Double-blinded
Placebo controlled
NIH-sponsored
0.9mg/kg IV t-PA
624 patients
Treatment within 3
hours
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1/2 within 90 minutes
1/2 within 91-180 minutes
0-1 2-3 4-5 Death
Placebo 26% 25 27 21
t-PA
39% 21 23 17
NEJM 1995; 333:1581-7.
0: No symptoms at all
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1: No significant disability despite symptoms; able to carry out all usual duties
and activities
_____________
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2: Slight disability; unable to carry out all previous activities, but able to look after
own affairs without assistance
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3: Moderate disability; requiring some help, but able to walk without assistance
_____________
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4: Moderately severe disability; unable to walk without assistance and unable to
attend to own bodily needs without assistance
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5: Severe disability; bedridden, incontinent and requiring constant nursing care and
attention
____________
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6: Dead
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Placebo
Group
tPA
Group
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“When was the last time you saw him/her totally normal?”
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How “normal” were they?
 Who saw them this morning?
 Clearly no symptoms?
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Times of reference
 “When the Colts game started”
Time (min)
Odds Ratio
(Favorable
Outcome)
95% CI
0-90
2.8
1.8-4.5
91-180
1.5
1.1-2.1
181-270
1.4
1.1-1.9
271-360
1.2
0.9-1.5
Lancet 2004; 363: 768–74
Lancet 2004; 363: 768–74
N Engl J Med 2008;359:1317-1329.
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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.
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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
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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).
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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
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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
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Common and natural consequence of infarction
 43% HT rate at 4 weeks in natural hx studies
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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
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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
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Nursing at bedside, may need to contact clinical supervisor
 Do NOT wait for ICU transfer
Accucheck
STAT labs
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BMP, CBC, Coags, Cardiac markers
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No need to wait for results unless clinical concern
If BP>185/110
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Start gentle: Labetolol 10mg IV, may repeat x 1
Discuss w/family
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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
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If not used, Genentech will reimburse
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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
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Interpretation <45 min
IV rt-PA started <60 min
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Earlier=better
Marler, NINDS/NIH, 1997.
 Background
 tPA for
acute ischemic stroke
 Stroke mechanisms
 Guidelines for anticoagulation
 Summary
Ischemic stroke mechanisms
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Embolic
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Thrombotic
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Cardio-embolic
Artery-artery embolic
Atherosclerotic
Small vessel disease
Hemodynamic failure, “watershed”
Cardioembolic
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Atrial fibrillation
Acute MI and LV thrombus
Cardiomyopathy
Native valvular heart disease
Prosthetic heart valves
Artery to Artery Embolism
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15-20% of all ischemic strokes
Carotid stenosis
Vertebral, intracranial arteries, aorta
 Background
 tPA for
acute ischemic stroke
 Stroke mechanisms
 Guidelines for anticoagulation
 Summary
Common misconceptions
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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
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Anticoagulation should be performed urgently after
ischemic stroke to prevent worsening or further strokes
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NO
Heparin is a common source of medication error in
stroke patients
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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 Stroke
Secondary prevention
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Atrial fibrillation
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Vitamin K antagonist
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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
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Carotid stenosis
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Antiplatelet therapy
Statin therapy and risk factor modification
CEA if indicated
Intracranial atherosclerosis
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Aspirin instead of warfarin (Class I, level B)
Angioplasty or stent placement is investigational
PFO
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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
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Odds ratio 3.1 for PFO alone, 15.5 with atrial septal
aneurysm
Overell. Neurology. 2000
PFO studies
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PFO in cryptogenic stroke study
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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
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2.3% recurrence with PFO
15% recurrence with PFO +atrial septal aneurysm
4.2% recurrence with neither
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Homma et al. Circulation, 2002
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Mas et al. NEJM, 2001
 Background
 tPA for
acute ischemic stroke
 Stroke mechanisms
 Guidelines for anticoagulation
 Summary
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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
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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;42:227276.
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Or google “AHA stroke guidelines”
Sara Huffer, MD
IU Health Arnett
shuffer@iuhealth.org