Pharmacy
STROKE
Anne Kinnear
Lead Pharmacist
NHS Lothian
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Aim
Pharmacy
To update pharmacists on Stroke: the disease
and its management and explore ways to
implement pharmaceutical care for this patient
group as part of normal working practice.
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Objectives
• Describe the disease, identify risk factors and signs
and symptoms associated with Stroke.
• Define the current therapeutic management of acute
Stroke and secondary prevention measures.
• Identify pharmaceutical care issues and respond to
symptoms in patient scenarios and identify
appropriate management solutions.
• Explore how to implement the principles of a
pharmaceutical care needs assessment tool in
practice.
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Pharmacy
Stroke
Pharmacy
Third commonest cause of death in Scotland
15,000 stroke patients in Scotland annually
One of leading causes of disability in adults
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“Time is Brain”
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Stroke
Pharmacy
2 million
neurones per
minute
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How do you know if someone is
having a stroke?
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What is FAST?
F acial weakness - can the
person smile? Has their
mouth or eye drooped?
A rm weakness - can the
person raise both arms?
S peech problems - can the
person speak clearly and
understand what you say?
T est – all 3
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Pharmacy
Stroke WHO Definition
Pharmacy
A neurological deficit (usually loss of function) caused
by reduction in blood supply to the brain. This is
usually because a blood vessel bursts or is blocked
by a clot. This affects the supply of oxygen and
nutrients, causing damage to the brain tissue.
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Chest Heart and Stroke
Definition
Pharmacy
A stroke is a brain attack.
It happens when the blood supply to the brain is
disrupted.
Most strokes occur when a blood clot blocks the flow
of blood to the brain.
Some strokes are caused by bleeding in or around
the brain from a burst blood vessel.
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Stroke
Pharmacy
• Transient Ischaemic Attack (TIA) – a stroke which
resolves within 24 hours
(10% risk of stroke within 7 days)
• Minor Stroke – a stroke resulting in persisting
symptoms but not causing significant disability
• Major Stroke – a stroke resulting in persistent deficit
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Diagnosis
Computed
Tomography scan
(CT scan)
`Immediate`
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Pharmacy
Diagnosis – stroke type
Cerebral
infarct
STROKE
CT
scan
Cerebral
haemorrhage
Stroke
Pharmacy
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Atherosclerotic thrombosis
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Pharmacy
Stroke
Pharmacy
1 - Anterior cerebral artery
2 - Anterior communicating artery
3 - Internal carotid artery
4 - Posterior communicating
artery
5 - Middle cerebral artery
6 - Posterior cerebral artery
7 - Superior cerebellar artery
8 - Basilar artery
9 - Anterior inferior cerebellar
artery
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Cerebrum – intellect, speech, emotion, sensory, movement
Cerebellum – balance, co-ordination
Brain stem – respiration, heart rate, blood pressure, wakefulness
Cerebrum
- left hemisphere – speech and language
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Risk factors
Pharmacy
Risk Factors For Stroke:
Treatable
Major
Less Well Documented
Diabetes
Hypertension
Smoking
Lifestyle
Diet
Cholesterol
Heart disease, esp. atrial
fibrillation
Transient ischaemic attacks
Excessive alcohol intake / drug
abuse
Acute infection
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Risk factors
Risk Factors for Stroke
That Cannot Be
Changed
Increased age
Being male
Race (e.g., AfricanAmericans)
Family history of stroke
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Pharmacy
Evidence Base for Treatment
ACTIVE
PROGRESS
CHARISMA
SPARCL
ESPRIT
MATCH
PROFESS
RE-LY
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Acute
Secondary Prevention
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Acute treatment
Thrombolysis
Antiplatelets
Blood pressure
Hydration
Oxygen
Blood glucose
Temperature
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Thrombolysis
• Lyses clot by digesting fibrinogen
• Intravenous recombinant tissue plasminogen
activator (tPA - Alteplase) 0.9mg/kg after test dose
• Within 4.5 hours (6hrs if IST-3 clinical trial)
• Reduces death and disability at 90 days
• 2% incidence of symptomatic haemorrhage at 24 hrs
• 8% incidence of symptomatic haemorrhage at 7 days
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Pharmacy
Antiplatelets
Pharmacy
Aspirin 300mg within 48 hours continued for
14 days
• reduces 14 day mortality and morbidity
No evidence for:
• Anticoagulants
• Combinations of antiplatelets or antiplatelets
with anticoagulants
• Neuroprotectants
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Blood pressure - not actively managed in acute phase
Hydration – IV Sodium Chloride 0.9% is preferred to
glucose 5%
Blood glucose - treat if blood glucose is >11mmol/L
Oxygen - supplemental Oxygen if saturation <95%
Temperature – prescribe antipyretics
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Secondary Prevention Treatment
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Pharmacy
Antiplatelets
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Pharmacy
Antiplatelets
Pharmacy
Evidence
Cochrane Reviews
Dipyridamole MR
Clopidogrel vs Aspirin
Randomised Clinical Trials
MATCH
Aspirin + Clopidogrel vs Clopidogrel
CHARISMA
Aspirin + Clopidogrel vs Aspirin
ESPRIT
Aspirin + Dipyridamole MR vs either alone
PROFESS
Aspirin + Dipyridamole MR vs Clopidogrel
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Antiplatelets
Aspirin and Dipyridamole MR in combination significantly reduces
risk of vascular events compared to aspirin alone (approx 25% risk
reduction)
• without an increase in bleeding
The combination of Aspirin and Clopidogrel is no more effective
than either alone
• is associated with an increase in moderate/life threatening
bleeding
•only 25% patients in studies had a history of previous stroke
•used in acute coronary syndrome (NSTEMI) or carotid stenosis
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Antiplatelets
The combination of Aspirin and Dipyridamole MR vs Clopidogrel
showed no difference in efficacy
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Pharmacy
Antiplatelets
Recommendations
Clopidogrel 75mg daily OR Aspirin 75mg daily and Dipyridamole
200mg MR twice daily should be prescribed after ischaemic stroke for
secondary prevention of vascular events
Aspirin alone – if dipyridamole intolerance
(headache 26% withdrawal ESPRIT trial)
- or if carotid stenosis 70% or unstable angina
The combination of aspirin and clopidogrel is not recommended for
prevention of ischaemic stroke or TIA
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Statins
Evidence
2 x Systematic reviews (170000 pts)
Randomised Clinical Trial – SPARCL (4700 pts)
• Statins significantly reduce relative risk of
ischaemic stroke by 21% but stroke death is not
reduced
• Effect occurs without an increase in haemorrhagic
stroke
• Statins reduce coronary events and all cause
mortality
• Effect occurs irrespective of baseline cholesterol
level (proportional to LDL lowering)
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Pharmacy
Statins
Pharmacy
Recommendations
A statin should be prescribed to patients who have had an
ischaemic stroke irrespective of cholesterol level
Which statin?
Simvastatin 40mg – high risk coronary event
Atorvastatin 80mg – TIA / ischaemic stroke
Should not be used in patients with a prior history of intracerebral
haemorrhage
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Anticoagulants
Pharmacy
Non-cardioembolic ischaemic stroke
Evidence
Systematic review
Anticoagulant vs antiplatelet
Randomised clinical trial – ESPRIT
• Anticoagulants no more effective than aspirin
• No difference in all cause mortality between antiplatelets
and low or medium anticoagulation
• Higher mortality and major bleeding at intensive
anticoagulation
Recommendation
Anticoagulation not recommended
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Anticoagulants
Atrial fibrillation and ischaemic stroke
Evidence
RE-LY trial
•
•
•
Warfarin MORE effective for prevention of all vascular events and
recurrent stroke
No significant increase in intracranial bleed
Not within 2 weeks
Recommendation
Warfarin should be offered with target INR of 2.0-3.0
OR
Dabigatran (direct thrombin inhibitor) 110mg or 150mg twice a day may
become an alternative to warfarin
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Anticoagulants
Atrial fibrillation and ischaemic stroke
Evidence
RE –LY trial (NEJM 2009)
• Warfarin versus Dabigatran in AF with primary outcome of
stroke
Recommendation
Equal efficacy for warfarin and dabigatran with no worse safety
profile for the dabigatran
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Antihypertensives
Pharmacy
Evidence
Well established link between BP reduction and stroke primary prevention
Systematic review (7 trials)
Randomised Clinical Trial - PROGRESS
•
•
•
Perindopril/Indapamide
Lowering BP reduced recurrent stroke and major vascular events
No effect on vascular or all cause mortality
Reduction in stroke related to difference in systolic BP between
groups
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Antihypertensives
Recommendation
BP should be assessed in all patients and therapy with an ACE
inhibitor and thiazide diuretic should be considered regardless of
BP
Target blood pressure is <140/85 – diabetics <130/80 mmHg
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Summary
Secondary Prevention of Ischaemic Stroke
Pharmacy
Aspirin 75mg + Dipyridamole 200mg twice daily
(or Clopidogrel 75mg if ACS)
Simvastatin 40mg / Atorvastatin 80mg
Thiazide diuretic
ACE inhibitor
Warfarin or dabigatran if AF
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Pharmacist Role
Public health, education
and information
Pharmaceutical care
Research
Multidisciplinary team
membership
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Pharmacy
Public Health, education and
information
Awareness and promotion of:
•
•
•
•
•
Public Health campaigns
CHSS campaigns and resources
Risk factors – action to take
Stroke Identification – FAST test
Lifestyle advice – smoking, weight loss/diet, vitamins
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Pharmacy
Pharmacist Role
Public health, education and
information
Pharmaceutical care
Research
Multidisciplinary team
membership
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Pharmacy
Pharmaceutical Care
Pharmacy
• Transfer of patient information primary/secondary care
interface
- continuity of care
- reduction of medication errors/discrepancies
• Identification and resolution of pharmaceutical care
issues
- level and type of resultant disability
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Modified Rankin Score (mRS) Disability
Score
Score
Symptoms
0
No symptoms
1
No significant disabling
symptoms
2
Slight disability
3
Moderate disability
4
Moderate/severe disability
5
Severe disability
6
Dead
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Disability
Pharmacy
Dysphasia Aphasia
Speech
Dysphagia Aphagia
Swallow
Hemiparesis
Weakness
Hemiplegic
Paralysis
Hemianopia
Visual difficulties
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Pharmaceutical Care Issues
Speech
Comprehension
Communication/counselling
• carers
Swallow
Ability to take medicines
• aspiration risk and liquids
• formulations
• bioavailability eg phenytoin
• NG and PEG tube feeding
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Pharmacy
Stroke
Pharmacy
Weakness or paralysis
Ability to operate devices
• inhalers, insulin
Ability to open containers
Visual problems
Ability to read instructions
• labels, leaflets, charts
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Pharmacist Role
Public health, education and
information
Pharmaceutical care
Research
Multidisciplinary team
membership
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Pharmacy
Research
Practice development project – MSc Strathclyde University
• Standardised pharmaceutical care plan validation
• Validation of care issues for transfer – needs assessment tool
Pharmacist Research Fellow
• Design and validate transfer document for stroke
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Research
Pharmacy
Audit of prescribing adherence to stroke guidelines and design
and evaluation of a pharmaceutical care model
• Prospective evaluation of prescribing in acute stroke unit
patients against guidelines and development of a pharmaceutical
care plan
• Retrospective evaluation of prescribing in the same patients
following discharge to primary care and design of documentation
to facilitate information transfer between secondary and primary
care
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Research
Pharmacy
Primary Care - Results
• adherence 75% (hospital 79%
94%)
• lower for quality indicators not included in GMS contract
• lower for communication criteria
Primary Care - Conclusions
Improvement areas for prescribing
• use of warfarin in atrial fibrillation
• achievement of clinical target blood pressure and glycaemic
control to audit and clinical standards
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Pharmacist Role
Public health, education and
information
Pharmaceutical care
Research
Multidisciplinary team
membership
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Pharmacy
Multidisciplinary team membership
SIGN – Scottish Intercollegiate
Network
Managed Clinical Network for
Stroke (MCN)
National Advisory Group for
Stroke
Stroke Unit Multidisciplinary
Team
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Stroke Key Messages
Time is brain
Think FAST
Brain attack – dial 999
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Useful Contacts
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