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Stop the Clot Current Guidelines for Primary and Secondary Ischemic Stroke Prevention

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Clopidogrel (Plavix) 75mg po daily. Dipyridamole 200mg ASA 25mg (Aggrenox) po twice daily ... ASA vs. Aggrenox vs. Plavix. Statin? Summary. Figure out who ... – PowerPoint PPT presentation

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Title: Stop the Clot Current Guidelines for Primary and Secondary Ischemic Stroke Prevention


1
Stop the Clot!Current Guidelines for Primary and
Secondary Ischemic Stroke Prevention
  • Brett Barrett, B.Sc.H., B.Sc.Phm., R.Ph
  • Clinical Pharmacist Medical Program
  • Grand River Hospital
  • Wednesday October 25th, 2006

2
Presentation Outline
  • Pathophysiology
  • Primary prevention
  • Risk factor reduction
  • Secondary prevention
  • Comparison of antiplatelet agents
  • Assessment of newer evidence
  • Review of anticoagulation

3
Stroke Outcomes
  • Out of every 100 stroke patients
  • 10 will have a complete recovery
  • 15 will die
  • 75 will have a permanent disability
  • 10 will require long-term care

4
Classification of Stroke
  • Hemorrhagic vs. ischemic stroke
  • Transient ischemic attack (TIA)
  • Primary vs. secondary prevention of ischemic
    stroke

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7
Primary Prevention
  • Who should we target?
  • Modified Framingham Stroke Risk Profile
  • What should we target?
  • Modifiable risk factors
  • Will Aspirin help?

8
Points
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9
Non-Modifiable Risk Factors
  • Age
  • Gender
  • Race
  • Family history
  • Low birth weight (lt2500g)

10
Modifiable Risk Factors
  • Cardiovascular disease
  • Hypertension
  • Lifestyle modifications
  • Drugs if still gt140/90
  • Isolated systolic hypertension
  • Smoke exposure

11
Modifiable Risk Factors cont
  • Diabetes
  • Tight control of blood pressure (goal lt130/80)
  • Tight control of blood sugar?
  • Statin therapy
  • Dyslipidemia
  • Lifestyle modifications
  • Statin therapy
  • Diet, Activity, Obesity

12
Aspirin for Primary Prevention?
13
Case Sally Troak
  • 67years old
  • Retired pharmacist, mother of two
  • Medical History
  • Hypertension
  • COPD
  • Remote appendectomy
  • Smokes 1 pack per day
  • Current Medications
  • Hydrochlorothiazide 12.5mg po daily
  • Combivent 2 puffs QID
  • Todays BP
  • 145/92

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15
Case Sally Troak
  • 67years old
  • Retired pharmacist, mother of two
  • Medical History
  • Hypertension
  • COPD
  • Remote appendectomy
  • Smokes 1 pack per day
  • Current Medications
  • Hydrochlorothiazide 12.5mg po daily
  • Combivent 2 puffs QID
  • Todays BP
  • 145/92

16
Case Mrs. Troak
  • Blood pressure
  • Goal lt140/90
  • Lifestyle modification!!
  • Maximize HCTZ dose, consider addition of ACE-I
    (or ARB, if intolerant)
  • Smoking cessation
  • Low-dose ASA?
  • Statin?

17
Secondary Prevention
  • Applies to TIA as well as ischemic stroke
  • Target modifiable risk factors
  • Hypertension, diabetes
  • Smoking
  • Alcohol consumption
  • Obesity, physical inactivity
  • Dyslipidemia

18
Statins for Secondary Prevention?
19
Antiplatelet Agents
  • ASA (Aspirin) 50 325mg po daily
  • Ticlopidine (Ticlid) 250mg po twice daily with
    food
  • Clopidogrel (Plavix) 75mg po daily
  • Dipyridamole 200mg ASA 25mg (Aggrenox) po twice
    daily

20
ASA (Aspirin)
  • Mechanism of action
  • Effectiveness
  • Side effects
  • Practical considerations
  • Cost
  • 3.00/30 days ODB benefit

21
Ticlopidine (Ticlid)
  • Mechanism of action
  • Effectiveness
  • Side effects
  • Practical considerations

22
Clopidogrel (Plavix)
  • Mechanism of action
  • Effectiveness
  • Side effects
  • Practical considerations
  • Cost
  • 95.00/30 days ODB benefit requires section 8

23
Dipyridamole ASA (Aggrenox)
  • Mechanism of action
  • Effectiveness
  • Side effects
  • Practical considerations
  • Cost
  • 70.00/30 days ODB benefit

24
Which One Should We Use?
  • What if you fail low-dose ASA?
  • Increasing dose of ASA doesnt seem to work
  • Perhaps use clopidogrel or Aggrenox over ASA to
    begin with?
  • Some evidence that Aggrenox is better
  • Are combinations better than single agents?
  • Combo of clopidogrel and ASA showed no benefit
    but doubled risk of hemorrhage

25
Atrial Fibrillation
  • 20 of ischemic strokes are cardiogenic
  • Warfarin better than ASA however, ASA may be
    considered in young patients with no other
    comorbidities
  • Goal INR 2.0 3.0
  • Can prevent 31 strokes per year for each 1000
    patients treated

26
Case Mrs. Troak
  • Discharged from GRH post-ischemic stroke
  • Right-sided weakness, mild dysphagia
  • Medical History
  • Hypertension
  • COPD
  • Remote appendectomy
  • Previous smoker
  • Current Medications
  • Hydrochlorothiazide 25mg po daily
  • Ramipril 5mg po daily
  • Combivent 2 puffs QID
  • ASA 81mg po daily
  • Todays BP
  • 132/82

27
Case Mrs. Troak
  • Blood pressure
  • Goal lt140/90
  • Antiplatelet therapy
  • ASA vs. Aggrenox vs. Plavix
  • Statin?

28
Summary
  • Figure out who you need to treat
  • Target your risk factors to prevent the first
    stroke
  • Add on antiplatelet agent, possibly statin, after
    the first stroke or TIA
  • Atrial fibrillation requires anticoagulation in
    majority of patients

29
References
  • Goldstein LB, Adams R, Alberts MJ, Appel LJ,
    Brass LM, Bushnell CD, Culebras A, DeGraba TJ,
    Gorelick PB, Guyton JR, Hart RG, Howard G,
    Kelly-Hayes M, Nixon JV, Sacco RL. Primary
    prevention of ischemic stroke a guideline from
    the American Heart Association/American Stroke
    Association Stroke Council. Stroke.
    2006371583-1633.
  • http//stroke.ahajournals.org/cgi/content/full/37/
    6/1583
  • McPherson R, Frohlich J, Fodor G, Genest J.
    Canadian Cardiovascular Society position
    statement recommendations for the diagnosis and
    treatment of dyslipidemia and prevention of
    cardiovascular disease. Canadian Journal of
    Cardiology. 200622(11)913-927.
  • Ridker PM, Cook NR, Lee I, Gordon D, Gaziano JM,
    Manson JE, Hennekens CH, Buring JE. A randomized
    trial of low-dose aspirin in the primary
    prevention of cardiovascular disease in women.
    New England Journal of Medicine.
    20053521293-1304.
  • Sacco RL, Adams R, Albers G, Alberts MJ,
    Benavente O, Furie K, Goldstein LB, Gorelick P,
    Halperin J, Harbaugh R, Johnston SC, Katzan I,
    Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH,
    Tomsick T. Guidelines for prevention of stroke
    in patients with ischemic stroke or transient
    ischemic attack a statement for healthcare
    professionals from the American Heart
    Association/American Stroke Association Council
    on Stroke. Stroke. 200637577-617.
  • http//stroke.ahajournals.org/cgi/content/full/37/
    2/577
  • The Stroke Prevention by Aggressive Reduction in
    Cholesterol Levels (SPARCL) Investigators.
    High-dose atorvastatin after stroke or transient
    ischemic attack. New England Journal of
    Medicine. 2006355549-559.

30
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