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Stroke prevention


Stroke prevention An interactive workshop for nurses and Aboriginal health workers October 2009 * * * The way in which people are affected by stroke depends on where ... – PowerPoint PPT presentation

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Title: Stroke prevention

Stroke prevention
An interactive workshop for nurses and
Aboriginal health workers October 2009
Learning Objectives
  • Identify the risk factors for stroke
  • Use a cardiovascular risk (CV) assessment tool to
    determine a patients overall CV risk
  • Recognise the role of medicines in stroke
  • Recommend non-pharmacological therapies to reduce
    patients risk
  • Reinforce to patients on warfarin the importance
    of INR monitoring and medication management

Topics for discussion today
  • Incidence of stroke in Australia
  • Risk factors for stroke
  • Overall cardiovascular risk reduction
  • Importance of stroke prevention as part of
    ongoing therapy
  • The safe use of warfarin
  • Clinical scenario

Stroke in Australia
  • Stroke is the second leading cause of death in
    Australia, and often results in significant
    long-term disability
  • Stroke remains one of the leading causes of
    death, disability and health care expenditure,
    but in many cases its incidence can be reduced or
  • Indigenous Australians living in remote areas
    were 50 more likely to report heart, stroke and
    vascular conditions than those living in non
    remote areas (24 compared with 18), and this
    happens at a younger age.

What is cardiovascular disease?
  • Cardiovascular disease (CVD) covers all
    diseases and conditions of the heart and blood
    vessels including
  • Coronary heart disease
  • Stroke
  • Heart failure
  • High blood pressure
  • Peripheral vascular disease
  • Rheumatic fever and rheumatic heart disease

What is a stroke?
  • A stroke (also known as cerebrovascular disease)
    occurs when the supply of blood to the brain is
    suddenly disrupted
  • Blood may stop moving through an artery because
    the artery is blocked by a blood clot or plaque,
    or because the artery breaks or bursts
  • A stroke can occur in two main ways
  • Ischaemic stroke (blocked artery)
  • Haemorrhagic stroke (bleed in the brain)

Meet Joe
  • Joe is a 38 year-old Aboriginal man who has come
    into the clinic.
  • You notice that Joe is a little puffed after his
    walk to the clinic, and he appears a bit
  • You have a chat with Joe whilst he is waiting to
    see the doctor and find that he
  • smokes about 10 cigarettes and drinks a bit
  • doesnt eat very well (lots of fried take-away)
  • You take his blood pressure and find it to be
    high 150/100mmHg, his pulse feels a little
    strange to you also.

Does Joe have any risk factors for stroke?
  • What are the risk factors for stroke?
  • Can you help Joe do anything to change these?

Some risk factors for stroke
  • Non-modifiable
  • age
  • ethnicity
  • (some cultures have a higher risk)
  • previous stroke

  • Modifiable
  • atrial fibrillation
  • (irregular heart beat)
  • Hypertension
  • (high blood pressure)
  • smoking
  • diabetes
  • cardiovascular disease
  • hypercholesterolaemia
  • (high cholesterol)

Is Joe at high risk of having a stroke or other
CV event?
  • Use the new Australian overall CV risk
    assessment tool to work out his overall CV risk?
  • Does he have diabetes?
  • Male
  • Smoker
  • Age
  • Blood pressure
  • Cholesterol

What did you find?
  • His risk is moderate (10-15 chance of an event
    over the
  • next 5 years) or high (gt15 chance of an event
    over the
  • next 5 years)
  • (depending on his cholesterol levels)
  • Refer him to see the doctor for further
  • AND
  • Consider counseling him to reduce his risks
  • (use life scripts tools to help you)
  • quit smoking
  • improve diet
  • increase exercise
  • less alcohol
  • lose weight
  • These will all help him to reduce his blood
    pressure also!

  • The doctor meets with Joe, and discovers
    alongside your findings of high blood pressure
    that he has an irregular heart beat (called
    atrial fibrillation).
  • The doctor decides to start him on two new
  • a blood pressure medicine (an ACE-inhibitor)
  • warfarin

What is AF?
  • Atrial Fibrillation (AF) is an important risk
    factor for stroke
  • It is the leading cause of cardiogenic stroke
    (stroke which starts in the heart), the subtype
    of stroke with the highest morbidity and
  • Many patients may not know that they have AF,
    until they have a stroke or transient ischemic
    attack (TIA), sometimes called a mini-stroke.
  • AF can be caused by
  • binge drinking
  • rheumatic heart disease

Joe starts warfarin
  1. What are the potential benefits and harms of his
  2. How can you help Joe to take his warfarin (and
    other medicines) safely?
  3. What written patient materials could you provide
    to him?

  • Benefits
  • Warfarin is approximately
  • 40 more effective than
  • other medicines used to
  • prevent stroke
  • (antiplatelet therapy with aspirin)
  • if you have AF
  • Harms
  • Warfarin increases the risk of
  • bleeding.

Common concerns
  • Bleeding risk
  • extra care is needed with medicines interactions
  • Diet (limit alcohol intake)
  • Discomfort and inconvenience of regular blood
  • regular blood tests are essential to use this
    medicine safely
  • Fear
  • Cant use if planning a pregnancy or pregnant

Encourage Joe to take ownership of his health!
  • Attend clinic visits and have regular blood tests
  • Know his numbers
  • INR
  • Current dose of warfarin
  • Tell his health care team members (dentist etc)
    that he takes warfarin
  • Check before starting or stopping other drugs,
    vitamin supplements, complementary or
    over-the-counter products.
  • Tell the clinic immediately if he has any
    unexplained bruising, bleeding, pink, red or dark
    brown urine, or black or red faeces.

INR monitoring maintain 2-3
  • Warfarin effects everyone differently so everyone
  • will need their own individual dose and have
  • tests to check that this dose is right for them.
  • most patients INR should be between 2 and 3

Blood tests are needed On starting warfarin, and
then daily until INR is stable in the therapeutic
range. Then at regular intervals of no more
than 4 weeks More frequently if there are changes
to the patients condition including concurrent
illness, concurrent drugs, amount of alcohol
consumed, or diet.
Make sure that Joe has had education on warfarin
  • His daily dose, date of blood test and INR result
  • What to do when starting or stopping medicines
    (prescription, OTC or complementary)
  • Signs and symptoms of bleeding and thrombotic
    events and to seek help if this occurs
  • The effect of diet (vitamin-K rich foods) and
    alcohol intake
  • Importance of using the same brand of warfarin

Patient materials
  • Ensure that Joe has written warfarin information
    or a warfarin booklet.
  • (These are available from your pharmacist)
  • The stroke foundation also produces patient
    leaflets see their website www.strokefoundation.

Other medicines used to prevent stroke
  • Aspirin
  • Recommended for most patients who have a high
    overall CV risk (calculated as gt15 over 5 years)
  • Reduces the risk of stroke compared to no
  • Inexpensive and easy to use
  • Can be used for patients with AF who are unable
    to take warfarin

Medicines used to prevent a second stroke
  • If Joe had already had a stroke than his risk of
    having a second stroke will be much higher.
  • At present, the selection of antiplatelet therapy
    after stroke and TIA should be individualised
  • Aspirin, aspirin plus dypridamole SR, or
    clopidogrel are options for long term
    antiplatelet therapy in patients with previous
    ischaemic stroke or TIA due to arterial disease.
  • Considerations cost, co-morbid illness, side

Key Messages stroke prevention
Identify the risk factors for stroke Use a
cardiovascular risk (CV) assessment tool
to determine a patients overall CV
risk Recommend non-pharmacological therapies
to reduce your patients risk Recognise the role
of medicines in stroke prevention Reinforce to
patients on warfarin the importance of INR
monitoring and medication management
Your name
  • Add your own contact details here for further

This activity has been endorsed by APEC number
061110344 on behalf of Royal College of Nursing,
Australia according to approved criteria, and
attracts 2 CNE points