Clinical Guidelines for Acute Stroke Management - Living on the EDge

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diuretic. 398 A subsequent trial compared an angotensin receptor blocker (ARB) with a calcium antagonist. Both agents were found to reduce blood pressure, although the ARB was significantly more effective in reducing mortality and all cardiovascular and cerebrovascular events, including all recurrent events. 399 It is noted that in this study only 1/3 used monotherapy <strong>for</strong> blood pressure lowering and of the 2/3 using combination therapy 46% were using a diuretic and 33% were using a Beta blocker with no difference in combination therapy between groups. 399 Only approximately 3% of patients commenced therapy within 1 week and no subgroup analysis was per<strong>for</strong>med <strong>for</strong> this aspect. The timing of commencing therapy remains unclear. Hyperacute therapy (within first 48 hours) is discussed separately as it relates to acute medical treatment rather than secondary prevention (see section 4.1.4). However, two recent small studies in those with mild stroke or TIA without major carotid disease, found blood pressure lowering therapy (with an angiotensin II receptor antagonist or ACE inhibitor) was safe when commenced 2-4 days after stroke, although follow up was short (2 weeks). 400, 401 Another study found a program of initiating secondary prevention medications, including blood pressure lowering therapy, while in hospital lead to improved rates of adherence both prior to discharge and 3 months after discharge. 394 Lifestyle change including diet and exercise, by themselves or in conjunction with pharmacotherapy, can also be used to reduce blood pressure (see section 7.1). Section 7 Secondary Prevention 7.2 BLOOD PRESSURE LOWERING GRADE LEVEL a) All patients after stroke or TIA, whether normotensive or hypertensive, should A Level I 398 receive blood pressure lowering therapy, unless contraindicated by symptomatic hypotension. b) Commencement of new blood pressure lowering therapy may occur prior to B Level II 400, 401 discharge or within the first week after stroke or TIA. & Level III-3 394 7.3 Antiplatelet therapy There is evidence from 21 RCTs in 23,000 patients with previous ischaemic stroke or TIA that, compared with control, antiplatelet therapy significantly reduces the risk of subsequent serious vascular events including stroke, MI or vascular death (17.8% compared with 21.4%). 402 Antiplatelet therapy may have adverse effects, particularly a small risk of haemorrhage, but the benefits outweigh the risks. 403 Although the benefits of antiplatelet therapy are well known and treatment can commence soon after stroke (see section 4.1.3), under treatment is common. 404 The evidence <strong>for</strong> antiplatelet therapy indicates: > Aspirin remains the most readily available, cheapest and most used anti-platelet agent. Aspirin reduces the risk of serious vascular events by about 13% in patients with previous ischaemic stroke or TIA. 405 Aspirin at lower doses (75-150mg) is just as effective as higher doses (300-1300mg) and is associated with a lower risk of gastrointestinal adverse effects. 402 The lowest therapeutic dose of aspirin remains unclear, but the DUTCH TIA trial showed that in more than 3,000 patients with TIA, 30 mg was as effective as 283 mg in preventing serious vascular events. 405 > Combination therapy with extended release dipyridamole (200mg bd) plus aspirin is more effective than aspirin alone (relative risk reduction [RRR] 18%). 406 The main adverse effect of combination therapy is headache (34% ceased medication compared with 17% <strong>for</strong> aspirin alone over 5 years). 406 > Dipyridamole alone at any dose is no more effective than aspirin. 407 45
S Secondary Preventio n ection 7 > Clopidogrel (75mg) is modestly more effective than aspirin in the prevention of major vascular events (RRR 8.7%). 402 > The combination of low dose aspirin (75-162mg) plus clopidogrel (75mg) has no net benefit compared with clopidogrel alone (RRR 6%) or aspirin alone (RRR 7%) because any long-term benefits with combination therapy are offset by an increase in bleeding (1.7-2.6% v 1.3%). 408, 409 > Like clopidogrel, ticlopidine is modestly more effective than aspirin in prevention of vascular events. 410 Ticlopidine is associated with less gastrointestinal complications than aspirin, but an excess of skin rash and diarrhoea. 410 Ticlopidine is currently only available <strong>for</strong> those intolerant of aspirin or with aspirin failure. Because it can cause neutropenia and thrombocytopenia, careful monitoring is required after commencement. However, its role has been superseded by clopidogrel which has a similar mechanism of action and similar efficacy, but without the serious haematological adverse effects. When selecting antiplatelet therapy, individual patient factors (e.g. comorbidities - especially acute coronary disease, tolerance, stroke recurrence while on antiplatelet agent) should be considered and management tailored accordingly. Ongoing trials are directly comparing clopidogrel with combined aspirindipryridamole (e.g. PRoFESS). The results of these studies will further guide choice of agents. 7.3 ANTIPLATELET THERAPY GRADE LEVEL a) Long term antiplatelet therapy should be prescribed to all people with A Level I 402 ischaemic stroke or TIA who are not prescribed anticoagulation therapy. b) Low dose aspirin and modified release dipyridamole should be prescribed to 406, 411 all people with ischaemic stroke or TIA who do not have concomitant acute coronary disease. c) Aspirin alone or clopidogrel alone may be used <strong>for</strong> people who do not tolerate 402 aspirin plus dipyridamole therapy. Clopidogrel alone should be used <strong>for</strong> those who are intolerant of aspirin or in whom aspirin is contraindicated. d) The combination of aspirin plus clopidogrel is not recommended in the A Level II 408, 409 secondary prevention of cerebrovascular disease in patients who do not have acute coronary disease or recent coronary stent. 7.4 Anticoagulation therapy There is evidence from robust systematic reviews involving a number of RCTs against the routine use of anticoagulant therapy in people with non-cardioembolic ischaemic stroke or TIA. 157, 412 Two subsequent studies of note have been reported in the last few years confirming this conclusion. One trial comparing oral coagulation (INR 2-3) and aspirin (30-325mg) found no difference in outcomes and was stopped early due to results of the other arm of the trial which found aspirin inferior to combined aspirin and dypridomole. 413 However, this trial was not sufficiently powered to detect benefits of anticoagulation compared with aspirin and other issues have been raised including the open trial method and variable aspirin dosage. Another trial of warfarin (INR 2-3) compared to aspirin (1300mg) <strong>for</strong> those with significant intracranial artery stenosis was also stopped early due to safety concerns <strong>for</strong> those receiving warfarin. 414 However, in people with non-rheumatic atrial fibrillation and a recent TIA or minor ischaemic stroke, the benefits of anticoagulants outweigh the risks and anticoagulants are more effective than antiplatelet therapy <strong>for</strong> long-term secondary prevention. 119, 415 They should there<strong>for</strong>e be prescribed unless there is a major contraindication (e.g. poor compliance, major bleeding risk). 46
Page 1 and 2:
Stop stroke. Save lives. End Suffer
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About the National Stroke</
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SECTION 6: PREVENTION AND MANAGEMEN
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KEY MESSAGES iiKey Messages This se
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1. Organisation of Services Message
Page 11 and 12: viKey Messages 3.2: Triage in emerg
Page 13 and 14: Key Messages c) Patients who fail t
Page 15 and 16: xKey Messages > avoiding excessive
Page 17 and 18: Key Messages b) The stroke survivor
Page 19 and 20: 2Introduction > Nurses perf
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Page 36 and 37: A notification system between emerg
Page 38 and 39: 3.4 INVESTIGATIONS GRADE LEVEL a) T
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Page 42 and 43: 4.1.3 Antithrombotic therapy Eviden
Page 44 and 45: Surgical management Surgical manage
Page 46 and 47: 4.3.4 NEUROPROTECTIVE AGENTS GRADE
Page 48 and 49: intense therapy, further high quali
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Page 52 and 53: The first step in planning manageme
Page 54 and 55: 5.7 INCONTINENCE GRADE LEVEL a) All
Page 56 and 57: 6 PREVENTION AND MANAGEMENT OF COMP
Page 58 and 59: 6.2 DEEP VENOUS THROMBOSIS (DVT) AN
Page 60 and 61: 7 SECONDARY PREVENTION 7.1 Behaviou
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Page 66 and 67: asymptomatic stenosis
Page 68 and 69: adults living at home with diabetes
Page 70 and 71: equires a home visit. Factors to co
Page 72 and 73: 8.6 Community rehabilitation Often
Page 74 and 75: 9 COST AND SOCIOECONOMIC IMPLICATIO
Page 76 and 77: stroke units that used care pathway
Page 78 and 79: 9.2.5 Carer training One study was
Page 80 and 81: APPENDIX A: Guideline development p
Page 82 and 83: d) If the search was for</s
Page 84 and 85: Consultation Public consultation wa
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Page 88 and 89: A systematic review of the above di
Page 90 and 91: GLOSSARY AND ABBREVIATIONS Activiti
Page 92 and 93: REFERENCES 1 National Strok
Page 94 and 95: 57 Larson J, Franzén Dahlin A, Bil
Page 96 and 97: 109 Ferro JM, Pinto AN, Falcao I, e
Page 98 and 99: 157 Gubitz G, Sandercock P, Counsel
Page 100 and 101: 207 Palesch YY, Hill MD, Ryckborst
Page 102 and 103: 262 Bamford J, Den
Page 104 and 105: 317 Anderson CS, Hackett ML, House
Page 106 and 107: 367 He FJ, MacGregor GA. Effect of
Page 108 and 109: 415 Saxena R, Koudstaal P. Anticoag
Page 110 and 111: 466 Glass TA, Berkman LF, Hiltunen
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517 Sesso HD, Chen RS, L'Italien GJ
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