2016 International Stroke Conference Hot Topics Lori M. Massaro, MSN, CRNP Kari Moore, MSN, AGACNP-BC

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1 2016 International Stroke Conference Hot Topics Lori M. Massaro, MSN, CRNP Kari Moore, MSN, AGACNP-BC Disclosures Lori M. Massaro, MSN,CRNP speakers bureau Genentech Kari Moore, MSN, AGACNP-BC -none 1

2 Objective Apply new research topics presented at the 2016 International Stroke Conference and discuss the relevance of at least two new practices that may influence their own program/practice. Highlights From Nursing Symposium Temperature and Glucose Control Observational multi-site study conducted to assess compliance with AHA/ASA stroke guidelines for glucose and fever control in consecutive acute stroke patients Patient sample derived from consecutive acute stroke patients admitted to 5 different U.S. Comprehensive Stroke Centers The first 5-days of glucose/temperature data were collected along with stroke typology, treatment, and outcome measures 2

3 Temperature and Glucose Control 235 acute stroke patients 1,669 consecutive glucose and 3,782 consecutive temperature measurements 87% ischemic and 13% ICH Admission median NIHSS 4.0 (range 0-34) and ICH score median 1 (range 0-5) 20% of ischemic strokes received IV t-pa alone, 2% received thrombectomy alone, and 4% received both IV t-pa and thrombectomy Discharge disposition was 44% home, 9% outpatient rehabilitation, 26% inpatient rehab, and 18% SNF; 3% died in hospital Glucose Results 31% had a history of type 2 diabetes HbA1c was (median range ) in non-dm diagnosed patients vs (range ; 95%CI= ;) in patients with a DM diagnosis Average glucose during hospitalization was (median 112) for non- DM vs (median 169; 95%CI=45-71;) for DM patients Glucose was >180 mg/dlfor >4 hours in 33% The most frequent method (35%) for glucose control was regular insulin sliding scale, whereas oral agents were prescribed for 6%, long acting insulin 17%, and insulin drip 2% 3

4 Glucose Control Variable In Control Out of Control Difference Consistently < 180 mg/dl At least 1 event > 180 mg/dl for > 4 hours Central Measures of Glucose (mg/dl) median median % CI = Admission NIHSS Median 4 Median 4 p=ns mrs Median = 2 Median = 3 p=0.03 ICU LOS ; median ; median 1 p=ns Total Hospital LOS ; median ; median 4 95% CI = p = Temperature Results Temperature was > 37.5 o for > 4 hours in 27% of patients Temperature was >38 o (noncompliant with US standards) for >4 hours in 10% of patients 8% had temperature out of control for > 8 hours (range 9-96, median 16.5 hours out of control) 39% did not have temperature measured in the ED mrsand LOS were significantly worse if temperature exceeded the European/Australian or US standards 4

5 Temperature Control Variable In Control Out of Control Difference < 37.5 o C E/A Standards > 37.5 o C for > 4 hours Mean Temperature (C o ) for Entire LOS Median Median % CI = Mean Temperature (C o ) for Entire LOS < 38 o C USA Standards Median 36.7 > 38 o C for > 4 hours Median % CI = Admission NIHSS Median 3 Median 12 mrs Median = 1 Median = 4 ICU LOS ; median ; median % CI = P<0.001 Total Hospital LOS ; median ; median 7 95% CI = Combined Glucose & Temperature Control Mean Glucose for Entire LOS (mg/dl) Mean Temperature (C o ) for Entire LOS In Control Out of Control Difference Median Median Median Median 37 95% CI = % CI = Discharge mrs Median 1 Median 4 ICU LOS Median Median 5 95% CI = p=0.001 Total Hospital LOS Median ; Median Temperature control to <37.5 o C was an independent predictor () of favorable (0-2) mrs at discharge 5

6 Conclusions Study underscores the need for more vigilant control of glucose and temperature bynurses at U.S. hospitals Given the time-sensitive ability of brain to recover from ischemia, even short-term non-compliance may have detrimental effects The current focus on shortened time to treatment may have overshadowed the importance of attending to the basics Important opportunity for nursing to take control of the protocolizedmanagement of these important measures! Early Mobilization Nursing initiatives encourage early mobilization neurocritical care pts Can this be generalized to stroke patients AVERT 1 st multisite, international RCT (Lancet, 2015; 386: 46-55) Systematic review last 5 years Very Early Mobilization (VEM) within 24 hours of admission exclusively to stroke patients Primary Efficacy Outcome: Neurologic disability reduction Improved function outcomes Primary Safety Outcome Neurologic deterioration Alexandrov, Anne et al., 2016, oral presentation, ISC

7 Methods Studies Reviewed 3 separate investigators Prospective randomized outcome-blinded evaluation (PROBE) designs were retained Findings synthesized and grade criterion assigned per Cochrane handbook Results 12 papers focused on early mobilization in acute stroke 6 observational studies excluded 1 excluded due to population 3 excluded due to mobilization >24 hours 2 papers were retained N = 2,160 patients Alexandrov, Anne et al., 2016, oral presentation, ISC 2016 Systematic Review Retained Studies Results Publications Methods Main Findings Sundseth A, Thommessen B, Ronning OM. Outcome after mobilization within 24 hours of acute stroke: A randomized controlled trial. Stroke;2012;43(9): AVERT Trial Collaboration Group. Efficacy and safety of VEMwithin 24 hours of stroke onset: A randomized controlled trial. PROBE design VEM patients showed a trend towards poor outcome (OR=2.7), death(or=5.26), or dependency(or=1.25); P=ns. (n=56) PROBE design FewerVEM patients had favorable outcome(46%; n = 480), compared to usual rested care (50%; n = 525; adjusted OR = 0.73; p=0.004). Death associated with neurologic deterioration or recurrent stroke in the VEM group totaled 42, compared to 26 in the usual care group; pneumonia as a cause of death occurred in 19 VEM vs 15 usual care patients. Stroke Progression occurred in 72 VEM vs. 56 usual care patients (n = 2104) ** Slower mobilization beyond 24 hours associated with favorable outcome mrs 0-2 at 90 days ** VEM (1 st 24 hours) associated with number needed to harm of 25 Alexandrov, Anne et al., 2016, oral presentation, ISC

8 Conclusions In acute stroke, evidence supports a rested approach to care in first 24 hours of hospitalization GRADE: Strong Recommendation, High quality of evidence Similar to AMI, vascular insufficiency in acute stroke likely warrants a more guarded approach to mobility Additional studies are needed to determine amount and timing of mobility in acute stroke and odoes it differ by stroke subtype (AIS, IPH, SAH) or o AIS etiology (LVO, lacunar) Alexandrov, Anne et al., 2016, oral presentation, ISC 2016 Large Hemispheric Stroke Guidelines: Where Do We Go From Here? 8

9 **No overwhelming evidence for care management in LHI **More research is needed 22 topics (acute treatments prevention of complications QoL) 34 questions 6 questions not addressed 52 recommendations Strength Of Recommendation Strong Weak High Moderate Low Very Low Quality of Evidence Only 2 topics with strong recommendation and High Quality Evidence - Osmotic Therapy - Decompressive Hemicraniectomy Clinical Trial Results IRIS Trial HEADLINE news Diabetic Drug drops CV event rates after stroke 3876 patients with recent AIS or TIA with Insulin Resistance were enrolled - Pioglitazone vs placebo All pts followed for 5 years after stroke Pioglitazone group had 9% stroke or MI incidence 52% less likely to develop diabetes that placebo Placebo/control group had 11.8% Stroke or MI incidence Increased risk of bone fracture, edema and/or weight gain in Pioglitazone group Used HOMA IR index of >3.0 for insulin resistance ( limitation lack of standardized Reference range) 9

10 Clinical Trial Results FIND AF - repeated 10 day cardiac holtermonitoring is effective in detecting Atrial fibrillation in cryptogenic stroke patients 398 patients at 4 German centers randomized to standard medical treatment vs 10 day cardiac monitoring at 3 different intervals Within 7 days of stroke again at 3 months and at 6 months Afibdetection rates Standard of care group 4.5% Repeat monitoring group 13.5% Clinical indications - repeated or extended monitoring increases detection rates of AfIb in the cryptogenic stroke patient population Clinical Trial Results Carotid Stenting vs Endarterectomy 2 trials reported CREST- 10 year follow up enrolled both symptomatic and asymptomatic patients 2502 pts enrolled 47% asymptomatic and 53% were symptomatic ACT 1-5 year follow up asymptomatic patients only with 70% stenosis or greater Results were identical there is non-inferiority of Carotid Stenting vs Carotid Endarterectomy Stent group in CREST - had earlier incidence of early events 10

11 Clinical Trial Results ARUBA Trial - looked at AVM treatment (surgical or endovascular) vs medical therapy for patients with unruptured AVM Stopped early because of higher event rates in intervention group in year results released Continue to show that medical therapy is associated with a significantly lower risk for stroke and death compared to any intervention 2.1%/year risk of spontaneous hemorrhage in pts with AVM Clinical Trail Results EVEREST Efficacy of Virtual Reality Exercises in Stroke Rehabilitation Compared virtual reality vs recreational activity Virtual reality included video games Recreational activity included - matching cards, dominoes, Jenga, ball game Conclusion virtual reality is not superior to intensive recreational therapy in improving motor function, grip strength, hand function, quality of movement, or quality of life. 11

12 Questions?? Thank You 12

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