Stroke After Care. Preventing the Next Stroke

Transcription

1 Stroke After Care Preventing the Next Stroke Jonathan P Hosey, MD, FAAN Director, Neurology Residency Geisinger Health System Professor of Neurology Temple University School of Medicine

2 Objectives In relation to recurrent stroke prevention, you will be able to discuss: 1. Evidence based guidelines for risk factor management AND 2. Update new evidence and controversies that may influence your practice

3 Lifetime Risk of Cardiovascular Disease (CVD) How much mileage do you get if you do not have CVD risk factors?

4 Lifetime Risk and Years Lived Free of Total Cardiovascular Disease (CVD) Question: What are the lifetime risks of CVD? Source: 5 NHLBI funded studies (Framingham Heart and Offspring Studies, ARIC, CHA Detection Project and CHS) Results of Overall Lifetime Risk of CVD (Index age 45 Years) Men: 60.3% Women: 55.6% Optimal Risk Profile from age years (BP: <120/80, TC<180 mg/dl, non-smoker/drinker): Men: >40% Women: >30% Compared to 2 major risk factors, optimal patterns live 14 years longer w/o CVD! Conclusion: Optimal risk factor profile in midlife postpones CVD by 14 years. WilkinsET. JAMA 2012.

5 Question: When discussing recurrent stroke prevention with your patient, which of the following means do you use to explain the benefit or risk of a particular strategy? 1. Relative terms (e.g., relative risk or relative risk reduction) 2. Absolute terms (absolute risk reduction or difference) 3. Number needed to treat (NNT) 4. None of the above 5. All of the above

6 Background Communicating effectively with your patient is an art. We are challenged by such issues as patient health literacy, patient sophistication in relation to the medical field, cultural knowledge and sensitivity, properly estimating patient risk (physicians tend to underestimate risk) and other issues. Can we more effectively communicate patient risk?

7 An Alternative Patient Communication Option: Using Microlives to communicate effects of lifetime habits! Microlife=a daily dose or gain of 30 minutes (1 million ½ hours = 57 years and roughly corresponds to a lifetime of adult exposure) Examples of loss of a microlife Smoking 2 cigarettes (15 minutes/cig) Taking 2 extra alcoholic bevrages Eating a portion of red meat Being 5kg overweight Watching television for 2 hours/day Examples of gains of a microlife 1 microlife: Take a daily statin, 1 drink/day 2 microlifes: 20 min of moderate daily exercise 4 microlifes: proper diet of fresh fruit and vegetables daily, being female rather than male

8 Example of Microlives to communicate Effects of lifetime Habits If you knew that you could lose 30 minutes of life on average each day by unhealthful living would it have a stronger impact on you rather than relative risk measures. Example: Smoking 20 cigarettes a day (10 microlives = 300 min = 5 hours) is as if you are moving towards your death at 29 hours/day instead of 24: each hamburger you eat takes 30 minutes off your life.

9 Evidence-Based Guidelines for Risk Factor Management AHA/ASA/AAN Level of Recommendation

10 Level of Recommendation Level A Effective by multiple studies Level B Probably effective Level C Possibly effective Level D Unknown, expert opinion

11 AHA/ASA Recommendations for Lifestyle and Risk Factor Management in TIA or Ischemic Stroke Factor Recommendation LOE HTN Initiate Rx beyond 24 : Individualize Rx, consider ACEI/diuretic BP reduction of 10/5 mm Hg LOE A Diabetes Use existent guidelines for glycemic and BP targets; aim for HbA1C < 7% LOE B Smoking D/C Smoking; Consider NRT and smoking cessation meds LOE A Alcohol Use Eliminate heavy drinking or reduce Men </= 2 drinks/day and non pregnancy Women </= 1 drink/day LOE B/C Obesity Goal BMI 18.5 to 24.9 kg/m 2 and waist circumference men No study in TIA/Stroke Physical Activity If capable; at least 30 minutes of moderate intensity to break a sweat or raise heart rate, 1-3x/week LOE C Furie KL; Stroke 2011

12 Question: What is the stroke prevention guideline blood pressure control target in persons with diabetes mellitus? 1. <140/90 mm/hg 2. <140/80 mm/hg 3. <130/90 mm/hg 4. <130/80 mm/hg 5. <120/80 mm/hg

13 Question: What is the stroke prevention guideline blood pressure control target in persons with diabetes mellitus? 1. <140/90 mm/hg 2. <140/80 mm/hg 3. <130/90 mm/hg 4. <130/80 mm/hg LOE A 5. <120/80 mm/hg Answer Goldstein LB: Stoke 2011.

14 Updates, New Evidence and Controversies that May Influence Your Practice

15 Update on Recurrent Stroke Prevention Antiplatelet Therapy Evidence-Based Guidance from ACCP 2012 ACCP = American College of Chest Physicians

16 ACCP-2012 Antithrombotic and Thrombolytic Therapy for Ischemic Stroke (Lansberg et al) In patients with acute ischemic stroke (AIS) or TIA: 1. Early (within 48 hours) aspirin therapy ( mg) over no aspirin therapy (LOE A)

17 Antiplatelet Therapy for Secondary Prevention of Noncardioembolic Stroke or TIA Long Term treatment with 1 of the following over no antiplatelet therapy. 1. ASA ( mg/day) 2. Clopidogrel (75 mg/day) 3. ASA/extended-release dipyridamole (25 mg/200 mg b.d) Chest 2012

18 Question: For primary prevention of cardiovascular disease and stroke, in which of the following persons do you recommend prophylactic aspirin use? 1. High risk (prior stroke or CVD) 2. Middle risk 3. Low risk 4. All my older patients receive prophylactic ASA 5. None of my patients receive ASA

19 Question: For primary prevention of cardiovascular disease and stroke, in which of the following persons do you recommend prophylactic aspirin use? 1. High risk (prior stroke or CVD) 2. Middle risk 3. Low risk 4. All my older patients receive prophylactic ASA 5. None of my patients receive ASA Answer: Controversy According to Guidelines

20 AHA/ASA st Stroke Prevention Guideline Update Aspirin for CVD-S Prophylactic recommendations: 1. For persons with high risk for benefits to outweigh risks of treatment (10 year risk of CV-S events of 6-10%; LOE A) 2. ASA 81mg/day or 100mg every other day can be useful for prevention of stroke in women at sufficiently high risk when benefits outweigh risks (LOE B) 3. ASA is not useful in preventing a 1 st stroke in persons at low risk (LOE A) 4. ASA is not useful for preventing a 1 st stroke in persons with diabetes or diabetes + PAD in the absence of other established CVD (LOE B)

21 Question: In your practice, for recurrent stroke prevention which of the following antiplatelet agents are you primarily recommending? 1. Aspirin 2. Aspirin plus Clopidogrel 3. Aspirin plus extended-release dipyridamole 4. Clopidogrel

22 Answer: 1. Estimates of CVD-S disease burden in US: >16 million with CHD (Includes MI and angina) 7 million with stroke 8 million with PAD 2. National ambulatory surveys on antiplatelet therapy administration: Prescribed at 47% of visits in those with ischemic vascular disease in Parehk; JAMA 2013

23 Answer: Aspirin: When risk/benefits/cost and outcome is globally considered; Challenging to beat in head to head comparisons in recurrent stroke prevention. Parehk; JAMA 2013

24 Are 2 Antiplatelet Agents better than 1 for Recurrent Stroke/TIA Prevention? MATCH In over 8000 patients with prior stroke/tia ASA + Clopidogrel did not add benefit over either alone but had 3x the bleeding risk.

25 Effects of Clopidogrel Added to Aspirin in Patients with Recent Lacunar Stroke Results: In this randomized trial of 3020 patients with recent symptomatic lacunar infarcts, the addition of clopidogrel to ASA did not reduce risk of recurrence but increased bleeding. SPS3: NEJM 2012

26 Antiplatelet Therapy and Resistance (Variability of Response) Controversy and New Data

27 Question: In your office practice which of the options describes your approach to platelet function testing or genetic testing. 1. Useful for most 2. Useful for some 3. Such testing is useless; I don t use it 4. Don t know

28 Answer: Office point of care platelet function or genetic testing has not been mandated by AHA/AAN guidelines thus far. Controversy exists!

29 Statins More data on treating to effect

30 Position The US FDA, the AHA, AAN have stated that the benefits of statin agents in relation to reduction of cardiovascular/cerebrovascular outcomes outweighs risks. 80% with CVD-S are treated with lipid lowering therapy, only 34% treated to goal. (EuroASPIRE III)

31 Conclusion 1. Multiple established high level recommendations established for stroke prevention. 2. No Guideline or recommendation is absolute. 3. Individual patient and population genetics will be further utilized to guide therapy.