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Informatics in Pharmacy

Ischemic Stroke

August 13, 2018 By Dr. G, PharmD

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Risk factors:

  • Age: risks double every decade over 55
  • Race: more risk in native Americans, second highest risk in African Americans then whites.
  • Sex: risk higher in men
  • Low birth weight
  • Family History
  • Diabetes
  • Hypertension
  • Oral contraceptive use
  • Post-menopausal hormone use
  • Atrial fibrillation
  • Coronary artery disease
  • Asymptomatic carotid stenosis
  • Dyslipidemia
  • Obesity
  • Physical inactivity
  • Sickle Cell Disease
  • Pregnancy
  • Peripheral artery disease
  • Patent foramen ovale
  • Depression
  • Alcohol Use
  • Smoking

Prevention:

  • Treat modifiable risks
  • Treat Afib (CHA2D2-VASc)

Acute Stroke:

  • TPA within 4.5 hours only: 0.9 mg/kg (up to 90 mg), 10% as a bolus dose, give the rest over 1 hour.  Hold antiplatelets for 24 hours.  DO NOT give in pregnancy.
  • Do not give if:
    • History of intracranial bleed
    • Active internal bleeding
    • Intracranial/spine surgery, head trauma or stroke within 3 months, risk of bleeding outweighs benefits
    • GI hemorrhage within 3 weeks or structural GI malignancy
    • Glucose < 6 or >400 until normalized
    • Arterial punch within 1 week
    • BP > 185/110, can be stabilized but must be kept below this for at least 24 hours after the TPA given
    • Intracranial, intraaxial neoplasm or an unruptured aneurysm
    • INR >1.7, APTT > 40, PT >15, platelet <100,000
    • LMWH in the last 24 hours, XA inhibitor in last 48 hours
    • Endocarditis
  • If TPA cannot be given, initiate ASA within 48 hours of stroke
    • Aspirin (75-100 mg daily), Aggrenox (200/25 BID) and clopidogrel (75 mg daily) are all options after the first stroke or TIA.  Cilostazol (100 mg BID) is not a preferred agent.  May consider ASA and Clopidogrel in combination for 90 days.
    • Can consider warfarin if patient has atrial fib, rheumatic mitral valve disease, mechanical prosthetic heart valves, bioprosthetic heart valves or left mitral thrombus formation. Target INR 2.5 (3 in mechanical heart valves)

Filed Under: Neurology

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020