1.  Understand guidelines for acute treatment of ischemic stroke

2.  Identify appropriate means to manage co-morbid illness in the stroke patient -Hyperglycemia

-Hyperlipidemia -Hypertension

3. Apply new research on stroke prevention to post-stroke care

Heart Disease and Stroke Statistics 2010 Update. Circulation. 2010;121:948-954.

Del Zoppo GJ et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009;40:2945-8.

Winkler DT. Thrombolysis in Stroke Mimics: Frequency, Clinical Characteristics, and Outcome. Stroke 2009:40:1522-25 Chernyshev OY. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology 2010; 74: 1340 - 1345. Scott PA. Misdiagnosis of Stroke in Tissue Plasminogen Activator-Treated Patients. Characteristics and Outcomes. Ann Emerg Med 2003;42:611-618

 Antiplatelet OR  Anticoagulant

 Statin  Lifestyle counseling

 Tobacco, diet, alcohol, exercise  Carotid Intervention

Medical Complications in a Comprehensive Stroke Unit and an Early Supported Discharge Service. Stroke 2008;39:414-420 Medical Complications Among Hospitalizations for Ischemic Stroke in the United States 1998-2007. Stroke 2010;41:980-986

Modern Stroke Center Data National Coding Data

Implications: Remove urinary catheter ASAP

Swallow evaluation and aspiration precautions DVT prophylaxis

Process of Care Associated With Acute Stroke Outcomes. Arch Intern Med 2010;170:804-810

Sugar

Loco Moco Burger

Salt

Hyperglycemia in Acute Ischemic Stroke: Pathophysiology and Clinical Management. Nature Reviews Neurology 2010;6:145-155

Hyperglycemia in Acute Ischemic Stroke: Pathophysiology and Clinical Management. Nature Reviews Neurology 2010;6:145-155

Intensive Insulin Therapy

Moderate Insulin Therapy

The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-1297

American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care. 2009;32:1119-1131

Statins and Clinical Outcome of Acute Ischemic Stroke: A Systematic Review. Int Arch Med 2010;3:22 Statintherapy in the Primary and Secondary Prevention of Ischaemic Cerebrovascular Diseases. Int J of Cardiology. 2010-in press Interventions in the Management of Serum lipids for Preventing Stroke Recurrence. Cochrane Database Sys Rev 2009;(3):CD002091

AcetylCoA+Acetoacetyl CoA

HMG-CoA

HMG-CoA synthase

Mevalonate

Isoprenoids

Cholesterol

HMG-CoA reductase Statins

Improved endothelial

function

Anti-thrombotic

effects

Anti-inflammatory

effects

Pleotrophic Effects

SPARCL Investigators. High-Dose Atorvastatin after Stroke or Transient Ischemic Attack. NEJM 2006;355(6):549-559 Update to the AHA/ASA Recommendations for the Prevention of stroke in Patients with Stroke and TIA. Stroke 2008;39:1647-1652

Guidelines for the Prevention of Stroke in Patients with Stroke or Transient Ischemic Attack. Stroke 2011;42-in press

Relationship of Blood Pressure, Antihypertensive Therapy, and Outcome in Ischemic Stroke Treated with IV Thrombolysis. 2009;40:2442-2449 Management of Blood Pressure after Acute Ischemic Stroke: An Evidence-Based Guide for the Hospitalist. Journal of Hospital Medicine 2007;2:261-267 Blood Pressure as a Prognostic Factor after Acute Stroke. Lancet Neurol 2009;8:938-48

150 125 100 75

50

25 Cerebral Perfusion Pressure (mm Hg))

Cer

ebra

l Blo

od F

low

(ml/1

00 g

/min

)

175

25

50

75

NORMAL

o o o o o o

•  CBF is tightly auto-regulated across a wide range of systemic blood pressures.

CBF=CPP/CVR

150 125 100 75

50

25 Cerebral Perfusion Pressure (mm Hg))

Cer

ebra

l Blo

od F

low

(ml/1

00 g

/min

)

175

25

50

75

NORMAL

ISCHEMIA

Chronic HTN

• In the setting of acute stroke auto-regulation is lost, • Cerebral blood flow becomes linear relationship with MAP

Effects of Antihypertensive treatment after acute stroke in the Continue or Stop Post-Stroke Antihypertensives Collaborative Study. Lancet Neurol 2010:9:767-75

Controlling Hypertension and Hypotension Immediately Post-Stroke. Lancet Neurol 2009;8:48-56

Connolly SJ et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. NEJM 2009;361:1139-51

Non-inferiority trial! FDA does not allow a claim of superiority over warfarin

Cumulative Hazard Rates for the Primary Outcome of Stroke or Systemic Embolism, According to Treatment Group.

Connolly SJ et al. N Engl J Med 2009;361:1139-1151.

Freeman JV et al. Cost-effectiveness of dabigatran compared with warfarin for stroke prevention in atrial fibrillation.Ann Intern Med 2011;154:1-11

Monte Carlo Simulation Patients over 65 with at least 1 CHADS2 points

Dabigatran Package Insert

Hackam DG et al. Stroke. 2007;38:1881-1885. Use of Stroke Secondary Prevention Services. Stroke. 2009;40:1811-1819

Hackam DG et al. Stroke. 2007;38:1881-1885.