1b) Shoutouts to #NoMercyOnStroke @WorldStrokeCampaign @American_Stroke @WorldStrokeOrg @svinsociety @neurocriticalcare @MainaliShradda @vcurrutiaMD @almuftifawaz @drdangayach @AlexChebl @GhadaMohamedMD @AmeerEHassan @aartsarwal @sheth_kevin @MitchElkind
— cardio-met (@cardiomet_CE) September 13, 2022
3a) Why focus on secondary stroke prevention? Because it is probably the single most important decision you make when discharging a patient who has experienced a stroke.
— cardio-met (@cardiomet_CE) September 13, 2022
4) The best current evidence for preventing recurrent stroke comes from the 2021 AHA/ASA Guidelines for Secondary Stroke Prevention. The top 10 take home messages are summarized here:
— cardio-met (@cardiomet_CE) September 13, 2022
🔓https://t.co/zKLN6pJHcU pic.twitter.com/bc1LJOtxGn
6a) Case summary: A 65 y/o woman with history of hypertension, DM2 and hyperlipidemia presents upon awakening with R face and arm weakness and dysarthria. NIHSS score is 3. BP is 185/113 mm Hg, HR is 87 and regular. Glucose is 194 mg/dl. NCCT of the brain is normal.
— cardio-met (@cardiomet_CE) September 13, 2022
7) Q1: Regarding her diagnostic work-up, which of the following should be completed within the next 48 hours?
— cardio-met (@cardiomet_CE) September 13, 2022
a) Echocardiogram
b) Cardiac rhythm monitoring
c) Lipid profile
d) All of the above
8b) Q2: Based on her work-up so far, what is the most likely cause of her stroke?
— cardio-met (@cardiomet_CE) September 13, 2022
a) Cardioembolism / ESUS
b) Carotid stenosis
c) Small penetrating artery vessel occlusion
d) Arterial dissection
10a) Q4: Her current medications include aspirin 81 mg daily, atorvastatin 40 mg daily, lisinopril 20 mg daily, and hydrochlorothiazide 25 mg daily. What would be the LEAST reasonable long-term treatment option?
— cardio-met (@cardiomet_CE) September 13, 2022
(see 10b for choices)
11) To recap, you just admitted a 65 y/o F with HTN, DM2, and HL. She has a right pure motor stroke with NIHSS=3 for face + arm weakness and dysarthria. The correct answer to Q1 is d) All of the above.
— cardio-met (@cardiomet_CE) September 13, 2022
13) One small study (N=38) made that assertion (https://t.co/glVxeecL2S); in some patients total chol was even HIGHER 12w later. So diagnosing high chol or LDL-C levels acutely after stroke is meaningful & warrants immediate intervention w/hi-dose statin therapy.
— cardio-met (@cardiomet_CE) September 13, 2022
15) … but by local atherothrombosis that occurs in diseased arterial segments. Platelet-vessel interactions play a huge role in the pathogenesis of these strokes. Hence the main weapon to prevent stroke recurrence from this mechanism is antiplatelet therapy. pic.twitter.com/z1C03DwRe7
— cardio-met (@cardiomet_CE) September 13, 2022
17) … is C: Target LDL-C to <70 mg/dl. Why is that? The suggested target BP is <130/70 mm Hg. Target HbA1C is <7%. The recommendation for moderate physical activity for only 10 mins 4x/week.
— cardio-met (@cardiomet_CE) September 13, 2022
19) Now the answer to Q4: Your patient had a mild completed pure motor stroke with an NIHSS score of 3 on ASA 81 mg daily. What would be the LEAST reasonable long-term treatment option? The answer is D) Cont ASA 81 mg qd and add apixaban 5 mg BID.
— cardio-met (@cardiomet_CE) September 13, 2022
21) The other options: increasing the ASA dose or adding clopidogrel or ticagrelor to ASA for 1-3 mo, are all reasonable. So would be switching to an ASA-dipyridamole combination pill. But–some of these options might be better than others. What do the clinical trials tell us?
— cardio-met (@cardiomet_CE) September 13, 2022
23) … can reduce the risk of recurrent stroke. CHANCE randomized > 5,000 pts with minor stroke or high risk TIA w/in 24h of the index event. The active treatment group received clopidogrel + ASA for 21d, vs ASA alone.
— cardio-met (@cardiomet_CE) September 13, 2022
25) POINT randomized almost 5,000 patients with minor stroke or high risk TIA within 12h of the index event. The active treatment group received clopidogrel + ASA for 30d, vs ASA alone. The result?
— cardio-met (@cardiomet_CE) September 13, 2022
27) So going back to our 65 y/o woman with a pure motor stroke and NIHSS of 3, loading with clopidogrel within 24 hours of onset and continuing DAPT for 30 days makes sense and is supported by the evidence. Are there any other alternatives to consider for DAPT? pic.twitter.com/8ztjXpUV0A
— cardio-met (@cardiomet_CE) September 13, 2022
29) Welcome back! I am @stephanamayer – denizen of neurocritical care & stroke – and we are back to discuss strategies for optimizing secondary stroke prevention here at the web's ONLY source of accredited tweetorials in #cardiometabolic medicine.
— cardio-met (@cardiomet_CE) September 14, 2022
31) Well, there’s #ticagrelor, an oral, reversible, direct-acting inhibitor of the ADP receptor P2Y12 that has a more rapid onset & ⬆️platelet inhibition than clopidogrel. #Clopidogrel is an irreversible P2Y12 blocker & is actually a prodrug. It needs to be metabolized …
— cardio-met (@cardiomet_CE) September 14, 2022
33) Ticagrelor significantly reduced the rate of death from vascular causes, MI, or stroke (9.8% vs 11.7%) compared to clopidogrel, without an increase in major bleeding. So the cardiologists love ticagrelor.
— cardio-met (@cardiomet_CE) September 14, 2022
35) … in 5.4% with DAPT, vs 6.9% with ASA monotherapy. pic.twitter.com/fgElMQaAS7
— cardio-met (@cardiomet_CE) September 14, 2022
36b) Minor stroke or TIA associated with Intracranial atherosclerotic disease (#ICAD) or ipsilateral athero appears to be the optimal responder group for ticagrelor + ASA. pic.twitter.com/GHLBoQKLYG
— cardio-met (@cardiomet_CE) September 14, 2022
38) So there’s every reason to treat with DAPT for 30 days. Which combination of therapy would you use?
— cardio-met (@cardiomet_CE) September 14, 2022
40) Some final thoughts about the role of DAPT in secondary stroke prevention. 1⃣ The dose of ASA should not exceed 325 mg QD. Higher doses increase the bleeding risk without additional clinical benefit.
— cardio-met (@cardiomet_CE) September 14, 2022
42) Final thoughts. 3⃣ #DAPT should generally not be used in patients with larger strokes (NIHSS >5) because of the increased risk of hemorrhagic infarction. 4⃣ There is no indication for continuing DAPT for >3 months for the secondary prevention of stroke.
— cardio-met (@cardiomet_CE) September 14, 2022
44) So you made it! Free CE/#CME! #physicians, #pharmacists, #nurses: go to https://t.co/IzIK0FwjAu and claim your credit! I am @stephanamayer. Follow @cardiomet_CE for more accredited tweetorials! #medtwittter #cardiotwitter @MedTweetorials @AAPAorg #FOAMed
— cardio-met (@cardiomet_CE) September 14, 2022