New AHA Guidelines New AHA Guidelines What is the blood pressure - - PowerPoint PPT Presentation

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NEUROCRITICAL CARE PROGRAM

UC SF

New AHA Guidelines

• A. Treat BP to goal of < 180/105 mmHg

after IV tPA

• B. Treat BP acutely if < 220/120 mmHg if

no intervention

• C. Treat BP to goal < 180/105 mmHg after

embolectomy

• D. Treat BP acutely if > 220/120 mmHg if

patient has CHF, other co-morbidities What is the blood pressure management after acute ischemic stroke? All of the following are correct except…

T r e a t B P t

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• a

l

• f

< 1 8 . . . T r e a t B P a c u t e l y i f < 2 2 . . . T r e a t B P t

• g
• a

l < 1 8 / . . . T r e a t B P a c u t e l y i f > 2 2 . . .

13% 27% 11% 48%

New AHA Guidelines

• A. Echocardiogram
• B. Extended cardiac monitor
• C. Fasting lipids
• D. Intracranial vessel imaging
• E. None of the above

What is recommended in standard diagnostic workup after acute ischemic stroke?

E c h

• c

a r d i

• g

r a m E x t e n d e d c a r d i a c m

• n

i t

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F a s t i n g l i p i d s I n t r a c r a n i a l v e s s e l i m a g i n g N

• n

e

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t h e a b

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e

18% 13% 13% 29% 27%

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PFO Patient Case - Question

• A. Yes
• B. No

Would you close a large PFO in a 35 year old with an embolic stroke and atrial fibrillation?

Y e s N

• 46%

54%

PFO Patient Case - Question

• A. Yes
• B. No

In patients with PFO and stroke, do you routinely screen for lower extremity DVT?

Yes No

40% 60%

ICH Patient Case - Question

A. SBP < 160 mmHg

• B. MAP < 110 mmHg
• C. SBP < 140 mmHg
• D. SBP < 180 mmHg

E. MAP < 140 mmHg

SBP < 160 mmHg MAP < 110 mmHg SBP < 140 mmHg SBP < 180 mmHg MAP < 140 mmHg

68% 4% 3% 14% 11%

55 yo man with a 40 cc right basal ganglia ICH, chronic hypertension with refusal to take outpatient medications, and an admission BP of 225/130 (MAP 162). His Glasgow Coma Scale score is 7. What is your goal blood pressure after 6 hours?

ICH Patient Case - Question

A. Perform neurological exams every 2 hours to watch for worsening

• B. Place a ventriculostomy and drain CSF at a

level of 10 cmH2O above the tragus

• C. Place a ventriculostomy and measure ICP,

draining CSF to keep below 20 mmHg

• D. Place a ventriculostomy and instill 2 mg of t-

PA into the ventricles E. Call a neurosurgeon to use an endovascular scope to remove the intraventricular clot 49 yo man with a small caudate ICH and significant intraventricular hemorrhage with

• hydrocephalus. His Glasgow Coma Scale

score is 10. You decide to:

P e r f

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m n e u r

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i c a l e x . . . P l a c e a v e n t r i c u l

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t

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y . . . P l a c e a v e n t r i c u l

• s

t

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y a . . P l a c e a v e n t r i c u l

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t

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y a . . C a l l a n e u r

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u r g e

• n

t

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. .

15% 14% 16% 16% 39%

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Highlights of New AHA Acute Ischemic Stroke Guidelines

• IV Alteplase should be administered

within 4.5 hours to eligible patients, with faster door to needle times recommended (goal 45-60 min)

• Use of telestroke and teleradiology to

faciltate acute stroke management and triage, prioritize CT and CTA.

• Expanded mechanical thrombectomy

indications within 6 hours and 6-24 hours in selected patients

Highlights of New AHA Acute Ischemic Stroke Guidelines

• Carotid imaging within 24 hours,

revascularization between 48h and 7 days in eligible patients

• Dual antiplatelet therapy with aspirin

and clopidogrel within 24 hours and continued for 21 days in mild stroke patients not treated with IV tPA

• Start oral anticoagulants in patients with

atrial fibrillation within 4-14 days

• High-intensity statin in patients with

atherosclerosis < 75 years old

Other ISC Trial Highlights

• Tenecteplase non-inferior to alteplase.

Showed improve outcomes wht embolectomy (EXTEND-IA TNK)

• Rivaroxiban (2.5 mg) + aspirin

decreased secondary stroke by half (COMPASS trial)

• First stroke reduced by 44 percent with

candesartan/HCTZ, rosuvastatin 10 mg (HOPE-3 trial)