Ischemic stroke medical therapy: Difference between revisions

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| style="padding: 5px 5px; background: #F5F5F5;" |[[Tissue plasminogen activator|'''Tissue plasminogen activator''']] '''(t-PA)'''
| style="padding: 5px 5px; background: #F5F5F5;" |[[Tissue plasminogen activator|'''Tissue plasminogen activator''']] '''(t-PA)'''
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* Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205  }} </ref><ref>{{cite journal |author= |title=Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group |journal=New England Journal of Medicine |volume=333 |issue=24 |pages=1581–7 |year=1995 |pmid=7477192 |url=http://content.nejm.org/cgi/content/full/333/24/1581}}</ref><ref name="Dubinsky06">{{cite journal | last =Dubinsky  | first = R| authorlink = | coauthors =Lai SM | title =Mortality of stroke patients treated with thrombolysis: analysis of nationwide inpatient sample | journal =Neurology | volume =66 | issue =11 | pages =1742–1744 | publisher = | date =2006 | url = | doi = | id =PMID 16769953  | accessdate =2007-01-22 }} </ref><ref>{{cite web|url=http://www.aaem.org/positionstatements/thrombolytictherapy.shtml |title=Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke |publisher=American Academy of Emergency Medicine |accessdate=2008-01-25}}</ref><ref name="pmid25072528">{{cite journal| author=Wardlaw JM, Murray V, Berge E, del Zoppo GJ| title=Thrombolysis for acute ischaemic stroke. | journal=Cochrane Database Syst Rev | year= 2014 | volume= 7 | issue=  | pages= CD000213 | pmid=25072528 | doi=10.1002/14651858.CD000213.pub3 | pmc=PMC4153726 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25072528  }} </ref><ref name="pmid25106063">{{cite journal| author=Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E et al.| title=Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. | journal=Lancet | year= 2014 | volume=  | issue=  | pages=  | pmid=25106063 | doi=10.1016/S0140-6736(14)60584-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25106063  }} </ref>  
* Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205  }} </ref><ref name="Dubinsky06">{{cite journal | last =Dubinsky  | first = R| authorlink = | coauthors =Lai SM | title =Mortality of stroke patients treated with thrombolysis: analysis of nationwide inpatient sample | journal =Neurology | volume =66 | issue =11 | pages =1742–1744 | publisher = | date =2006 | url = | doi = | id =PMID 16769953  | accessdate =2007-01-22 }} </ref><ref>{{cite web|url=http://www.aaem.org/positionstatements/thrombolytictherapy.shtml |title=Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke |publisher=American Academy of Emergency Medicine |accessdate=2008-01-25}}</ref><ref name="pmid25072528">{{cite journal| author=Wardlaw JM, Murray V, Berge E, del Zoppo GJ| title=Thrombolysis for acute ischaemic stroke. | journal=Cochrane Database Syst Rev | year= 2014 | volume= 7 | issue=  | pages= CD000213 | pmid=25072528 | doi=10.1002/14651858.CD000213.pub3 | pmc=PMC4153726 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25072528  }} </ref><ref name="pmid25106063">{{cite journal| author=Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E et al.| title=Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. | journal=Lancet | year= 2014 | volume=  | issue=  | pages=  | pmid=25106063 | doi=10.1016/S0140-6736(14)60584-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25106063  }} </ref>  
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Revision as of 13:52, 14 March 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]

Overview

The medical therapy of ischemic stroke is mainly directed to fibrinolysis of clot by r-tPA with in 3 to 4.5 hours of symptom onset. Acute treatment with antiplatelets may have a role if given within 24-48 hours of stroke onset. Long term management with statins, antiplatelets, anticoagulants, antihypertensive and antidiabetic agents may help prevent the recurrence.[1] Acute treatment to control blood pressure, blood glucose and fever may help prevent the complications and have a prognostic significance.

Medical Therapy

For AHA/ASA guidelines for Intravenous Fibrinolysis in patients with ischemic stroke, please click here
For AHA/ASA guidelines for General Supportive Care and Treatment of Acute Complications in patients with ischemic stroke, please click here
For AHA/ASA guidelines on anticoagulants usage in patients with ischemic stroke, please click here
For AHA/ASA guidelines on antiplatelets usage in patients with ischemic stroke, please click here
For AHA/ASA guidelines on volume resuscitation usage in patients with ischemic stroke, please click here
For AHA/ASA guidelines on neuroprotective agents in patients with ischemic stroke, please click here
For AHA/ASA guidelines on General Stroke Care in patients with ischemic stroke, please click here

Medical treatment Drug class Recommendations
Acute Long-Term
Reperfusion therapy Tissue plasminogen activator (t-PA)
  • Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients[2][3][4][5][6]
  • None
Antithrombotic agents Antiplatelet agents
  • Oral administration of aspirin (initial dose is 325 mg) is recommended within 24 to 48 hours after stroke onset in most patients[2]
  • Aspirin is contraindicated in patients with ischemic stroke within 24 hours of t-PA administration[2]
  • DAPT therapy (aspirin and clopidogrel) is recommended for 90 days in patients with symptomatic intracranial large artery disease
  • Long term therapy with clopidogrel or aspirin extended release dipyridamole may be used for secondary prevention of non cardioembolic stroke
Anticoagulants
  • Parenteral or oral anticoagulation is not recommended within 48 hours of onset of ischemic stroke[7]
  • Oral anticoagulants may be used for secondary prevention of ischemic stroke in patients with atrial fibrillation or other cardioembolic disease[8]
Antilipid therapy Statins
  • Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable[2]
  • Long term management of ischemic stroke with high intensity statins may be recommended for patients with atherosclerotic disease
  • Patients who cannot tolerate high intensity dose, medium or low intensity statins may prove beneficial
Antihypertensive therapy Intravenous antihypertensives

(Labetolol, nitroprusside)

  • Used to control high blood pressure in patients with BP>185/110 mmHg before starting t-PA[2]
  • Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
Oral antihypertensive therapy
  • Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
Antihyperglycemic agents Insulin
  • May be used to control blood glucose between range of 140-180 mg/dl since hyperglycemia is associated with worst outcome in patients with acute ischemic stroke[2]
  • Long term oral antidiabetic may be used for secondary prevention of ischmeic stroke in patients with diabetes mellitus

References

  1. ↑ Hackam DG, Spence JD (2007). "Combining multiple approaches for the secondary prevention of vascular events after stroke: a quantitative modeling study". Stroke. 38 (6): 1881–5. doi:10.1161/STROKEAHA.106.475525. PMID 17431209.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM; et al. (2013). "Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 44 (3): 870–947. doi:10.1161/STR.0b013e318284056a. PMID 23370205.
  3. ↑ Dubinsky, R (2006). "Mortality of stroke patients treated with thrombolysis: analysis of nationwide inpatient sample". Neurology. 66 (11): 1742–1744. PMID 16769953. Unknown parameter |coauthors= ignored (help); |access-date= requires |url= (help)
  4. ↑ "Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke". American Academy of Emergency Medicine. Retrieved 2008-01-25.
  5. ↑ Wardlaw JM, Murray V, Berge E, del Zoppo GJ (2014). "Thrombolysis for acute ischaemic stroke". Cochrane Database Syst Rev. 7: CD000213. doi:10.1002/14651858.CD000213.pub3. PMC 4153726. PMID 25072528.
  6. ↑ Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E; et al. (2014). "Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials". Lancet. doi:10.1016/S0140-6736(14)60584-5. PMID 25106063.
  7. ↑ Paciaroni M, Agnelli G, Micheli S, Caso V (2007). "Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials". Stroke. 38 (2): 423–30. doi:10.1161/01.STR.0000254600.92975.1f. PMID 17204681. ACP JC synopsis
  8. ↑ Hart RG, Pearce LA, Aguilar MI (2007). "Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation". Ann. Intern. Med. 146 (12): 857–67. PMID 17577005.


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