WTM0210/1 March 2012 Learning portfolio Stroke learning@lunch flex solutions for national hospital pharmacy learning needs
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WTM0210/1March 2012
Learning portfolio
Stroke
learning@lunch flexsolutions for national hospital pharmacy learning needs
Learning portfolio
Learning with CPPEThe Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range of learningopportunities for the pharmacy workforce. We are based in the University of Manchester’sSchool of Pharmacy and Pharmaceutical Sciences and are funded by the Department ofHealth to provide continuing education for practising pharmacists and pharmacy techniciansproviding NHS services in England. For further information about our portfolio, visithttp://www.cppe.ac.uk.
AcknowledgementsCPPE programme managerMaria Bell, regional manager, Yorkshire and Humber
AuthorIan Rowlands, lead pharmacist for stroke services, Imperial College Healthcare NHS Trust
ReviewersAngela Alexander, regional manager, South Central, CPPETania Cork, local pharmacy tutor, North Staffordshire, CPPE Katti Nwosu, senior pharmacist for care of the elderly and stroke, North MiddlesexUniversity Hospital NHS TrustJosceline Williams, lead pharmacist for elderly care and stroke, Guy’s and St Thomas’ NHSFoundation Trust
EditorNeil Condron, editor, CPPE
ThanksThis programme was piloted at Frimley Park Hospital NHS Foundation Trust by AlisonMarshall, medicines information pharmacist, and at Plymouth Hospitals NHS Trust by AliHarris, neurosciences pharmacist. We appreciate their feedback and that of participants inthe pilot sessions.
ProductionPeacock Design & Print Limited.
Published in March 2012 by the Centre for Pharmacy Postgraduate Education, School ofPharmacy and Pharmaceutical Sciences, University of Manchester, Oxford Road,Manchester M13 9PT. http://www.cppe.ac.uk
Stroke
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About this learning@lunch flex programme
The overall aim of this learning@lunch flex programme onstroke is to support pharmacists and pharmacy technicians inadvancing their knowledge and skills in relation to the care ofpatients who have experienced a stroke and their carers.
Learning objectives
On completion of this learning programme, you should be able to:
This learning programme will provide you with evidence of learning for the followingdimensions of the NHS Knowledge and Skills Framework:
• discuss the diagnosis and pathophysiology of stroke• describe the essential components of basic stroke care, including risk factors,
assessment, acute management and long-term care• apply your knowledge of therapeutics to post-stroke patients• discuss the holistic approach to the care of stroke patients• explain the role of the multidisciplinary team in the care of stroke patients• demonstrate an understanding of the resources and signposting available for patients
and carers.
Health and wellbeing HWB 2
Health and wellbeing HWB 6
Health and wellbeing HWB 7
Health and wellbeing HWB 8
Health and wellbeing HWB 10
Communication
Review and monitor care plans – Level 3
Monitor and review related treatment plans – Level 3
Interventions and treatments – Level 3
Report on biomedical investigations or interventions – Level 2
Prepare and supply specialised products – Level 3
Develop and maintain communication regarding difficultsituations – Level 3
Learning portfolio
It will also provide you with evidence for the following General Level Frameworkcompetency clusters:
About this learning portfolio
We have developed this learning portfolio as part of the learning@lunch flexprogramme on stroke. The learning and activities in the learning@lunch flex serieswill help you to think about changing your practice and demonstrate yourcontinued fitness to practise.
Case studies
When you are on the ward reviewing patients you have access to lots of different sourcesof information about the patient and their clinical condition. In the case studies that follow,we give you the key points about each patient and you should make a decision based onthese points alone.
The cases are designed to illustrate some of the difficult therapeutic decisions involved indealing with stroke patients and to allow you to discuss solutions to long-term care issueswith your colleagues.
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Delivery of patient care
Selection of drug
Monitoring drug therapy
Personal
Team work
Problem solving
Gathering information
Analysing information
Drug-patient selectionDrug-disease interactions
Use of guidelines
Pharmacy team
Accesses information
Appraises options
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CASE STUDY 1 – TOM
Thomas Barker is a 54-year-old account manager who is an inpatient on your orthopaedicward. Tom has sustained a right ankle fracture-dislocation when dismounting his bicyclewhile it was still moving. This morning, he went for an open reduction and internal fixationof his right ankle and was fitted with a plaster splint.
Tom comes round uneventfully from the anaesthetic and is drowsy but can answerquestions. While he is being prepared for transfer back to the ward, he suddenly becomesaphasic with a weakness of his right arm.
Suspecting a stroke, the anaesthetist sends Tom for an urgent brain computerisedtomography (CT) scan. The CT was unremarkable, with no evidence of infarction orhaemorrhage. On transfer back to the ward, Tom’s speech begins to return and he regainsfull power in his upper limbs. The symptoms had lasted about 45 minutes. “It was a funnyfeeling,” he says. “I wanted to ask for some water but I couldn’t get the words out!”
The medical team are asked to see him. After reviewing the case with the anaesthetist andspeaking to Tom, the medical registrar says that he thinks that Tom might have had atransient ischaemic attack (TIA).
What is a stroke and how does this differ from a TIA?
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The patient has had a CT scan which did not show any signs ofinfarction or haemorrhage. What other tests could be performed tohelp with the diagnosis?
What treatment should be started in the meantime?
Your hospital policy is for all trauma and orthopaedic surgery inpatients to be prescribed aprophylactic low-molecular weight heparin (LMWH) unless contraindicated. Should Tom beprescribed a LMWH?
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The medical team organise a magnetic resonance imaging (MRI) scan for later in the day.The results of this are reported as unremarkable: they show no sign of acute stroke and noabnormalities are detected. The next morning, results of his carotid Doppler tests show aninsignificant narrowing of the right and left carotid arteries, and no irregularity is detectedon the electrocardiogram (ECG). Despite no obvious cause for this event, the symptomsand timescale lead the medical team to diagnose this event as a TIA.
On checking Tom’s medical notes the day after his operation and TIA, you find thefollowing medical summary from his GP surgery.
Past medical history: • hypertension• hypercholesterolaemia• ex-smoker (20 pack years, quit smoking two years ago).
Current medications:• bendroflumethiazide 2.5 mg once daily• simvastatin 10 mg at night.
Current bedside observations/results:• blood pressure: 166/84 mmHg• total cholesterol: 5.8 mmol/L• low-density lipoprotein (LDL) cholesterol: 3.9 mmol/L.
You check with Tom to confirm his medication history and he admits to you that he wasn’ttaking his tablets regularly as he didn’t think that he needed them.
How would you counsel Tom?
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A random blood glucose level of 9 mmol/L is investigated further by an oral glucosetolerance test, the results of which show that Tom has impaired glucose tolerance.
Based on these findings, would you advise any amendments to his prescription?
Three days later, Tom is ready to be discharged with a non-weight bearing cast. Theorthopaedic senior house officer approaches you to ask for your advice on Tom’s dischargeprescription. He has been asked by the medical team to write the patient up for the‘standard secondary prevention medications’, but he isn’t sure what these medicationsshould be.
What is your advice to the senior house officer?
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CASE STUDY 2 – LILY
Lily Adams is an 84-year-old lady who is admitted to the acute stroke unit at 11:00am. Thestaff at the day centre that she attends had called her daughter after Lily had not arrived atthe centre that morning.
Her daughter went to Lily’s house at 10:30am to find her mum still in bed, unable to speakor to stand up. An ambulance was called and, as the patient was FAST-positive (facialweakness, arm weakness and speech problems), Lily was brought to her local acute strokeunit for investigation. The notes read:
Presenting complaint:• aphasia• right-sided weakness.
History of presenting complaint:• previously fit and well• Lily’s daughter had spoken to her at 8:30pm on the phone last night and reported no
concerns.
Previous medical history: • Hypertension, 15-20 year history.
Drug history:• atenolol one 50 mg tablet in the morning• aspirin one 75 mg tablet in the morning• senna two tablets at night• Adcal-D3
® two tablets in the morning• paracetamol two tablets four times a day when required.
Family history:• parents: father died 68 (heart attack), mother died 84 (cause of death unknown) • siblings: one living brother (72), one brother died four years ago aged 76 (stroke) • children: two daughters (54 and 50), both fit and well.
Social history:• retired post office worker• widowed• lives alone in two-bedroom terraced house, bathroom/toilet upstairs • daughter lives locally and helps with weekly shopping• cooks and cleans for herself • attends day centre three times a week • non-smoker, drinks alcohol occasionally.
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On examination the following is recorded:• temperature 37.5°C • Glasgow Coma Scale (GCS) 12 (E4, V3, M5), drowsy but rousable, orientated in
person but not time or place• respiratory rate 18, saturation 95 percent on room air, chest clear• cardiac: pulse 78 bpm, sinus rhythm; blood pressure 186/92 mmHg • right arm weakness (power 3/5) and right leg weakness (power 3/5), left side normal
power• receptive and expressive dysphasia• cranial nerves difficult to assess as the patient is confused and not following commands
reliably. May have slight right-sided facial droop.
What are the differential diagnoses?
What initial investigations would you expect to see carried out?
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A CT scan is carried out on Lily at 11:35am and shows a left-middle cerebral arteryinfarction with no evidence of haemorrhagic transformation.
Is Lily a candidate for thrombolysis?
Brain Stroke
Blockage ofblood vessels;lack of blood
flow to affectedarea.
Rupture ofblood vessels;
leakage ofblood.
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How should Lily be medically managed in the acute phase?
Should the raised blood pressure be treated at this stage?
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Lily remains in the care of the acute stroke unit. Three days later, the following results areobtained:• ECG: normal sinus rhythm• carotid Doppler: right 40 percent, left 55 percent stenosis.
Lily has been assessed by the stroke unit dietitian, occupational therapist, physiotherapist,and speech and language therapist. She has recovered full power in her right arm and leg,but still has a right-sided visual field defect and is having persistent problems with language.She can reliably follow one-stage but not two-stage commands, and is demonstrating someproblems finding words (she cannot accurately identify common items such as a watch, apen or a telephone). She is fully continent and can mobilise to the toilet with the assistanceof one member of nursing staff. Her swallowing is safe and she is eating a normal diet, butrequires regular prompting to ensure she eats her full meals. She is able to sit out of bedfor two hours at a time but gets tired easily and regularly gets back into bed. The decisionis made to transfer Lily from the acute stroke unit to the accompanying stroke unit forfurther rehabilitation.
After four days on the stroke unit (seven days post stroke), Lily is still hypertensive. Herlatest blood pressure reading is 162/74 mmHg. Her inpatient drug chart currently reads:• aspirin 300 mg by mouth once daily• atenolol 50 mg by mouth once daily• simvastatin 40 mg by mouth at night• Adcal-D3
® two tablets once daily.
How should her blood pressure be managed? What is the target for blood pressure afterstroke?
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After two weeks as an inpatient receiving specialist stroke care and rehabilitation, Lily ismaking excellent progress but still has a degree of word-finding difficulty and occasionallyrequires prompting in her activities of daily living (dressing, washing, eating, etc.). She hasbeen accepted for an early supported discharge back to her own home in association with acommunity stroke team, with input from her family and support from communityoccupational therapists and speech and language therapists to work on her communication.The stroke team are preparing the discharge prescription.
The plan is to continue simvastatin and the antihypertensives you recommended. Whatshould be the long-term plan for antiplatelet therapy?
If signs and symptoms of atrial fibrillation (AF) had been present on Lily’s ECG, whatadditional or alternative medication would you expect to see prescribed?
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CASE STUDY 3 – ALPANA
Alpana Kapoor is a 78-year-old, right-handed lady who was admitted to the acute strokeunit via accident and emergency at 11:00pm last night. You see the patient during the wardround on the following morning.
The notes read as follows:
Presenting complaint: • patient unconscious and unable to rouse• has vomited (query aspiration).
History of presenting complaint: • patient’s son found his mother slumped on sofa at approximately 10:00pm• patient was last seen well at 8:30pm, after dinner • no recent history of illness and no complaints voiced. Son reports patient has been
under increased stress due to recent deterioration and hospitalisation of his father,who suffers from dementia.
Previous medical history: • hypertension and hypercholesterolaemia• diet-controlled type 2 diabetes.
Drug history (from GP records):• felodipine modified-release 10 mg once daily• bisoprolol fumarate 2.5 mg once daily• bendroflumethiazide 5 mg once daily• doxazosin modified-release 8 mg once daily• rosuvastatin 10 mg one at night• aspirin enteric-coated 75 mg once daily• omeprazole capsule 10 mg once daily• allergic to penicillin (Alpana’s son has brought in all of her medication. While
undertaking a medicines reconciliation you check through the patient’s own medicinesand discover that there are several boxes of unopened medicines, with different datesof dispensing many months prior, some of which have expired).
Family history: • unable to confirm.
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Social history: • is primary carer for husband who has dementia• lives with her son, daughter-in-law and three grandchildren • non-smoker, does not drink alcohol.
On examination:• appears overweight• temperature 37.4°C, heart rate 86 beats per minute (regular), blood pressure
214/120, respiratory rate 18, saturation 94 percent on room air, GCS 5 (E2 V1 M2)• urea and electrolytes all within reference range• full blood count all within reference range• liver function tests all within reference range• random total cholesterol 5.8 mmol/L• C-reactive protein 19• random blood glucose 14.3 mmol/L.
CT (brain): • shows left-sided basal ganglia haemorrhage.
Diagnosis: • intracerebral haemorrhage (ICH) – left-sided basal ganglia haemorrhage.
You note the doctors’ plan in the medical record, which reads:• neurological observations every 30 minutes• treat for suspected aspiration pneumonia• ECG and blood pressure monitoring• blood glucose monitoring• patient to remain nil by mouth (NBM) until speech and language therapy review • dietitian review• physiotherapist review.
What actions need to be taken immediately regarding Alpana’s regular medication?
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What are the therapeutic options for the management of Alpana’s blood pressure?
Later in the afternoon the stroke speech and language therapist reviews Alpana andrecommends that she has a nasogastric (NG) tube inserted, as the patient is not sufficientlyconscious for a swallow assessment to be performed. An NG tube is inserted and thecorrect position confirmed by a chest X-ray. The stroke dietitian has assessed Alpana’snutritional status and written a plan for NG feeding to start that evening.
Last night, Alpana had a random blood glucose level of 14.3 mmol/L. How should this bemanaged?
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Observations carried out by nursing staff show Alpana’s blood pressure as being 186/106 mmHg. The stroke consultant has decided to administer oral antihypertensives viathe feeding tube with an aim of weaning parenteral agents.
What would your advice be regarding the choice, and administration, of antihypertensivesvia the NG tube?
Alpana remains on the stroke unit for treatment and, after one week, her conditionstabilises. The stroke has left her aphasic, with right-sided hemiparesis and hemisensoryloss, a right-sided visual field defect and a gaze preference to the left.
On the speech and language therapist’s advice, she remains NBM and is receiving allnutrition and medications via an NG tube. The speech and language therapist identifies thatthe patient has sialorrhoea (drooling or excessive saliva secretion) and is at an increased riskof aspiration. They approach you for advice.
What are the options for the management of post-stroke sialorrhoea?
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It has been noted that Alpana has been showing little interest in her surroundings and hermood tends to vary. The physiotherapists report that she frequently refuses input intorehabilitation exercises and they are struggling to get her to engage in the treatment plan.Alpana is assessed (using a validated scale) for depression and the results indicate that thepatient may be depressed.
How should post-stroke depression be managed?
Over the course of several weeks of rehabilitation, Alpana has been affected by spasticity(increased muscular tone) in her right arm. This particularly affects her wrist, producingexaggerated reflexes and painful spasms on contact, including when the patient is beingtransferred out of bed to a chair. It is felt that this spasticity is greatly impacting on Alpana’sability to participate in rehabilitation exercises. She has been prescribed appropriateanalgesia to help with the pain and is treated by the physiotherapists with specificallytailored exercises and stretching to help relieve the spasticity. However, it is felt that thepatient may benefit from antispastic medication.
What are the pharmacological options for the management of post-stroke spasticity?
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After your learning@lunch flex session
You have now reached the end of your learning programme for stroke.
At this point you should have:• completed the pre-session reading • answered the reflective questions• discussed your local guidelines for thrombolysis in stroke patients• considered your own role in supporting effective prescribing of medication and
considered the implications of using medication outside its product licence• applied the knowledge gained via the tasks to our case studies• reflected on how the national guidelines may apply to the patients you see on your wards.
Next stepsNow it is time to record your learning and to plan how you will put your knowledge intopractice.
There are three steps that you should undertake to achieve this, listed in the table below.Use the table to plan and record your actions.
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Next step
Complete your ownCPD records for thesedifferent elements
Develop your ownaction plan for whatyou’re going to do next
Put together an actionplan to make sure thateveryone on your teamknows how strokemanagement guidelinesare applied.
Action required When will you do this? Datecompleted
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Learning checklist
Use this checklist to highlight key areas of learning and how you may wish to extend yourknowledge.
Activity
Read the two articles fromClinical Pharmacist
Complete the pre-sessiontasks
Find your trust’spolicy/policies onprescribing LMWH forstroke patients
Complete the case studies
Consider yourinvolvement in the multi-disciplinary team caringfor stroke patients
Tick if completedas part of Strokelearning@lunchflex session
If not undertaken as pre-session or sessionlearning, how do you plan to update yourknowledge?
Learning portfolio
Further readingShould you be interested in extra reading to support your knowledge, you might like toread the following articles:
1. McArthur KS. Diagnosis and management of transient ischaemic attack and ischaemicstroke in the acute phase. British Medical Journal 2011;342: d1938.
2. McArthur KS. Post-acute care and secondary prevention after ischaemic stroke. BritishMedical Journal 2011;342: d2083.
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Suggested answers to:Reflective questionsCase studies
In this section of the learning portfolio, we offer some suitable answers to thereflective questions and the case studies. Points stimulating debate are provided,and the answers encourage you to apply your learning to practice.
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Reflective questions before workshop
By this stage you will have completed this learning@lunch flex programme onstroke. On the pre-session handout, we asked you to consider some reflectivequestions. Here are some suggested answers.
1. What are the major risk factors for stroke?
2. How does secondary prevention differ for patients who have ischaemic stroke(related to atherosclerotic vascular disease) from ischaemic stroke (related tocardioembolism)?
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Suggested answer
Non-modifiable risk factors for stroke include age (only ten percent of strokes occur inpatients under the age of 45), male sex, ethnicity and family stroke history. The majormodifiable risk factors include hypertension, AF, previous history of stroke or TIA,smoking, ischaemic heart disease and peripheral vascular disease, physical inactivity anddiabetes.
Hypercholesterolaemia is a risk factor for ischaemic stroke, whereas low cholesterollevels, or cholesterol-lowering therapy, may increase the risk of haemorrhagic stroke,though this subject is controversial.1, 2
Suggested answer
The main difference is that patients who have a stroke as a result of atheroscleroticvascular disease should receive antiplatelet therapy, whereas patients with cardioembolicstroke (eg, patients with AF) should receive therapeutic anticoagulation, unlesscontraindicated. In both cases, patients may have other risk factors, such as hypertensionor hypercholesterolaemia, that would also need to be actively treated.
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3. Dysphagia (difficulty in swallowing) is very common after stroke. Patients may requireenteral feeding tubes or modified diets to help with this. What are the mainconsiderations when prescribing and administering medications to patients withdysphagia or enteral feeding tubes?
Suggested answer
If patients cannot swallow solid forms of medicines safely then there may be thepossibility of giving medication via non-oral routes, such as transdermally, rectally, or viainjection. However, the majority of medicines that are used in secondary prevention ofstroke only come as tablets, with very few preparations available in liquid or dispersibleform. Similarly, manufacturing of liquids as specials may be financially prohibitive.
Crushing tabletsFor patients with dysphagia, we are often left with little option otherthan to crush tablets to administer them, either via a feeding tubeor mixed with thickened fluids and foods (eg, yoghurt). Bycrushing a tablet for administration, we may be going outsideof the product licence and this raises many safety issues, suchas an increased risk of side-effects, interactions with enteralfeeds and a potentially variable therapeutic response. Beforeyou advise a member of nursing staff or a patient/carer to crusha tablet, please ensure that you have checked that it is safe to doso, that the preparation is appropriate (eg, not modified-release,enteric-coated, etc.) and that there is no better alternative. If you areworking on a stroke unit and commonly see patients with dysphagia, it is advisable tofamiliarise yourself with the commonly used drugs and how to administer them viafeeding tubes. A resource such as the Handbook of Drug Administration via Enteral FeedingTubes (2nd Edition, Pharmaceutical Press, 2008) may prove indispensable.
Extra notesDysphagia is very common after stroke and may result in patients requiring enteral feedingtubes to ensure they receive adequate fluid and nutrition.
Aspiration pneumonia is a major risk in patients with dysphagia, so patients are closelyassessed to ensure that anything given orally – be it food, fluids or medicines – can beswallowed safely. To safely administer medications to patients with dysphagia, it is essential tofind out what the patient’s swallowing status is. Speech and language therapists assess if thepatients are NBM or if they require thickened fluids.
The best source of information to help you with this would be a speech and languagetherapist, as they would be able to provide advice on swallowing status and guide yourdecisions on what medicines to use and how to administer them.
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4. Thrombolysis with alteplase has been shown to significantly improve the outcome ofpatients with ischaemic stroke. However, only a small percentage of patients actuallyreceive alteplase. What issues may affect a patient’s likelihood to receive thrombolysis?
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Suggested answer
Thrombolysis with alteplase in acute ischaemic stroke has been shown to significantlyreduce the risk of permanent disability from stroke. This procedure is not without risk, asit also significantly increases the risk of having a life-threatening bleed. There are manycontraindications to receiving alteplase - this reduces the number of patients who areeligible to receive it.
Time is key; the earlier alteplase can be administered, the greater the chance of a positiveoutcome. It is only licensed for administration within three hours of the onset ofsymptoms, so it is essential that the timescale of symptoms is totally clear. Some hospitalsmay thrombolyse at times up to 4.5 hours, but this is at the medical team’s discretion. Ifpatients wake up with stroke symptoms, then they will generally be excluded, as it isnearly impossible to say at which point during their sleep they had a stroke. Age may be acontraindication, as alteplase is only licensed in patients aged between 18 and 80, thoughtrials are being conducted in patients outside of these age ranges and at times in excess ofthree hours, to see if more patients may benefit.
Alteplase has been shown to reduce disability but not prevent death; so if patients weretotally dependent prior to the new stroke then they are excluded, as the drug would notimprove outcome but only provide greater bleeding risk. Patients are excluded if theyhave very minor deficits or if their symptoms are rapidly improving (ie, they may havehad a TIA). There are numerous other contraindications, mainly related to patients whohave an increased risk of haemorrhage. They include patients where there is evidence ofintracranial haemorrhage on CT or a history of intracranial haemorrhage, stroke, headtrauma or surgery in the past three months, and patients on therapeutic anticoagulation(as reversal would take too long) or other coagulopathies.
To summarise, alteplase is effective, but there are many contraindications to its use,reducing the number of patients eligible to receive treatment – and giving it to anunsuitable patient could be catastrophic. Access to specialist stroke services and imagingin the timescale allowed is also a major issue that may restrict administration ofthrombolysis. You will need to consider what services exist in your hospital or local arearegarding thrombolysis and whether there is a local thrombolysis protocol of which youneed to be aware.
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Case studiesThe case studies, along with our suggested answers and any discussion points, are listedbelow. You may, or may not, have worked through all of these case studies at your session.
CASE STUDY 1 – TOM
Thomas Barker is a 54-year-old account manager who is an inpatient on your orthopaedicward. Tom has sustained a right ankle fracture-dislocation when dismounting his bicyclewhile it was still moving. This morning, he went for an open reduction and internal fixationof his right ankle and was fitted with a plaster splint.
Tom comes round uneventfully from the anaesthetic and is drowsy but can answerquestions. While he is being prepared for transfer back to the ward, he suddenly becomesaphasic with a weakness of his right arm.
Suspecting a stroke, the anaesthetist sends Tom for an urgent brain CT scan. The CT wasunremarkable, with no evidence of infarction or haemorrhage. On transfer back to theward, Tom’s speech begins to return and he regains full power in his upper limbs. Thesymptoms had lasted about 45 minutes. “It was a funny feeling,” he says. “I wanted to askfor some water but I couldn’t get the words out!”
The medical team are asked to see him. After reviewing the case with the anaesthetist andspeaking to Tom, the medical registrar says that he thinks that Tom might have had a TIA.
What is a stroke and how does this differ from a TIA?
Suggested answer
A stroke is defined by the World Health Organization as ‘rapidly developing clinical signs offocal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer, orleading to death, with no apparent cause other than of vascular origin.’3
A TIA is described as stroke symptoms which last for fewer than 24 hours, though themajority of TIAs resolve within one hour. Although a TIA is self-terminating, it needs tobe fully investigated as patients with TIA are at very high risk of stroke.
Discussion pointThe risk of recurrent stroke has been estimated at 8 percent at one week, 11.5 percent atone month and 17.3 percent at three months following TIA.4
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The patient has had a CT scan which did not show any signs of infarction or haemorrhage.What other tests could be performed to help with the diagnosis?
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Suggested answer
Following an initial TIA or stroke, investigations should include: MRI, carotid imaging,blood pressure at intervals, ECG, full blood count, urea and electrolytes, blood glucose,cholesterol, erythrocyte sedimentation rate, thyroid function and inflammatory markers.
Discussion pointsMost stroke centres will use CT scanning as the initial imaging technique, as it is quick, cheapand can easily identify haemorrhagic stroke, which is of use when identifying patients who maybe suitable for thrombolysis. CT, however, is not sensitive for early ischaemic stroke (less thansix hours from onset) or small areas of ischaemia. MRI produces more detailed images and ismore sensitive to early stroke and small stroke than CT, but fewer centres have access tothem, scanning is more expensive and it takes longer to perform and process the results.
Carotid imaging assesses the blood flow in the carotid arteries that supply the brain withblood. Carotid artery stenosis (narrowing of these vessels) may be a cause of ischaemic strokeor TIA, and if blood flow is sufficiently impaired, patients can be offered surgery to improvecarotid blood flow. ECG monitoring is done to see if patients have AF, as this is a major riskfactor for stroke. Similarly thyroid dysfunction, particularly hyperthyroidism, is a risk factor fordeveloping AF, and so thyroid function ought to be assessed. Hypertension,hypercholesterolaemia and diabetes are all risk factors for stroke, so it is important that theseare identified and monitored as appropriate.
The other biochemical tests will be used as part of the diagnostic process to assess whetherthere are any other disease processes occurring that can help to rule TIA or stroke out.
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What treatment should be started in the meantime?
Your hospital policy is for all trauma and orthopaedic surgery inpatients to be prescribed aprophylactic LMWH unless contraindicated. Should Tom be prescribed a LMWH?
Suggested answer
As haemorrhage has been ruled out, and assuming there are no other contraindications,aspirin 300 mg should be administered as soon as possible and continued daily untildiagnosis is confirmed.
Discussion pointsThe recommendation for the administration of 300 mg aspirin for suspected ischaemic strokeor TIA comes from the National Collaborating Centre for Chronic Conditions’ document,Stroke: national clinical guideline for diagnosis and initial management of acute stroke andtransient ischaemic attack (TIA).5
Suggested answer
There are two main issues to consider here. Firstly, the patient has had orthopaedicsurgery and is at increased risk of venous thromboembolism (VTE) and, secondly, thepatient is being investigated for suspected TIA. The National Institute for Health andClinical Excellence (NICE) clinical guideline 92 on reducing VTE risk in hospital inpatientsrecommends that orthopaedic surgery patients be considered for both mechanical andpharmacological VTE prophylaxis, based on a risk assessment and discussion with thepatient, and continued until the patient no longer has any significantly reduced mobility.6
The national clinical guideline for diagnosis and initial management of acute stroke and TIArecommends that heparins are not routinely used in the treatment of acute stroke, due tothe increased risk of ICH.5
In practice, this means that therapeutic and prophylactic heparins or LMWHs are not usedunless strongly indicated. The MRI result here is key; if the MRI rules out acute stroke, andthere is no significant acute ischaemic damage, then the patient should be prescribed aLMWH and continued until they are no longer immobile.
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The medical team organise an MRI scan for later in the day. The results of this are reportedas unremarkable: they show no sign of acute stroke and no abnormalities are detected. Thenext morning, results of his carotid Doppler tests show an insignificant narrowing of theright and left carotid arteries, and no irregularity is detected on the ECG. Despite noobvious cause for this event, the symptoms and timescale lead the medical team todiagnose this event as a TIA.
On checking Tom’s medical notes the day after his operation and TIA, you find thefollowing medical summary from his GP surgery.
Past medical history: • hypertension• hypercholesterolaemia• ex-smoker (20 pack years, quit smoking two years ago).
Current medications:• bendroflumethiazide 2.5 mg once daily• simvastatin 10 mg at night.
Current bedside observations/results:• blood pressure: 166/84 mmHg• total cholesterol: 5.8 mmol/L• LDL cholesterol: 3.9 mmol/L.
You check with Tom to confirm his medication history and he admits to you that he wasn’ttaking his tablets regularly as he didn’t think that he needed them.
How would you counsel Tom?
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Suggested answer
Patients with hypertension and hypercholesterolemia will, in general, not experience anyday-to-day problems from their condition. Treatment for these conditions and theassociated side-effects may actually make them feel worse. One of the main challenges ofattaining adherence to secondary prevention medication is therefore to provide insight asto why the patient actually needs to take their treatment. An event such as a stroke orTIA will, for a lot of patients, act as a ‘wake-up call’ and make them more receptive toyour advice. Also bear in mind that this can be a very stressful time for patients, sohealthcare professionals should emphasise the benefits from treatment and explain thatstrokes, with the right medication, are largely preventable.
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A random blood glucose level of 9 mmol/L is investigated further by an oral glucosetolerance test, the results of which show that Tom has impaired glucose tolerance.
Based on these findings, would you advise any amendments to his prescription?
Suggested answer
Lifestyle interventions would be recommended as a first choice for impaired glucosetolerance (weight loss, increased physical activity, reduce dietary fat intake) beforeprescribing antidiabetic medication.
However, currently Tom is prescribed a thiazide diuretic, which would not berecommended in a patient at risk of developing diabetes, as thiazides can causehyperglycaemia. The hypertension recommendations in the National clinical guideline forstroke from the Intercollegiate Stroke Working Party on blood pressure7 match the NICEguidelines on the management of hypertension for patients under 55 years old; thereforehypertensive patients younger than 55 should be treated first-line with an angiotensin-converting enzyme (ACE) inhibitor (or angiotensin-II receptor antagonist if ACE inhibitorsare not tolerated). In this case, there is also the risk of diabetes, and an ACE inhibitorwould have the benefit of offering renal protection should diabetes develop.
It is advised that a check should be carried out to ensure there are no contraindicationsand that the team should stop bendroflumethiazide and prescribe perindopril 4 mg oncedaily (see the discussion points below for more information). If the ACE-inhibitor therapyis optimised and proves to be insufficient in controlling blood pressure, then a calcium-channel blocker such as amlodipine could be added in. A thiazide diuretic (indapamide)could reasonably be considered as an add-in at third-line therapy (given the patient’s riskof diabetes).
Discussion pointsThe PROGRESS trial is one of the key trials regarding antihypertensive treatment stroke riskreduction.8 In this study, patients with a history of stroke or TIA in the previous five years wererandomised to receive either a regime of perindopril, plus or minus indapamide, or matchingplacebo. 6105 patients were randomised and followed up for a median of 3.9 years; the mainfinding was that there was a 28 percent overall reduction in stroke risk, and a 9/4 mmHgmean blood-pressure reduction, in patients in the active treatment group.
The name of the trial, PROGRESS (Perindopril Protection Against Recurrent Stroke Study),should, however, be taken with a pinch of salt, as it overlooks the role of indapamide. Theresults show that patients who received combination therapy had a lower stroke risk and loweraverage blood pressure than patients who received perindopril alone.
It is widely recognised that there is a direct relationship between blood pressure and stroke.PROGRESS aside; there is a distinct lack of stroke-specific data on the subject. It may be thatit is not necessarily the agent that is used, but to what extent the blood pressure is reduced,that reduces the risk of stroke. Until there is more evidence in this area, perindopril andindapamide-based regimes will continue to be the most commonly used post-stroke.
Learning portfolio
Three days later, Tom is ready to be discharged with a non-weight bearing cast. Theorthopaedic senior house officer approaches you to ask for your advice on Tom’s dischargeprescription. He has been asked by the medical team to write the patient up for the‘standard secondary prevention medications’, but he isn’t sure what these medicationsshould be.
What is your advice to the senior house officer?
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Stroke
Suggested answer
Patients who have experienced a TIA should receive low-dose aspirin (75 mg daily) withmodified-release dipyridamole (200 mg twice daily), to be continued indefinitely.9 Manypatients will not tolerate the full dose of dipyridamole initially and headache is the mostcommon reason for discontinuing. Starting at a lower dose of dipyridamole and titratingup might be beneficial and reduce this side-effect. Patients who do not tolerate aspirin anddipyridamole in combination should be prescribed clopidogrel monotherapy (75 mg daily),though some centres may use this daily as first-line therapy post-TIA due to the decreasedtablet burden and increased tolerability.
Tom is already taking a statin but the dose of simvastatin should be increased to 40 mg atnight; atorvastatin 80 mg daily could be considered but the cost implications of this wouldalso need to be taken into account (see discussion points below on evidence for statins inischaemic stroke).
Perindopril should be continued, with instructions to the GP to increase the dose to 8 mgin two to four weeks, if tolerated.
Discussion pointsThe majority of evidence for statins in stroke reduction comes from trials of patients withischaemic heart disease, with stroke as a secondary outcome measure. An example of this isthe research by the Heart Protection Study Collaborative Group; 20,536 UK adults withcoronary disease, occlusive arterial disease or diabetes were randomised to receive eithersimvastatin 40 mg daily or matching placebo.10 Over a mean duration of five years, there was arelative reduction in stroke risk of 25 percent in patients treated with simvastatin. Large meta-analysis of statin trials provides compelling evidence for stroke reduction and safety, but theevidence is not specific for patients with history of stroke or TIA.
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The SPARCL trial was the first trial of statins to specifically look at patients with a history ofstroke or TIA, without a previous history of heart disease. 4731 patients with a history in theprevious six months of ischaemic stroke, TIA, or haemorrhagic stroke at risk of further ischaemicstroke, and an LDL cholesterol of 2.6-4.9 mmol/L, were randomised to receive either 80 mg ofatorvastatin daily (2365 patients) or a matching placebo (2366 patients). The primary outcomewas the time from randomisation to first fatal or non-fatal stroke. Secondary outcomes includedTIA, major cardiac events and all-cause death.2
Median follow-up was 4.9 years; the incidence of fatal or non-fatal stroke was 11.2 percent inthe atorvastatin group versus 13.1 percent in the placebo group. This reduced incidence ofstroke overall was despite an increase in the incidence of haemorrhagic stroke in theatorvastatin group (55 versus 33 in placebo). Based on this risk reduction, 46 patients wouldneed to be treated with atorvastatin for five years to prevent one stroke. There was also asignificant reduction in the incidence of major cardiovascular events in patients takingatorvastatin, though all-cause mortality was similar in both groups.
The National clinical guideline for stroke recommends that patients with ischaemic stroke orTIA, and total cholesterol above 3.5 mmol/L and LDL cholesterol above 2.5 mmol/L, be treatedwith a statin, but does not recommend which specific statin to use.7 While the current strongestevidence for stroke prevention in patients with history of stroke or TIA is for high-doseatorvastatin, the cost pressures of such a policy have reduced the uptake of SPARCL results inpractice.
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CASE STUDY 2 – LILY
Lily Adams is an 84-year-old lady who is admitted to the acute stroke unit at 11:00am. Thestaff at the day centre that she attends had called her daughter after Lily had not arrived atthe centre that morning.
Her daughter went to Lily’s house at 10:30am to find her mum still in bed, unable to speakor to stand up. An ambulance was called and, as the patient was FAST-positive (facialweakness, arm weakness and speech problems), Lily was brought to her local acute strokeunit for investigation. The notes read:
Presenting complaint:• aphasia• right-sided weakness.
History of presenting complaint:• previously fit and well• Lily’s daughter had spoken to her at 8:30pm on the phone last night and reported no
concerns.
Previous medical history: • Hypertension, 15-20 year history.
Drug history:• atenolol one 50 mg tablet in the morning• aspirin one 75 mg tablet in the morning• senna two tablets at night• Adcal-D3
® two tablets in the morning• paracetamol two tablets four times a day when required.
Family history:• parents: father died 68 (heart attack), mother died 84 (cause of death unknown) • siblings: one living brother (72), one brother died four years ago aged 76 (stroke) • children: two daughters (54 and 50), both fit and well.
Social history:• retired post office worker• widowed• lives alone in two-bedroom terraced house, bathroom/toilet upstairs • daughter lives locally and helps with weekly shopping• cooks and cleans for herself • attends day centre three times a week • non-smoker, drinks alcohol occasionally.
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On examination the following is recorded:• temperature 37.5°C • Glasgow Coma Scale (GCS) 12 (E4, V3, M5), drowsy but rousable, orientated in
person but not time or place• respiratory rate 18, saturation 95 percent on room air, chest clear• cardiac: pulse 78 bpm, sinus rhythm; blood pressure 186/92 mmHg • right arm weakness (power 3/5) and right leg weakness (power 3/5), left side normal
power• receptive and expressive dysphasia• cranial nerves difficult to assess as the patient is confused and not following commands
reliably. May have slight right-sided facial droop.
What are the differential diagnoses?
What initial investigations would you expect to see carried out?
A CT scan is carried out on Lily at 11:35am and shows a left-middle cerebral arteryinfarction with no evidence of haemorrhagic transformation.
Suggested answer
• Stroke• Seizure• Urinary tract infection• Sepsis• Space-occupying lesion• Fall and head injury
Suggested answer
• Brain imaging – CT is the most widely available• Full blood count, urea and electrolytes, blood glucose, clotting screen, septic screen• ECG• Chest X-ray
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Is Lily a candidate for thrombolysis?
How should Lily be medically managed in the acute phase?
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Stroke
Suggested answer
Thrombolysis for ischaemic stroke must be initiated within three hours of symptom onset.One of the key questions when deciding whether to thrombolyse a patient musttherefore be: “Do we have a confirmed time of symptom onset?”
This event has occurred at some stage between 8:30pm last night and 10:30am thismorning. In this case, it is unclear when the symptoms actually started. If there is anydoubt about time and onset of symptoms, then a patient cannot be thrombolysed, and somost patients who wake up with stroke symptoms cannot be thrombolysed.
The fact that the infarction is visible on the CT scan also suggests that the strokehappened earlier than three hours ago, as CT has low sensitivity for ischaemia less thansix hours old. CT scans are very sensitive to ‘acute blood’ (ie, a recent bleed), whichmight indicate ICH and therefore contraindicate thrombolysis; it may also identify otherconditions that might mimic stroke (eg, neoplasm or abscess). In this case, the patient’sage may also exclude her from thrombolysis, as at 84 years old she exceeds the licensedage for administration, (though many centres would still consider patients over 80 forthrombolysis). The main issue with Lily would be the unclear timescale of events.
Suggested answer
All patients with acute ischaemic stroke (haemorrhagic stroke excluded) should beadministered 300 mg aspirin as soon as possible and it should be continued for up to twoweeks after the stroke.5
Tests will be performed to identify the cause of the stroke and, once known, a long-termantiplatelet (or anticoagulant in cardioembolic stroke) treatment plan can be initiated.
Statins are not indicated in the acute phase of ischaemic stroke but may be initiated 48hours after stroke. Patients who are admitted with ischaemic stroke and are alreadytaking a statin are allowed to continue statin therapy.
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Should the raised blood pressure be treated at this stage?
Lily remains in the care of the acute stroke unit. Three days later, the following results areobtained:• ECG: normal sinus rhythm• carotid Doppler: right 40 percent, left 55 percent stenosis.
Lily has been assessed by the stroke unit dietitian, occupational therapist, physiotherapist,and speech and language therapist. She has recovered full power in her right arm and leg,but still has a right-sided visual field defect and is having persistent problems with language.She can reliably follow one-stage but not two-stage commands, and is demonstrating someproblems finding words (she cannot accurately identify common items such as a watch, apen or a telephone). She is fully continent and can mobilise to the toilet with the assistanceof one member of nursing staff. Her swallowing is safe and she is eating a normal diet, butrequires regular prompting to ensure she eats her full meals. She is able to sit out of bedfor two hours at a time but gets tired easily and regularly gets back into bed. The decisionis made to transfer Lily from the acute stroke unit to the accompanying stroke unit forfurther rehabilitation.
Suggested answer
Post-stroke hypertension is very common; in many cases it will be a combination of pre-existing hypertension and a part of the body’s physiological response to the stroke. Inmost cases, a patient’s blood pressure will return to baseline in the first four to ten daysafter stroke, at which point the team should start thinking about long-term blood pressurecontrol.
Hypertension is only treated in acute stroke in the context of hypertensive emergencies(eg, sustained pressures above 220/120 mmHg) or if thrombolysis is being considered.Clinical trials are ongoing as to whether patients should stop or continue preadmissionantihypertensives; until there are definitive results from these trials, each patient should betreated on a case-by-case basis. In this case, the patient was already taking atenolol and,while beta-blockers are not first-line therapy for hypertension, to withdraw it suddenlymay introduce more vascular instability. If the patient can take the drug, it should becontinued until the patient is more stable and a long-term plan can be considered.
Other physiological parameters, such as blood glucose and oxygen saturation, should beclosely monitored and treated if required. Lily will require her swallowing to be assessedfor safety and her nutrition status assessed. Swallowing difficulties are very common afterstroke, and so many patients may require intravenous fluids and/or NG feeding to ensurethey meet their nutritional requirements.
Learning portfolio
After four days on the stroke unit (seven days post stroke), Lily is still hypertensive. Herlatest blood pressure reading is 162/74 mmHg. Her inpatient drug chart currently reads:• aspirin 300 mg by mouth once daily• atenolol 50 mg by mouth once daily• simvastatin 40 mg by mouth at night• Adcal-D3
® two tablets once daily.
How should her blood pressure be managed? What is the target for blood pressure afterstroke?
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Stroke
Suggested answer
According to the National clinical guideline for stroke, hypertension should be treated inthe following way:7
• Optimal blood pressure target is 130/80 mmHg.• Patients aged 55 or older, or black patients of any age, should be treated first-line
with a calcium-channel blocker or a thiazide-type diuretic.• Patients under 55 should be treated first-line with an ACE inhibitor (or angiotensin-II
receptor antagonist if ACE inhibitor not tolerated).• Add in an ACE inhibitor, calcium-channel blocker or thiazide if target blood pressure
is not reached with first-line therapy.• Beta-blockers should not be used as first or second-line therapy for stroke
prevention.
In this case, the patient was taking atenolol prior to admission but, according to theNational clinical guideline for stroke, beta-blockers should not be used first or second-linefor stroke prevention and so atenolol should be discontinued.7 A suitable first-linetreatment would be a calcium-channel blocker or a thiazide-type diuretic. Amlodipine5 mg once daily or modified-release indapamide 1.5 mg once daily would be suitableoptions, adding in the other agent or an ACE inhibitor (ideally perindopril) later ifrequired. Most patients will require a combination of optimised antihypertensives toachieve their target blood pressure. It should be noted that the National clinical guidelinefor stroke differs from NICE guidelines on hypertension in that NICE have reserved theoption for diuretic use until third-line therapy;11 in this patient group, however, theevidence for using indapamide justifies its usage before the third-line stage.
In summary, a target blood pressure of 130/80 mmHg can prove quite a challenging goalin many cases, so it is common to see stroke patients taking a combination of severalantihypertensives in an attempt to reach this.
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After two weeks as an inpatient receiving specialist stroke care and rehabilitation, Lily ismaking excellent progress but still has a degree of word-finding difficulty and occasionallyrequires prompting in her activities of daily living (dressing, washing, eating, etc.). She hasbeen accepted for an early supported discharge back to her own home in association with acommunity stroke team, with input from her family and support from communityoccupational therapists and speech and language therapists to work on her communication.The stroke team are preparing the discharge prescription.
The plan is to continue simvastatin and the antihypertensives you recommended. Whatshould be the long-term plan for antiplatelet therapy?
Suggested answer
You should recommend that theteam stops aspirin and switches toclopidogrel 75 mg daily, to becontinued indefinitely.
NICE guidance recommendsclopidogrel 75 mg once daily asthe treatment option to preventocclusive vascular events inpatients who have had anischaemic stroke. Patients whocannot take clopidogrel, or areintolerant of it, should receive acombination of aspirin andmodified-release dipyridamole.Patients who cannot tolerate thiscombination should receiveaspirin.9
AF is a major cause of stroke anda risk factor for recurrent stroke.In this case the ECG test showednormal sinus rhythm.
Learning portfolio
If signs and symptoms of AF had been present on Lily’s ECG, what additional or alternativemedication would you expect to see prescribed?
CASE STUDY 3 – ALPANA
Alpana Kapoor is a 78-year-old, right-handed lady who was admitted to the acute strokeunit via accident and emergency at 11:00pm last night. You see the patient during the wardround on the following morning.
The notes read as follows:
Presenting complaint: • patient unconscious and unable to rouse• has vomited (query aspiration).
History of presenting complaint: • patient’s son found his mother slumped on sofa at approximately 10:00pm• patient was last seen well at 8:30pm, after dinner • no recent history of illness and no complaints voiced. Son reports patient has been
under increased stress due to recent deterioration and hospitalisation of his father,who suffers from dementia.
Previous medical history: • hypertension and hypercholesterolaemia• diet-controlled type 2 diabetes.
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Stroke
Suggested answer
The National clinical guideline for stroke recommends that all patients with AF should beanticoagulated unless contraindicated, after imaging to exclude ICH, and usually not until14 days have passed after the stroke. For most patients with AF who have had a stroke,this will mean treatment with warfarin, assuming the patient can safely take the medicine.In patients with AF, aspirin should be continued until warfarin has been initiated and theinternational normalised ratio has reached therapeutic levels, after which aspirin can bestopped. Newer oral anticoagulants, such as dabigatran, have been investigated for strokeprevention in AF, and may have the benefit of reduced monitoring requirements and easeof administration. However, national guidance is awaited on these newer agents.
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Drug history (from GP records):• felodipine modified-release 10 mg once daily• bisoprolol fumarate 2.5 mg once daily• bendroflumethiazide 5 mg once daily• doxazosin modified-release 8 mg once daily• rosuvastatin 10 mg one at night• aspirin enteric-coated 75 mg once daily• omeprazole capsule 10 mg once daily• allergic to penicillin (Alpana’s son has brought in all of her medication. While
undertaking a medicines reconciliation you check through the patient’s own medicinesand discover that there are several boxes of unopened medicines, with different datesof dispensing many months prior, some of which have expired).
Family history: • unable to confirm.
Social history: • is primary carer for husband who has dementia• lives with her son, daughter-in-law and three grandchildren • non-smoker, does not drink alcohol.
On examination:• appears overweight• temperature 37.4°C, heart rate 86 beats per minute (regular), blood pressure
214/120, respiratory rate 18, saturation 94 percent on room air, GCS 5 (E2 V1 M2)• urea and electrolytes all within reference range• full blood count all within reference range• liver function tests all within reference range• random total cholesterol 5.8 mmol/L• C-reactive protein 19• random blood glucose 14.3 mmol/L.
CT (brain): • shows left-sided basal ganglia haemorrhage.
Diagnosis: • ICH – left-sided basal ganglia haemorrhage.
You note the doctors’ plan in the medical record, which reads:• neurological observations every 30 minutes• treat for suspected aspiration pneumonia• ECG and blood pressure monitoring• blood glucose monitoring• patient to remain NBM until speech and language therapy review • dietitian review• physiotherapist review.
Learning portfolio
What actions need to be taken immediately regarding Alpana’s regular medication?
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Stroke
Suggested answer
Despite having a list of medicines from the GP surgery, it is unclear from the patient’sown medicines whether she was adherent with prescribed therapy. Without furtherinformation, her actual drug history is unknown.
The most important action would be to stop aspirin therapy, as any antiplateletadministration could worsen the haemorrhage.
Alpana’s blood pressure will need to be treated but, as she has been made NBM, herregular antihypertensives cannot currently be administered.
Omeprazole can be withheld temporarily, though an intravenous formulation is available ifindicated (ie, in event of gastrointestinal haemorrhage).
Discussion pointsThe issue of statins and haemorrhagic stroke is controversial. There may be an increased riskof ICH in patients being treated with statins. Large-scale studies of statins have not produceda conclusive answer; some results have shown no effect of statins on ICH,12 while another studyhas shown a significant increase in risk of ICH.2 Current practice is to not use statins routinelyfollowing haemorrhagic stroke unless the patient has a significant risk of ischaemic vascularevents and the benefit outweighs the potential haemorrhagic risk. In this case, it would beadvisable to withhold the statin in the short term, review once the haemorrhage has resolvedand restart if strongly indicated by vascular disease or hypercholesterolaemia.
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What are the therapeutic options for the management of Alpana’s blood pressure?
Later in the afternoon the stroke speech and language therapist reviews Alpana andrecommends that she has a NG tube inserted, as the patient is not sufficiently conscious fora swallow assessment to be performed. An NG tube is inserted and the correct positionconfirmed by a chest X-ray. The stroke dietitian has assessed Alpana’s nutritional status andwritten a plan for NG feeding to start that evening.
Suggested answer
Antihypertensive treatment should only be initiated in patients with ICH if their systolicblood pressure persistently exceeds 200 mmHg.5 Rapid or excessive blood pressurereduction should also be avoided as this could have a negative effect on stroke outcome.
There is a lack of treatment options for patients who are NBM (and do not have feedingtubes). Intravenous labetalol or intravenous/transdermal glyceryl trinitrate (GTN) are themain options.
Intravenous labetalol is very effective and will have an effect within minutes, but has aprolonged duration of action and cannot be reversed, which may prove problematic asblood pressure can be very labile after stroke. Patients need to be confined to bed whenreceiving labetalol due to risk of postural hypotension, though this would not be an issuein this case.
Conversely, GTN has a short plasma half-life of two to four minutes, and removing apatch or stopping an infusion of the drug will rapidly remove its therapeutic effect, whichmay be of benefit if blood pressure drops suddenly.
It may therefore be of benefit to try a GTN patch (5-10 mg / 24 hours) in the firstinstance. If there has been no response after one to two hours, a labetalol infusion couldbe set up according to local policy starting with a low dose (ie, 1-2 mg/minute and up-titrating as required). Labetalol could be considered as first-line therapy if this wasdeemed to be an emergency situation. Depending on the outcome of the speech andlanguage therapist and dietitian’s reviews, it may be possible later in the day to use oralmedications, if the patient can swallow or has a feeding tube inserted.
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Last night, Alpana had a random blood glucose level of 14.3 mmol/L. How should this bemanaged?
Observations carried out by nursing staff show Alpana’s blood pressure as being 186/106 mmHg. The stroke consultant has decided to administer oral antihypertensives viathe feeding tube with an aim of weaning parenteral agents.
What would your advice be regarding the choice, and administration, of antihypertensivesvia the NG tube?
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Stroke
Suggested answer
Hyperglycaemia is very common in acute stroke and may be associated with worseoutcomes. Patients with acute stroke should therefore have their blood glucose levelmaintained at 4-11 mmol/L.5
A repeat blood glucose level would need to be taken and, if still above 11 mmol/L, thisshould be treated. Treatment will depend on local policy, so refer to your hospitalprotocols. In most cases this will involve the administration of intravenous insulin andglucose. The patient should be referred for a diabetic review when possible, after which itmay be possible to initiate a long-term diabetic management plan.
Suggested answer
It is unclear in Alpana’s case if her antihypertensives were being taken prior to admission.This would be a good opportunity to rationalise therapy and initiate secondary preventionin line with national recommendations. Looking at the medication list from her GP, she iscurrently prescribed modified-release felodipine and bendroflumethiazide; however,modified-release tablets should not be administered via feeding tubes where possible, asthe release of the drug into the bloodstream is unpredictable. Furthermore, a thiazidemay not be the best first choice in somebody with diabetes.
According to the National clinical guideline for stroke,7 as the patient is aged over 55 theinitial choice of therapy would be a calcium-channel blocker or a thiazide diuretic, with asecond agent (calcium-channel blocker, thiazide or ACE inhibitor) added in if necessary.Therefore, for Alpana, amlodipine 5 mg once daily would be a good choice and could beadministered via the feeding tube, with perindopril 2 mg once daily added in if a secondagent is required, with the doses up-titrated according to response.
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Alpana remains on the stroke unit for treatment and, after one week, her conditionstabilises. The stroke has left her aphasic, with right-sided hemiparesis and hemisensoryloss, a right-sided visual field defect and a gaze preference to the left.
On the speech and language therapist’s advice, she remains NBM and is receiving allnutrition and medications via an NG tube. The speech and language therapist identifies thatthe patient has sialorrhoea (drooling or excessive saliva secretion) and is at an increased riskof aspiration. They approach you for advice.
What are the options for the management of post-stroke sialorrhoea?
Discussion pointAdministering medications via an enteral feeding tube will be outside of the product licence formost preparations and is not without risk, as this may increase the risk of adverse effects andproduce a different therapeutic response than expected.
Soluble or liquid preparations are generally preferable and easier to administer, but there is alack of commercially available products and they may be difficult to source when a patient isdischarged.
Therefore, in many cases, crushing or dispersing tablets may be the only viable option. There isthe possibility for interactions between enteral feeds and medication, so it may be necessary toliaise with the dietitian to organise times for feeding and medication administration that disrupteach other the least.
Suggested answer
Antimuscarinics inhibit parasympathetic stimulation of the salivary glands and reduce salivasecretion. The main therapeutic options are hyoscine and glycopyrronium, but this isbased on clinical practice as there is little evidence available, and all usage for thisindication is unlicensed.
Hyoscine patches may be used to reduce saliva secretion and are easy to administer,though prolonged use may be limited by central side-effects such as confusion andrestlessness, especially in elderly patients and in those who require more than one patchat a time.
The best initial option (assuming no contraindications) would be to start with onehyoscine patch (1 mg / 72 hours), and adjust the dose according to response.Glycopyrronium has fewer side-effects than hyoscine, but oral absorption is erratic andtablet preparations are not widely available (it may be available on a named-patient basis).Injections of glycopyrronium may be administered via a feeding tube, but this techniquewould be impractical outside of the hospital environment. Subcutaneous injections ofglycopyrronium may be useful in the short term, but repeated injections over a longperiod of time should be avoided for patient comfort.
Learning portfolio
It has been noted that Alpana has been showing little interest in her surroundings and hermood tends to vary. The physiotherapists report that she frequently refuses input intorehabilitation exercises and they are struggling to get her to engage in the treatment plan.Alpana is assessed (using a validated scale) for depression and the results indicate that thepatient may be depressed.
How should post-stroke depression be managed?
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Stroke
Suggested answer
Mood disturbances are very common post-stroke. There may be incidences ofdepression, anxiety, emotionalism, or a combination of these. Patients who are low inmood may be less inclined to participate in rehabilitation, which could therefore have animpact on recovery.
It can be very difficult to accurately assess patients with communication difficulties formood disturbance, so early identification and monitoring of patients with potentialproblems is crucial.
Patients with minor depression should be monitored for progression of their symptoms,whereas patients whose depression is more severe or ongoing should be offered one ormore of antidepressant therapy, psychological therapy and interventions to reducecontributing factors (eg, pain).7
Although post-stroke depression is common, there is a lack of data on its treatment. ACochrane review concluded that while antidepressants may have a small but significanttreatment effect after stroke, patients were at an increased risk of adverse effects.13 Aftersuffering a stroke, patients may be at increased risk of anxiety and seizure, which shouldbe considered before starting therapy. Most experience in treating post-stroke depressioncomes from the use of selective serotonin reuptake inhibitors (SSRIs), though there is noconsensus as to which agent to use. If the decision is made to start an SSRI, the patientshould be initiated at a low dose and regularly monitored for efficacy and adverse effects.
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Over the course of several weeks of rehabilitation, Alpana has been affected by spasticity(increased muscular tone) in her right arm. This particularly affects her wrist, producingexaggerated reflexes and painful spasms on contact, including when the patient is beingtransferred out of bed to a chair. It is felt that this spasticity is greatly impacting on Alpana’sability to participate in rehabilitation exercises. She has been prescribed appropriateanalgesia to help with the pain and is treated by the physiotherapists with specificallytailored exercises and stretching to help relieve the spasticity. However, it is felt that thepatient may benefit from antispastic medication.
What are the pharmacological options for the management of post-stroke spasticity?
Suggested answer
For patients with spasticity, muscle relaxants such as baclofen, tizanidine or gabapentin,administered orally or via a feeding tube, could be considered. However, these agentshave variable efficacy and the disadvantage of producing a systemic effect, so are notspecific to the affected muscles. All of these drugs will cause significant drowsiness soshould be started at a low dose and gradually up-titrated according to response. Thesedrugs should also be used in conjunction with physiotherapy, along with objectivemeasurement of muscular tone and subjective measurement of a patient’s ability toperform tasks and their progress. These results can then influence whether or not tocontinue antispasticity medication.
Botulinum toxin has been used in post-stroke spasticity and has the benefit of beingtargeted to the affected muscles only. The National clinical guideline for strokerecommends that patients affected by persistent focal spasticity in one or two jointsshould be treated with intramuscular botulinum toxin, in conjunction with weeks ofspecialist rehabilitation therapy and administered by an expert spasticity service.7 Thepeak effect from botulinum toxin injection generally occurs after four weeks and patientsshould be monitored for effect. If found to be beneficial, the injection can be repeatedwhen the initial effect has worn off, but should not be repeated within 12 weeks. Thedownside to botulinum toxin in this setting is the increased expense and the expertiserequired in its administration.
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References
1. Yano K, Reed DM, MacLean CJ. Serum cholesterol and hemorrhagic stroke in theHonolulu Heart Program. Stroke 1989;20:1460-1465.
2. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL).Investigators High-Dose Atorvastatin after Stroke or Transient Ischemic Attack. TheNew England Journal of Medicine 2006;355: 549-559.
3. Aho K et al. Cerebrovascular disease in the community: results of a WHOcollaborative study. Bulletin of the World Health Organization 1980;58(1): 113-130.
4. Coull AJ, Lovett JK, Rothwell PM on behalf of the Oxford Vascular Study. Populationbased study of early risk of stroke after transient ischaemic attack or minor stroke:implications for public education and organisation of services. British Medical Journal2004;328(7435): 326-328.
5. National Collaborating Centre for Chronic Conditions. Stroke: national clinical guidelinefor diagnosis and initial management of acute stroke and transient ischaemic attack (TIA).London: Royal College of Physicians; 2008.
6. National Institute for Health and Clinical Excellence. Clinical guideline 92: Reducing therisk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) inpatients admitted to hospital. January 2010.
7. Intercollegiate Stroke Working Party. National clinical guideline for stroke. 3rd edition.London: Royal College of Physicians; 2008.
8. Chapman N et al. Effects of a Perindopril-Based Blood Pressure-Lowering Regimen onthe Risk of Recurrent Stroke According to Stroke Subtype and Medical History: ThePROGRESS Trial. Stroke 2004;35: 116-121.
9. National Institute for Health and Clinical Excellence. Technology appraisal guidance210: Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascularevents (review of technology appraisal guidance 90). December 2010.
10. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study ofcholesterol lowering with simvastatin in 20 536 high-risk individuals: a randomisedplacebo-controlled trial. Lancet 2002;360(9326): 7-22.
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11. National Institute for Health and Clinical Excellence. Clinical guideline 127:Hypertension: Clinical management of primary hypertension in adults. August 2011.
12. Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy and safety ofcholesterol-lowering treatment: prospective meta-analysis of data from 90,056participants in 14 randomised trials of statins. Lancet 2005;366(9493): 1267-1278.
13. Hackett ML et al. Interventions for treating depression after stroke. CochraneDatabase of Systematic Reviews 2008;4: Art. No.: CD003437.
Learning portfolio
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