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Stroke
Logan Kesler, PharmD

Community Health Network

General Medicine
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Objectives
 Recognize an ischemic stroke based on presentation
 State inclusion and exclusion criteria for tPA use
 Identify appropriate secondary stroke treatment options
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Background
795,000 people 240,000
in US experience a
experience a transient
stroke ischemic attack

Leading Cause
4th Leading
of functional
Cause of Death
impairment >65
in US
years old
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Types of Stroke

 Ischemic Stroke

 Lacunar

 Non-Lacunar

 Hemorrhagic Stroke

 Transient Ischemic
Attack
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Risk Factors

Modifiable Unmodifiable

• Hypertension • Age > 80 years old

• Dyslipidemia • Race
• Diabetes • Gender
• Smoking • Family History
• Physical Inactivity
• Atrial Fibrillation
• Alcohol Intake
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Ischemic
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Stroke
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Presentation

Blood Pressure
Vital
Breathing
Signs
Fever

CT or Distinguish from
MRI other diagnosis
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Prevention

Hyperlipidemia
•Statin Therapy is recommended

Diet and Nutrition

•Reduced Sodium and Increased Potassium
•DASH Diet, Mediterranean Diet
Hypertension
•Goal: <140/90

Obesity
•20min 2x/week

Glucose Control
•A1c <7%

Smoking

Atrial Fibrillation
•Anticoagulation

Image: https://www.memorialcare.org/services/stroke-care/stroke-prevention
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Diagnosis

National Institute of Health

Stroke Scale (NIHSS)

Calculates severity
• Very severe: >25
• Severe: 15-24
• Mild to moderate: 5-14
• Mild: 1-5
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Acute Therapy
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1stLine Treatment:
IV Alteplase

Inclusion for tPA Exclusion for tPA

 Time is critical Diagnosis of ischemic BP: Systolic > 185 or
stroke Diastolic > 110
 Dose: Onset of symptoms Use of DOAC
<4.5hrs
 0.9mg/kg over 60 minute
Age > 18 years Recent GI
 First 10% over 1 minute surgery/bleeding

 Max: 90mg
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Tenecteplase

NOR-TEST 26
• Tenecteplase 0.4mg/kg vs. Alteplase 0.9mg/kg
• Aim was to show non-inferiority
• ICH was more common with Tenecteplase
• Mortality was more common with Tenecteplase
Campbell et. al7
• Tenecteplase 0.25mg/kg vs. Alteplase 0.9mg/kg
• Tenecteplase showed more reperfusion of greater than
50%
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Alternate 1st Line Treatment: Mechanical
Thrombectomy

o Some patients with large artery

occlusions
 Can be used up to 24 hours
 With or without tPA

Image: https://www.strokejournal.org/article/S1052-3057%2818%2930265-9/fulltext
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Other Acute Considerations

 Airway/Oxygen
 Oxygen saturation >94%

 Blood Pressure
 Hypotension should be corrected

 IV alteplase needs <185/110, after <180/105 is recommended

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MATCH4 Trial

• To show if Aspirin plus Clopidogrel could have greater benefit than just Clopidogrel
Objective

• Randomized, double blind, placebo-controlled trial

• Primary endpoint was a composite of ischemic stroke, MI, vascular death, or
Methods rehospitalization for acute ischemia

• 15.7% of patients reach the primary endpoint in the DAPT group vs. 16.7% in the
clopidogrel group alone (relative risk reduction 6.4%, [95% CI -4.6 to 16.3]
• Life threatening bleedings were higher in the DAPT group vs clopidogrel alone
Results (2.6% vs 1.3%; absolute risk increase 1.3% [95% CI 0.6 to 1.9])
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CHANCE and POINT Trials5

• Obtain Precise estimates of efficacy and risk of DAPT after minor ischemic stroke
or TIA
Objective

• This analysis pooled data from the CHANCE and POINT Trails
Methods

• Clopidogrel-Aspirin treatment reduced the risk of major ischemic events at 90 days

vs. Aspirin alone (6.5% vs 9.1%; HR, 0.70 [95% CI, 0.61-0.81]; p<0.001)
• The reduced risk was mainly seen in the first 21 days (5.2% vs. 7.8%; HR 0.66
Results [95% CI, 0.56-0.77] p<0.001)
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Secondary Treatment

 Secondary Prevention Options:

 Aspirin 50 to 325mg daily

 Clopidogrel 75mg

 Aspirin 25mg and Extended-release

dipyridamole 200mg BID

 Dual Antiplatelet
 Aspirin+Clopidogrel within 12-24 hours
 Continued for 21-90 days
 Followed by single antiplatelet therapy
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References
 1. Wang Y, Pan Y, Zhao X, Li H, Wang D, Johnston SC, Liu L, Meng X, Wang A, Wang C, Wang Y; CHANCE Investigators.
Clopidogrel With Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE) Trial: One-Year Outcomes. Circulation.
2015 Jul 7;132(1):40-6. doi: 10.1161/CIRCULATIONAHA.114.014791. Epub 2015 May 8. PMID: 25957224.

 2. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for
Healthcare. AHA/ASA. 2019; 50:e344-e418. https://doi.org/10.1161/STR.0000000000000211.

 3. Kleindorfer DO, Towfighi A, Chaurvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and
Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. AHA/ASA.
2021;52:e364-e467. https://doi.org/10.1161/STR.0000000000000375.

 4. Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic
stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet.
2004;364(9431):331-337. doi:10.1016/S0140-6736(04)16721-4

 5. Pan Y, Elm JJ, Li H, et al. Outcomes Associated With Clopidogrel-Aspirin Use in Minor Stroke or Transient Ischemic Attack: A
Pooled Analysis of Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events (CHANCE) and Platelet-
Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trials [published correction appears in JAMA Neurol. 2019
Sep 30;:] [published correction appears in JAMA Neurol. 2021 Aug 16;:null]. JAMA Neurol. 2019;76(12):1466-1473.
doi:10.1001/jamaneurol.2019.2531

 6. Kvistad CE, Næss H, Helleberg BH, et al. Tenecteplase versus alteplase for the management of acute ischaemic stroke in
Norway (NOR-TEST 2, part A): a phase 3, randomised, open-label, blinded endpoint, non-inferiority trial. Lancet Neurol.
2022;21(6):511-519. doi:10.1016/S1474-4422(22)00124-7

 7. Campbell BCV, Mitchell PJ, Churilov L, et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J
Med. 2018;378(17):1573-1582. doi:10.1056/NEJMoa1716405
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Questions?