Description
Essay Elements:
One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
Brief introduction of the case
Identification of the main diagnosis with supporting rationale
Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
Diagnostic plan with supporting rationale or references
A specific treatment plan supported by recent clinical guidelines
Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.
Patient Name: Glenn Wright 70 yo male
Summary of most recent progress note:
Date: Four months prior
Chief Concern: Follow-up hypertension and hyperlipidemia
Subjective: Persistent stiffness in knees, but pain relieved with acetaminophen. Urine flow improved. Reports no exertional chest discomfort, decreased stamina, headaches, dizziness, or weakness. Occasionally omits diuretic and statin.
ROS: Occasional dizziness and decreased energy for 2 to 3 months. Decreased night vision. Occasional heartburn, stiff back, and knees. Reports no fever, syncope, headache, weight loss, abdominal discomfort, or change in bowel habits or stool.
Past Medical History: Essential hypertension, osteoarthritis, peptic ulcer disease, benign prostatic hyperplasia, hyperlipidemia, cataracts, and shingles. No surgery.
Family History: type 2 diabetes mellitus, hypertension, glaucoma.
Social History: Widowed for four years, retired railroad worker. Children: two daughters out-of-state and a son who lives nearby. Smoking: 1/2 pack per day resumed four years ago after ten-year abstinence. Alcohol: a single shot of whiskey most nights. Hobbies: quail hunting and fishing.
Medications: Hydrochlorothiazide 25 mg daily, amlodipine 10 mg daily, doxazosin 2 mg every evening, simvastatin 20 mg every evening, over-the-counter famotidine (Pepcid AC), acetaminophen.
Allergies: No known allergies.
Immunizations: H zoster, pneumococcal, Tdap, and influenza vaccines are current.
Objective: Blood pressure is 166/80 mmHg. No carotid bruits. Lungs: Clear. Heart: Regular rhythm. Rate in the 70’s beats/minute range, point of maximal impulse (PMI) laterally displaced.
Labs: Fasting lipid profile: total cholesterol 190 mg/dl, HDL 31 mg/dl, LDL 129 mg/dl, triglycerides 150 mg/dl.
Assessment: Hypertension – poorly controlled, hyperlipidemia – poorly controlled, osteoarthritis of the knees, benign prostate hyperplasia.
Plan: Follow up in 6 to 8 weeks.
Physical Exam
Vital signs:
Temperature is 37 C (98.6 F)
Pulse is 100 beats/minute
Respiratory rate is 16 breaths/minute
Blood pressure has no orthostatic changes
Weight is 80 kgs (176 lbs)
Height is 178 cm (70 in)
Pain is 0
Orthostatic Vital Signs
Position – Supine:
Pulse is 110 beats/minutes
Blood pressure is 166/82 mmHg
Position – Standing:
Pulse is 120 beats/minute
Blood pressure is 162/80 mmHg
Physical exam:
General: 70-year-old well-nourished man in no distress, alert, cooperative, and fully oriented.
TUG test: Normal
Head/Neck: Atraumatic, symmetric facies, no carotid bruit or neck vein distension.
Eyes: Normal visual acuity, pupils equal, round, reactive to light and accommodation (PERRLA), extraocular movements intact (EOMI), no nystagmus, normal visual fields, suboptimal fundoscopic exam secondary to cataracts, but no evidence of papilledema.
Ear/nose/throat: Unremarkable.
Chest: Normal respirations and lung fields.
Cardiovascular: Rate 118, irregularly irregular rhythm (not previously noted), no murmur, point of maximal impulse (PMI) 5th intercostal space laterally displaced 3cm.
Abdomen: Unremarkable.
Genitourinary: Deferred.
Musculoskeletal: Osteoarthritic knee changes. No apparent injury.
Neurological: No dysphonia or dysphagia, gag intact. No sensory or proprioceptive deficit. No Babinski, normal Romberg. FAST test: Symmetric smile. Muscle strength 4/4 in all limbs. No pronator drift. Able to repeat, “No ifs, ands, or buts” without slurring or difficulty.
Unformatted Attachment Preview
Family Medicine 22: 70-year-old male with new-onset unilateral
weakness
User: Janessa Pamintuan
Email: [email protected]
Date: January 17, 2024 11:54 PM
Learning Objectives
The student should be able to:
Assess signs and symptoms of transient ischemic attack (TIA) and stroke.
Interpret laboratory data related to patients with new onset neurological symptoms, particularly numbness or weakness in an extremity with or
without accompanying speech difficulty.
Determine a patient’s cholesterol goals based on current guidelines and the patient’s risk factors.
Describe the appropriate therapy for acute stroke and primary and secondary prevention of stroke.
Discuss the evidence for the role of lifestyle changes in prevention of stroke.
Describe the importance of effective communication between physicians, students, patients, and families in the management of atherosclerotic
cardiovascular disease.
Demonstrate the ability to care for patients with coronary artery disease from diverse patient backgrounds and at different points in their illness.
Describe the basic principles of atrial fibrillation managment.
Discuss depression with a patient appropriately.
Perform a screening test for cognitive decline (e.g. the clock drawing test or the Mini-Mental Status Examination).
Perform a screening test for functional decline in a geriatric patient.
Knowledge
Risk Factors for Cerebrovascular Disease
The risk factors for cerebrovascular disease are very similar to those for coronary artery disease.
For more required information on ASCVD risk factors and for lifestyle modifications for ASCVD prevention, see the Aquifer Cholesterol Guidelines
module.
Due to this risk, the United States Preventive Services Task Force recommends that:
ALL adults > 18 yrs be screened for hypertension
Adults aged 40-75 should universally be screened for hyperlipidemia
All adults should be asked about tobacco use, and all smokers should be given tobacco cessation interventions.
The decision to initiate low-dose aspirin for the primary prevention of CVD in adults aged 40 to 59 years who have a 10% or greater 10-year
CVD risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small. Persons who are not at
increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit (grade C).
Initial Physical Exam of Neurologic Symptoms
Exam of cranial nerve VII
Facial asymmetry is not specific to stroke, as it can also be caused by Bell palsy or Horner syndrome. Weakness or
asymmetry of the muscles of facial expression (CN VII) is a common presenting sign of stroke.
Auscultation of carotids
Listen for carotid bruits as emboli from carotid arteries are associated with TIA and stroke and these emboli may
result in transient monocular blindness or visual field defects.
Romberg
Ischemic blood flow in the vertebrobasilar system is associated with ataxic gait and instability of balance, which may
be revealed with Romberg testing.
Cardiopulmonary
The presence of murmurs or irregular rhythms on the cardiovascular exam may signal valvular disease and
intracardiac mural thrombi as sources for cardiac emboli.
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Gross visual fields
Emboli from carotid bruits are associated with TIA and stroke and these emboli may result in transient monocular
blindness or visual field defects.
Proprioception
Proprioceptive and spatial deficits are present in patients who have suffered brain ischemia affecting the sensory
areas.
Mental status exam and
assessment of motor
strength
Documentation of mental status to include the level of alertness, orientation, comprehension (both receptive and
expressive), and memory are essential, as are tests of gross motor strength and coordination.
12 lead electrocardiogram
An electrocardiogram can detect abnormalities of QT interval, conduction abnormalities, and ST changes suggestive
of paroxysmal arrhythmia or myocardial ischemia producing transient central nervous system hypoperfusion.
Orthostasis
Orthostasis is a reduction of systolic or diastolic blood pressure of at least 20 or 10 mmHg respectively, measured three minutes after a patient who
has been accommodated to the supine position assumes a standing or sitting position.
Some experts also consider the test to be positive when the pulse rate remains elevated by 20 beats per minute or more (16 beats per minute in the
elderly).
Atrial Fibrillation: Definition, Epidemiology, and Characterization
Definition
Atrial fibrillation is rapid, irregular, and chaotic atrial activity without definable p waves on an electrocardiogram. Its presence should be suspected in
individuals presenting with dizziness, syncope, dyspnea, or palpitations. While palpation of an irregular pulse or auscultation of an irregular heart rate
may raise suspicion of atrial fibrillation, the diagnosis requires confirmation with an electrocardiogram.
Epidemiology
Atrial fibrillation (AF) is the most common arrhythmia physicians face in clinical practice, accounting for about one-third of hospitalizations for
arrhythmia. The prevalence of AF increases with age and the severity of congestive heart failure or valvular heart disease. Furthermore, in most
cases, AF is associated with the cardiovascular diseases of hypertension, coronary artery disease, cardiomyopathy, and mitral valve disease.
Pulmonary disorders of COPD, obstructive sleep apnea, and pulmonary embolism are associated and predisposing factors. Other associated
conditions include surgery, excess alcohol intake, hyperthyroidism, and febrile illnesses.
Distinguishing persistent versus paroxysmal
Atrial fibrillation less than 72 hours total duration would be classified as new onset. Chronic atrial fibrillation may be either persistent or paroxysmal. In
the paroxysmal form, atrial fibrillation may recur and then revert back to normal rhythm spontaneously, with variable periods of normal sinus rhythm
between episodes. The presence of normal rhythm does not rule out the existence of paroxysmal atrial fibrillation. This arrhythmia can occur
episodically without clinical detection or significant symptoms for several months.
Mechanisms of TIAs or Possible Stroke
Cardiovascular or Cerebrovascular Mechanisms
1. Embolic
Most commonly from the heart or carotid artery—arrhythmias may produce emboli from mural thrombi, atrial appendages, or from
diseased heart valves
2.
Native clot within the intracranial vasculature—85% of strokes are caused by vascular occlusion (thrombotic)
Thrombotic
3.
Secondary to a decrease in cerebral perfusion caused by decreased cardiac output (e.g.: anginal event associated with coronary
Cardiogenic artery disease), severe hypotension, or hypoxemia related to severe anemia or poor oxygen saturation
4.
Secondary to pathologic cerebrovascular changes within the brain attributable to aging, smoking, hypertension, and hyperlipidemia.
Hemorrhagic
Hematologic and Vascular Mechanisms
Hyperviscosity or myeloproliferative syndromes (polycythemia, leukemias, or thrombocytosis), vascular obstruction (sickle cell anemia),
Hematologic severe anemia, and conditions associated with hypercoagulable states (lupus anticoagulant or antiphospholipid antibody; presence of
Factor V Leiden; or deficiencies of protein C, protein S, or antithrombin III).
Vascular
Hypertension leading to thrombosis or bleeding, atherosclerotic emboli from carotid or vertebral plaques, extrinsic compression of
mechanisms cranial vessels (cervical osteophytes, or rotational kinking, tumor), vasospasm (migraine, cocaine) and vasculitis.
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TIA Symptoms Preceding Stroke
Individuals experiencing TIA symptoms have been shown to have an 8% to 12% chance of having a stroke within one week and an 11% to 15%
chance of having a stroke within one month.
Stroke Systematic Assessment and Outcomes
The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool that provides a quantitative measure of stroke-related
neurologic deficit. Originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials, now, the scale is also
widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome.
Patients with symptoms highly suggestive of stroke are preferentially routed to a hospital that has been certified as a stroke center, as patients with
symptoms of stroke who receive treatment at hospitals with this certification have been shown to have improved outcomes among patients treated for
stroke.
Universal Precautions
Universal precautions are safety procedures designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and
other blood-borne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are
considered potentially infectious for HIV, HBV, and other blood-borne pathogens. Implementation involves the use of protective barriers such as
gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the healthcare worker’s skin or mucous membranes
to potentially infectious materials. Proper disposal and precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or
devices are also a part of this medical safety practice.
Evaluation of a Patient with Suspected Ischemic Stroke
Time is crucial in the evaluation of a patient with suspected ischemic stroke because if given within four-and-a-half hours, intravenous tPA has
proven beneficial in salvaging hypoxic brain tissue. Intra-arterial therapy improves functional outcomes if it can be given within six hours.
Since time is so critical, there is an organized protocol for the emergency evaluation of patients with suspected stroke. The goal is to complete an
evaluation and to decide on treatment within 60 minutes of the patient’s arrival in the emergency department. A designated acute stroke team
includes physicians, nurses, and laboratory/radiology personnel. All patients with suspected acute stroke are triaged with the same priority as
patients with acute myocardial infarction or serious trauma, regardless of the severity of the deficits.
As for all critically ill patients, the initial evaluation follows the path of evaluation and stabilization of the patient’s CABs ( circulation, airway,
breathing). This is quickly followed by a secondary assessment of neurological deficits and possible comorbidities with the National Institutes of
Health Stroke Scale (NIHSS).
The overall goal is not only to identify people with possible stroke, but also to exclude stroke mimics, identify other conditions requiring immediate
intervention, and determine potential causes of the stroke for early secondary prevention.
A limited number of hematologic, coagulation, and biochemistry tests are recommended during the initial emergency evaluation of a patient with
suspected acute ischemic stroke.
Although it is desirable to know the results of these tests before giving recombinant tissue plasminogen activator (rtPA), thrombolytic therapy should
not be delayed while awaiting the results unless:
1. There is clinical suspicion of a bleeding abnormality or thrombocytopenia
2. The patient has received heparin or warfarin
3. Use of anticoagulants is not known
Atrial Fibrillation with Rapid Ventricular Response: Etiology, Complications, and Treatment
Atrial fibrillation (AF) with rapid ventricular response (RVR) is the presence of physiologic or nonphysiologic (electrical) ventricular tachycardia in the
presence of AF.
Etiology
Fever, myocarditis, pericarditis, volume contraction, thyrotoxicosis, endogenous catecholamines, and AV nodal dysfunction are causative.
Complications
In the presence of a diminished cardiac output at baseline, AF with RVR predisposes to hemodynamic instability, functional impairment, heart failure
and ischemia.
Treatment
Rate control: Controlling the heart rate with intravenous diltiazem, beta-blockers, or verapamil improves blood flow and does not delay
immediate need for emergency stroke treatment.
Rhythm control: Cardioversion either via electric shock to the heart with the patient under sedation or via medications given orally or
intravenously. Both methods carry a risk of stroke, which is greatest in patients who have had atrial fibrillation for more than 48 hours, or who
have not been given three weeks of prior anticoagulant therapy.
Symptoms of Right Parietal Infarct
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Right-hand dominant patients with strokes in the area of the brain are likely also to have left hemiplegia. Patients with right middle cerebral infarcts
affecting the right parietal hemisphere may have difficulties with their spatial and perceptual abilities, which causes them to misjudge distances, or
they may attempt to read holding books upside down. They may ignore people or objects in their left visual field or not pay attention to that area of
the room. They may also not recognize their functional impairments (denial of stroke disability).
Stroke Symptoms of Other Regions:
Strokes that occur in the brain stem would likely be the cause of respiratory impairment and affect vital functions of blood pressure, heartbeat
and consciousness.
Expressive and receptive aphasia and right facial weakness are classically associated with a left middle cerebral artery stroke.
A central nerve injury such as a stroke often spares involvement of the portion of the facial nerve that controls the forehead. This is because
there is bilateral central control of this portion of the facial nerve.
A peripheral injury to the facial nerve (such as Bell’s Palsy) causes facial weakness of the forehead.
A more extensive listing of stroke symptoms correlating with functional neuroanatomy can be found at the Family Practice Notebook website .
Common Stroke Complications
Aspiration pneumonia
Malnutrition/dehydration
Pressure sores
Activities of Daily Living (ADLs)
Basic activities of daily living (BADLs)
Bathing
Dressing and undressing
Eating
Transferring from bed to chair, and back
Voluntarily control urinary and fecal discharge
Using the toilet
Walking (not bedridden)
Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning, but enable the individual to live
independently within a community
Light housework
Preparing meals
Taking medications
Shopping for groceries or clothes
Using the telephone
Managing money
Role of Primary Care Clinicians in Primary and Secondary Prevention of Cardiovascular Disease
Primary care clinicians play a central role in the detection and management of cardiovascular disease risk factors, including poor nutrition, excessive
alcohol intake, smoking, obesity, insufficient physical activity, hypertension, diabetes, and hyperlipidemia, in addition to secondary effects of
cardiovascular disease, cancer, and stroke. Effective communication between clinicians, students, patients, and families for both the primary and
secondary prevention of disease requires a persistent effort.
Coronary Heart Disease and Stroke in African Americans
African Americans have the highest rates of coronary heart disease (CHD) of any ethnic group in America, and stroke mortality rates are strikingly
high in this population group in general.
Post-Stroke Depression: Epidemiology, Definition, Cause, Complications, Management
Epidemiology
One-third of stroke survivors experience post-stroke depression.
Definition
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DSM 5 defines this as the occurrence of a mood disorder judged to be due to the direct physiological effects of another medical condition.
Cause
The precise cause of depression following stroke is unknown and its development is thought to be due to multiple factors which include lesion
location, individual adjustment to disability, and levels of family or social support.
Complications
Untreated post-stroke depression can impede rehabilitation progress and lead to impaired functional outcomes, cognitive decline, and increased
mortality.
Management
SSRIs are accepted as first-line therapy and have been proven to improve clinical outcomes for sufferers of post-stroke depression. Selection of a
particular SSRI is guided by the potential for drug-drug interactions and patient tolerance.
Clinical Skills
Pronator Drift
The pronator drift is one of the most sensitive tests for upper extremity weakness.
The patient is asked to flex their arms 90 degrees at the shoulders, supinate their forearms, close their eyes, and hold the position. If a
forearm pronates, then the patient is said to have pronator drift on that side.
Pronator drift
The National Institutes of Health Stroke Scale (NIHSS)
A standardized comprehensive tool with proven utility for efficiently ensuring systematic documentation of key components of the neurologic exam in
a patient with suspected stroke. Its application enables the performance of a standardized exam for TIA and stroke patients, which can then be
subsequently used by examiners to more precisely evaluate neurologic improvement and deterioration.
Use this scale to score components of the preceding examination that have been performed and to familiarize yourself with the components that
ideally should have been included.
You may also view a video on the performance of the NIHSS exam.
Face Arm Speech (FAST) Test
Face Arm Speech (FAST) test is used by ambulance paramedics and physicians for the rapid clinical assessment of patients with suspected
transient ischemic or stroke symptoms.
FAST is an acronym for “face drooping, arm weakness, speech difficulty, time to Call 911” with Instructions found here.
Developed in 1998 as a stroke identification instrument, to be used outside the hospital. Studies have demonstrated variable diagnostic
accuracy of stroke by paramedics and emergency medical technicians with positive predictive values between 64% and 77%.
Timed Up and Go Test
Measures mobility and fall risk in people who are able to walk on their own. The person may wear their usual footwear and can use any assistive
device they normally use.
Instructions to the patient:
1. Sit in the chair with your back to the chair and your arms resting in your lap.
2. Without using your arms, stand up from the chair and walk 3 m (10 ft).
3. Turn around, walk back to the chair, and sit down again.
Timing begins when the person starts to rise from the chair and ends when he or she returns to the chair and sits down. The person should be given
one practice trial and then three actual trials. The times from the three actual trials are averaged.
Prediction of Mobility
Average Number of Seconds for TUG Mobility Prediction
< 10
Freely mobile
< 20
Mostly independent
20-29
Variable mobility
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> 30
Impaired mobility
Note: This test is more discriminative in patients who are more debilitated.
Acknowledge Religious Discordance in the Clinical Setting
Doctors don’t need to be religious or share the beliefs of their patients to recognize the importance of spirituality in the lives of their patients. Patients
and their families who find themselves during hospitalizations under a great deal of emotional stress commonly turn to their faith to provide a context
for their crisis and for emotional strength. The patient and family may judge the doctor for lack of compassion if he/she refuses to accept a request to
join in prayer. Perceptions of spiritual or compassionate care are often tagged to clinician behaviors such as active listening, availability, and
understanding. Clinician presence can lead to more insight into what motivates or may inspire a patient. However, if the provider feels conflicted
about praying with patients, one option is just to stand by quietly as the patient prays in his or her own tradition. Offering chaplain services is also
often very helpful. A lot depends on the clinician’s relationship with the patient and family so one option does not cover all the circumstances.
Management
Recommendations for Stroke Prevention in Atrial Fibrillation
Prevention of a first stroke
There are multiple pharmacologic choices to use to prevent stroke in a patient with AF. To make this decision, utilize a risk calculator like CHADSVASc score to determine if the patient should utilize an antiplatelet versus an anticoagulant to reduce their risk.
1. For patient with AF and a CHADS-VASc score of 2 or greater in men and 3 or greater in women, direct oral anticoagulants (DOACs) are
recommended including dabigatran, rivaroxaban, apixaban, and edoxaban.
DOACs are recommended over warfarin in DOAC-eligible patients with AF (except with mod-severe MS or a mechanical heart valve) (Class I; Level
of Evidence A).
For patients with moderate to severe mitral stenosis or a mechanical heart valve, warfarin is recommended. (Class I; Level of Evidence B).
2. Adjusted-dose warfarin (target INR, 2.0-3.0)
Recommended for all patients with nonvalvular AF deemed to be at high risk and many deemed to be at moderate risk for stroke who can receive it
safely (Class I; Level of Evidence A).
3. Antiplatelet therapy with aspirin
Recommended for low-risk and some moderate-risk patients with AF on the basis of patient preference, estimated bleeding risk if anticoagulated,
and access to high-quality anticoagulation monitoring (Class I; Level of Evidence A).
4. Dual-antiplatelet therapy with clopidogrel and aspirin
Offers more protection against stroke than aspirin alone but with an increased risk of major bleeding and might be reasonable for high-risk patients
with AF deemed unsuitable for anticoagulation (Class IIb; Level of Evidence B).
Prevention of stroke in patients with a history of stroke or TIA
1. For patients with ischemic stroke or TIA with paroxysmal (intermittent) or permanent AF
Anticoagulation with a vitamin K antagonist (target INR, 2.5; range, 2.0-3.0) or DOAC is recommended (Class I; Level of Evidence A).
2. For patients unable to take oral anticoagulants
Aspirin alone (Class I; Level of Evidence A) is recommended. The combination of clopidogrel plus aspirin carries a risk of bleeding similar to
that of warfarin and therefore is not recommended for patients with a hemorrhagic contraindication to warfarin. (Class III; Level of Evidence
B).
The selection of an antithrombotic agent should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug
interactions, and other clinical characteristics, including time in INR therapeutic range if the patient has been taking warfarin.
CHA2DS2-VASc Score for Atrial Fibrillation Stroke Risk
The CHA2DS2-VASc score is a validated instrument that applies known cardiovascular risk factors to provide calculated guidance to help weigh the
benefits and risks of anticoagulation.
Certain types of stroke are associated with an increased risk of intracranial hemorrhage at the site of the infarct with early anticoagulation. Current
guidelines recommend delaying starting anticoagulation.
Stroke Rehabilitation Therapy
Rehabilitative therapy begins in the acute-care hospital after the patient’s medical condition has been stabilized, often within 24 to 48 hours after the
stroke. The first steps involve promoting independent movement because many patients are paralyzed or seriously weakened. Patients are prompted
to change positions frequently while lying in bed and to engage in passive or active range-of-motion exercises to strengthen their stroke-impaired
limbs. Patients progress from sitting up and transferring between the bed and a chair to standing, bearing their own weight, and walking, with or
without assistance.
Rehabilitation nurses and therapists help patients perform progressively more complex and demanding tasks, such as bathing, dressing, and using a
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toilet, and they encourage patients to begin using their stroke-impaired limbs while engaging in those tasks. Beginning to reacquire the ability to carry
out these basic activities of daily living represents the first stage in a stroke survivor’s return to functional independence.
Post-stroke rehabilitation involves physicians, rehabilitation nurses, physical, occupational, recreational, speech-language, and vocational therapists;
and mental health professionals.
Secondary Stroke Prevention
The disease management program called: “Preventing Recurrence of Thromboembolic Events through Coordinated Treatment” (PROTECT)
implements eight secondary prevention goals at the time of discharge. Four of these goals are aimed at treatable risk factors, and four of these goals
are aimed at modifiable lifestyle risk factors of recurrent thromboembolism.
You decide to model your treatment plan after this program coordinated with recommendations from the American Heart Association and American
Stroke Association.
Recommendation
Hyperlipidemia
Level of
Evidence
All patients with a history of TIA or CVA should be placed on high-intensity statin such as atorvastatin 40 or 80 mg Class I,
or rosuvastatin 20 mg.
Level A
Antihypertensive treatment is recommended for prevention of recurrent stroke and other vascular events in
persons who have had an ischemic stroke and are beyond the hyperacute period.
Recent guidelines suggest that setting a blood pressure goal of 130/80 mmHg is appropriate. Given his age, one
should be cautious about lowering his blood pressure too aggressively, leading to orthostasis and a subsequent
fall.
Hypertension
Class I,
The older JNC8 guidelines had suggested a blood pressure goal of 150/90 mmHg for adults over age 60, however Level A
there is still data that suggests more intense blood pressure management (< 140/90) may lead to lower rates of
stroke recurrence.
JNC-8 guidelines also recommend utilizing an ACEi and a diuretic for recurrent stroke prevention.
For more REQUIRED information about hypertension management, see the Aquifer Hypertension module.
Smoking
Diet
All ischemic stroke or TIA patients who have smoked in the past year should be strongly encouraged not to
smoke.
The ACC/AHA Lifestyle Guidelines recommend all adults consume a Mediterranean diet to reduce their risk of
ASCVD.
Class I,
Level C
Class I,
Level A
Furthermore, patients with hypertension should limit sodium intake to 2,400 mg per day or less.
Physical
activity
On the basis of moderate quality evidence, all adults are encouraged to engage in moderate-to-vigorous intensity
Class IIb,
physical activity 3-4 times per week for 40 minutes per session. For those with disability after ischemic stroke, a
Level C
supervised therapeutic exercise regimen is recommended.
Stroke
education
Stroke education includes knowledge of stroke warning signs and the need to call 911 in the event of a
cerebrovascular event as well as awareness of the individual's own risk factors.
Studies
Recommended Tests for the Initial Emergency Evaluation of a Patient with Suspected Acute Ischemic Stroke
The American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention
Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups have all
come together to create guidelines for the early management of adults with ischemic stroke . The following tests are recommended.
CT and MRI
Imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke.
Multimodal CT and MRI may provide additional information that will improve diagnosis of ischemic stroke.
Abnormalities of renal function or electrolyte disturbances are prevalent in patients who have risk factors for
Renal
function/electrolytes stroke and should be assessed.
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Class I,
Level of
Evidence
A
Class I,
Level of
Evidence
B
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An electrocardiogram (ECG) is recommended because of the high incidence of heart disease in patients with
stroke.
Electrocardiogram
(ECG)
General agreement supports the use of cardiac monitoring to screen for atrial fibrillation and other potentially
serious cardiac arrhythmias that would necessitate emergency cardiac interventions. It is generally agreed that
cardiac monitoring should be performed during the first 24 hours after onset of ischemic stroke.
Class I,
Level of
Evidence
B
Markers for cardiac Markers for cardiac ischemia are important for all patients with suspected ischemic stroke, as myocardial
ischemia
ischemia is a potential complication of acute cerebrovascular disease.
Serum glucose
The American Heart Association and American Stroke Association recommend that a serum glucose be
measured in all patients being worked up for a cerebrovascular event.
CBC and PT/PTT
Abnormalities of the CBC and PT/PTT provide information that should prompt consideration of infectious,
hypoxic/hypoperfusion, thrombotic, and hemorrhagic etiologies.
Oxygen saturation
Stroke etiology may be due to underlying CAD, and the extent of brain injury may be lessened by maintaining
normal oxygen saturation. Hypoxic patients with stroke should receive supplemental oxygen.
Class I,
Level of
Evidence
C
Chest x-rays have not been found to significantly alter the clinical management of patients presenting with acute ischemic stroke. In patients who
may have chronic lung or cardiovascular disease, chest x-rays are recommended. Chest x-rays would be appropriate in patients with hypertension,
hyperlipidemia, and atrial fibrillation.
Blood glucose should be checked to rule out hypoglycemia and, if present, treated in patients with acute ischemic stroke (Class I, Level of Evidence
C). The goal is to achieve normoglycemia avoiding extremes of low or elevated blood glucose levels.
In selected patients defined by their clinical history and the circumstances of their presentation alcohol and toxicology screens may be indicated.
Lumbar puncture should be performed if there is suspicion of meningitis, endocarditis, or CNS vasculitis, and when the possibility of subarachnoid
hemorrhage is not eliminated by a normal or negative head CT.
Other tests that may be warranted in selected patients include: hepatic function tests, pregnancy tests, arterial blood gas tests (if hypoxia is
suspected), and electroencephalogram (if seizures are suspected).
Cardiac Biomarkers
Troponins and other substances are released into the blood by ischemic or infarcting myocytes. Troponins are the markers of choice for the
diagnosis of myocardial infarction and should be used instead of CK-MB. Rising four to six hours after an ischemic injury, troponins remain
elevated for up to ten days and are more specific than CK-MB. Because troponin can remain elevated for days, however, the precise timing of
the injury can be difficult to determine.
Creatine kinase MB (CK-MB) may be helpful for the timing of injury, because this enzyme level rises in the serum 4 to 12 hours after the
event, but remains elevated for only 36 to 48 hours. An elevated serum CK-MB can help confirm the timing of an acute myocardial infarction;
in addition, repeat elevations may indicate recurrent myocardial injury.
B-type Natriuretic Peptide (BNP) is a 32-amino-acid polypeptide secreted by the cardiac ventricles in response to ventricular volume
expansion and pressure overload. The levels of BNP are elevated in patients with left ventricular dysfunction, and the levels correlate with
both the severity of symptoms and the prognosis.
The standard approach is as follows:
Serum troponin-T (cTnT) or troponin-I (cTnI) is measured at first presentation.
If the serum troponin is not elevated, the test is repeated at six to nine hours. It is not uncommon to measure a second troponin earlier than
six hours in patients who are highly suspected of having ongoing non-ST-elevation myocardial infarction (NSTEMI). In an occasional patient in
whom the index of suspicion for acute myocardial infarction is high, but the first two serum troponin measurements are not elevated, a repeat
measurement at 12 to 24 hours may be necessary.
Emergency Imaging and rtPA Treatment
Emergency CT scanning is done to identify most cases
