The treatment of acute ischemic stroke will change due to new American Heart Association and American Stroke Association guidelines. Help update your hospital's screening and treatment protocols... Strive for faster turnaround times in stroke patients. For example, aim to rule out a hemorrhagic stroke with brain imaging within 20 minutes even though the quality measure is 45 minutes.
Mechanical thrombectomy
Expect more patients to receive this treatment, or be transferred to a hospital that can perform it. New evidence suggests thrombectomy may reduce disability when performed in eligible patients up to 24 hours after symptom onset, instead of just 6 hours even if they've received alteplase.
Alteplase (Activase) - thrombolytic agent
- Verify your criteria are current...
- For example, avoid alteplase if a low-molecular-weight heparin (Clexane) is used in the previous 24 hours at TREATMENT doses. But PROPHYLACTIC doses are okay.
- New evidence suggests tenecteplase may be a better option, but it's too soon to recommend switching. Stick with alteplase for now.
VTE prophylaxis
Continue to use mechanical compression devices such as Sequential Compression Device (SCDs, etc) in immobile patients. But don't jump to using medications for VTE prophylaxis. The risk of intracranial hemorrhage in ischemic stroke patients is similar to the reduction in symptomatic pulmonary embolism (PE). Work with neurology specialists to determine which patients may be more likely to benefit.
- Continue to document VTE prophylaxis or reason for not using by day 2 of admission for all patients to meet the Joint Commission measure.
- Before discharge, evaluate chronic medication needs, starting antihypertensive medications or statins in-house is associated with better long-term control.
References
-
Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation. 2018 Mar 20;137(12):e67-e492. Available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000558
Campbell BCV, Mitchell PJ, Churilov L, Yassi N, Kleinig TJ, Dowling RJ, Yan B, Bush SJ, Dewey HM, Thijs V, Scroop R, Simpson M, Brooks M, Asadi H, Wu TY, Shah DG, Wijeratne T, Ang T, Miteff F, Levi CR, Rodrigues E, Zhao H, Salvaris P, Garcia-Esperon C, Bailey P, Rice H, de Villiers L, Brown H, Redmond K, Leggett D, Fink JN, Collecutt W, Wong AA, Muller C, Coulthard A, Mitchell K, Clouston J, Mahady K, Field D, Ma H, Phan TG, Chong W, Chandra RV, Slater LA, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Bladin CF, Sharma G, Desmond PM, Parsons MW, Donnan GA, Davis SM; EXTEND-IA TNK Investigators. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med. 2018 Apr 26;378(17):1573-1582. Available at: https://www.nejm.org/doi/10.1056/NEJMoa1716405
Dennis M, Caso V, Kappelle LJ, Pavlovic A, Sandercock P; European Stroke Organisation. European Stroke Organisation (ESO) guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischaemic stroke. Eur Stroke J. 2016 Mar;1(1):6-19. Available at: https://journals.sagepub.com/doi/10.1177/2396987316628384
0 تعليقات