Secondary Stroke Prevention: Evidence-based Recommendation
Secondary Stroke Prevention: Evidence-based Recommendation
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Content
0.08 -> for the los angeles
2.159 -> for the los angeles county department of
4.24 -> health services and associate chief
6.399 -> medical director of neurological
8.4 -> services and chief of neurology
10.88 -> at la county and university of southern
13.44 -> california medical center dr tofighi's
16.96 -> research has focused on healthcare
18.88 -> delivery redesign to improve access to
21.76 -> care quality of care and patient
24.32 -> outcomes in safety net settings to
26.72 -> reduce inequalities she has collaborated
29.599 -> closely with ucla researchers developing
32.719 -> and testing novel models of healthcare
34.96 -> delivery in the department of health
38.16 -> safety net system
40.16 -> she's published extensively on sex race
43.2 -> ethnic and social economic disparities
46.399 -> in stroke and has tested interventions
48.96 -> designed to address disparities in
51.44 -> post-stroke care
53.199 -> she received the robert g seeker new
55.6 -> investigator and stroke award from the
57.84 -> american heart association and the
59.92 -> michael s pesson stroke
62 -> leadership prize from the american
63.6 -> academy of neurology she served as chair
66.56 -> of the american stroke association
68.4 -> quality and outcomes committee and
70.32 -> served on numerous writing groups for
72.08 -> american heart association scientific
74.159 -> statements and guidelines including
76.56 -> chair of the post-stroke depression
78.56 -> scientific statement and she's the vice
81.04 -> chair of the secondary stroke prevention
82.96 -> guidelines which she will be presenting
84.64 -> today it's my pleasure to turn over the
87.36 -> presentation to dr tufigi
91.439 -> thank you so much for that kind of
94 -> introduction deb
96 -> and it's really my pleasure to be here
98.479 -> discussing the secondary stroke
100.32 -> prevention guidelines today
102.88 -> these guidelines are an update to the
105.119 -> 2014 guidelines for the secondary for
108.079 -> secondary stroke prevention
115.68 -> um i just want to acknowledge our
118.159 -> amazing writing group i served as the
120.079 -> vice chair don kleindorfer was the chair
122.719 -> of the guideline committee and we had a
125.36 -> terrific
126.799 -> work group working on these guidelines
128.959 -> for the past two years
131.2 -> i have no disclosures
133.44 -> so there's three learning objectives for
135.52 -> today the first is to compare and
137.44 -> contrast the changes that were made to
139.28 -> the new guidelines
141.04 -> with respect to format and
144.16 -> sections the second is to explain
146.56 -> rationale for
147.84 -> specific strategies for secondary stroke
150 -> prevention and the third is to be able
152.08 -> to describe the top 10 most important
154.959 -> takeaway points from the guidelines
158.48 -> so just to give you a little bit of
159.92 -> background in 2017 the american heart
163.04 -> association changed the way they were
164.879 -> doing guidelines in the past the
166.64 -> guidelines had been very wordy had been
169.519 -> really like extensive systematic reviews
172.239 -> of the literature and were hard to read
174.879 -> so in 2017 they made changes to make the
178 -> text much shorter
179.76 -> and to have module modular chunks
183.36 -> for each topic and in each chunk you
186.159 -> have a table of recommendations a brief
188.64 -> synopsis of the recommendations and for
191.2 -> each recommendation there's specific
193.68 -> text supporting that recommendation
196.319 -> we try to incorporate flow diagrams and
199.28 -> algorithms whenever possible
201.599 -> and uh the references are hyperlinked
204.64 -> and you can refer to the data supplement
207.2 -> which is a separate document that has
208.959 -> all the evidence tables if you want to
210.64 -> get
211.599 -> more information about where the
213.519 -> recommendations came from
216.799 -> i also want to tell you a little bit
218.319 -> about the scope of this guideline
220.56 -> this guideline pertains specifically to
223.36 -> secondary prevention of ischemic stroke
225.68 -> so individuals who've had an ischemic
227.68 -> stroke or tia what do you do to prevent
230 -> a recurrent stroke
232.4 -> we did cover some things in the acute
235.12 -> care setting only if it was pertinent to
237.519 -> secondary stroke prevention
239.36 -> and we did not include topics that are
241.04 -> covered in other guidelines such as
242.56 -> acute management intracerebral
244.48 -> hemorrhage primary prevention and a few
247.2 -> special considerations such as special
248.959 -> considerations in women which was a
250.879 -> scientific statement that we released as
253.599 -> well as the cerebral venous sinus
255.28 -> thrombosis recommendations
259.199 -> compared to 2014 there were a few
261.04 -> changes in the way it was organized we
263.919 -> added a new section on diagnostic
266.479 -> evaluation as it pertains to secondary
269.199 -> stroke prevention
270.72 -> then we had a category a section on
273.44 -> vascular risk factor management
276.16 -> and the third category was on management
279.28 -> by etiology and by etiology we went with
282.24 -> the toast classification that includes
284.4 -> large vessel atheros small vessel
286.32 -> disease cardio embolism other
289.36 -> and a new section on embolic stroke of a
292 -> determinate source
294.24 -> and finally we had a section on systems
296.639 -> of care for secondary stroke prevention
300 -> each section has knowledge gaps and
302.32 -> future research uh segments
304.8 -> um with recommendations on
307.52 -> additional areas for research
312.72 -> i want to talk briefly about how the
315.759 -> the guy the
317.36 -> the strength of recommendation as well
319.039 -> as the quality of evidence so for every
321.36 -> recommendation you'll see a class
323.84 -> which is
325.28 -> 1 2 a 2 b 3 benefit and no benefit and 3
329.28 -> harm
330.16 -> so if um
332.4 -> if a treatment strategy causes
335.6 -> much more benefit than risk that would
337.919 -> be a class 1 strong recommendation
340.56 -> class 2a is if the benefit is still
343.84 -> greater than the risk
346 -> and class 2b is if the benefit is
348.96 -> greater than or equal to risk
351.36 -> now there's two class three
352.639 -> recommendations one is no benefit that's
355.12 -> if the benefit equals the risk and then
357.52 -> there's a class three harm where the
359.36 -> risk is greater than the benefit
362 -> now the strength of the recommendation
363.919 -> has nothing to do with the quality of
365.919 -> the data the quality of the data are
369.919 -> covered under the level of evidence so
373.12 -> level a is when there's
375.36 -> one or more high quality randomized
377.6 -> control trials
379.199 -> or meta-analyses of high-quality
381.28 -> randomized control trials
383.52 -> level two sorry level b r
386.72 -> is
387.52 -> moderate evidence from one or more
390.08 -> randomized trials or meta-analyses of
392.72 -> moderate quality randomized trials
395.28 -> vnr is moderate quality evidence from
398.72 -> well-executed non-randomized studies
402.08 -> cld is limited data so there may be
404.8 -> randomized or non-randomized
406.88 -> observational observational registries
408.4 -> that have limitations in design
411.44 -> and level ceo is expert opinion so here
415.199 -> you're not we're not basing it on
417.28 -> randomized trials or even non-randomized
419.68 -> trials these are just clinical
421.28 -> experience
422.4 -> of experts
425.759 -> so i'm going to talk about the first
428.56 -> section which is the diagnostic
430.24 -> evaluation which was a new section for
431.919 -> these guidelines
433.68 -> so
434.639 -> i mentioned before that we divided
437.44 -> the management according to stroke
439.36 -> subtypes so in order to figure out what
441.28 -> the stroke subtype is you need a
442.639 -> diagnostic evaluation
444.479 -> and to just ground you in just the um
447.759 -> the nomenclature here as you know
450.96 -> about 85 to 88 of strokes are ischemic
454.4 -> strokes and amongst ischemic strokes
456.88 -> about
457.84 -> one quarter are lacunar and the rest are
460.96 -> non-lacunar
462.8 -> and amongst non-lacunar strokes they can
465.52 -> be divided into cardioembolism
467.52 -> cryptogenic large artery athero and
470.319 -> other
471.68 -> now within cryptogenic strokes there's
474.72 -> two types there's embolic stroke of
476.879 -> undetermined source
478.639 -> or esis and non-aesis
481.44 -> so
482.319 -> when you think about isis think about
485.759 -> a stroke that is cryptogenic that looks
488.479 -> embolic in origin and when i say
491.12 -> embolican origin i'm talking about it
492.879 -> might be
493.919 -> bilateral or in anterior and posterior
496.319 -> circulations and often cortical strokes
500.879 -> throughout the guidelines
502.8 -> um we assume that clinicians will be
505.52 -> doing shared decision making with their
507.28 -> patients describing the risks benefits
509.599 -> and options to patients and
511.84 -> developing a plan that take into account
514.399 -> patients wishes
516.159 -> and the second thing that i want to
517.76 -> point out is um it's so important to
521.279 -> assess adherence at every visit and not
524.24 -> to assume that
525.839 -> a recurrent stroke is due to a failure
528.959 -> of a medication but to check whether or
531.519 -> not the patient is taking the medication
534.32 -> um i feel that often that is forgotten
537.36 -> when people are talking about this
538.64 -> antiplatelet versus that antiplatelet um
541.519 -> a key thing is our patients taking their
543.839 -> medications and if not what can we do to
546.56 -> help them to to be able to take their
548.72 -> medications
552.56 -> so
553.76 -> for the diagnostic evaluation section we
556.24 -> have um an algorithm
558.48 -> and i'm just going to rather than
560.56 -> walk you through the entire algorithm
562.32 -> i'm just going to tell you a few key
564.24 -> basic points so we have class 1
566.56 -> recommendations for get for diagnostic
569.279 -> imaging of the brain
571.279 -> parenchyma to diagnose a stroke so
573.279 -> either ct or mri is class 1. if
577.279 -> there's no stroke seen on the initial ct
579.68 -> or mri it's reasonable to do
582.56 -> repeat imaging
584.16 -> the second class 1
586 -> recommendation is to do ekg and basic
588.56 -> lab tests and those are delineated in
591.36 -> the guideline but they include things
592.959 -> such as
595.36 -> electrolytes cbc coax a1c lipid profile
600.88 -> um
602.079 -> then the the other class one medication
604.88 -> is non-invasive
606.56 -> carotid imaging with cta mra or
609.36 -> ultrasound
610.72 -> and um
612.399 -> class 2a recommendations for
614.72 -> intracranial imaging of the vasculature
617.92 -> as well as extra cranial vertebral
620 -> basilar system
621.68 -> there's a class two b recommendation for
625 -> echocardiography to look for cardio
627.44 -> embolic sources
629.36 -> and with all of those those studies if a
632.959 -> cause is not identified
635.04 -> um then there's a class one
637.12 -> recommendation for prolonged rhythm
639.04 -> monitoring to um
641.36 -> uh to detect
643.44 -> uh atrial fibrillation
645.36 -> and class two recommendations for
647.76 -> other studies such as screening for a
649.519 -> pfo
650.64 -> testing for genetic stroke symptoms
652.64 -> vasculitis and other causes of stroke
655.12 -> all of these depend on the clinical
657.12 -> picture of course and um we do not
660.48 -> recommend
661.44 -> sending all these studies without
664 -> a clinical reason
666.959 -> so the next section is on vascular risk
669.04 -> factor management i'm going to start
671.44 -> with antithrombotic medications this is
673.6 -> really one of the big pillars of
675.68 -> secondary stroke prevention it is such
678.24 -> an important and controversial topic
680.32 -> that we actually asked for a separate
682.8 -> systematic review which was published by
685.92 -> a separate group that
688.399 -> there was basically a wall between the
691.519 -> guideline committee and the evidence
693.2 -> review committee who did this
694.56 -> evidence-based review
696.24 -> some of the guidelines here are based on
698.72 -> the evidence-based review
701.12 -> but we specifically asked them about
702.8 -> single versus stool anti-platelet
704.64 -> therapy and our guidelines cover a
706.64 -> little bit more than that
708.48 -> so we have um
710.72 -> uh the wars trial from many years ago
713.12 -> looked at warfare versus aspirin and
715.44 -> showed that aspirin is superior to
717.44 -> warfarin for secondary stroke prevention
719.36 -> because of the bleeding risk with
721.279 -> warfarin
722.399 -> and so there's a class one
724 -> recommendation for anti-platelet therapy
725.92 -> over anticoagulation
728 -> additionally multiple trials have shown
730.959 -> that either aspirin plus extended
733.279 -> release diperinimal aspirin alone
736 -> clopidogrel alone
738.24 -> are um
739.68 -> are reasonable options for secondary
741.76 -> stroke prevention and the trials include
744.8 -> um
745.6 -> capri that looked at aspirin plus
747.2 -> clopidogrel esps2 and esprit that looked
750.639 -> at
751.36 -> extended release uh diprotomal plus
753.519 -> aspirin versus aspirin and profess which
756.639 -> looked at
758.72 -> agronox versus clopidogrel
762 -> now um we have a few new trials so
766.88 -> chance and point looked at dual
768.56 -> anti-platelet therapy for this for a
770.959 -> short time period
772.639 -> after minor stroke or high risk tia
776.079 -> and uh based on these two trials there's
779.279 -> a level there's a class one a
781.68 -> recommendation for
783.519 -> dual anti-platelet therapy with aspirin
785.68 -> plus clip integral for
787.92 -> three weeks to 90 days
790.48 -> followed by single antiplatelet therapy
792.88 -> in patients who have a high risk tia or
796.399 -> a
797.04 -> low
798.079 -> a small stroke a minor non-cardioembolic
800.32 -> stroke
801.44 -> um additionally there was a trial that
804.32 -> looked at titagalore in patients with
807.36 -> minor to moderate stroke and high-risk
809.519 -> tiaa the high-risk ti was
812.48 -> defined a little bit differently in this
814.16 -> trial
815.12 -> um
816.72 -> and um
818.32 -> this was the thales trial and so it's
821.04 -> reasonable to
823.199 -> give tycagular plus aspirin for 30 days
826.639 -> however it may increase the risk of
829.36 -> bleeding therefore it's a 2b
831.279 -> recommendation
834.399 -> in patients who are already taking
836.24 -> aspirin the effectiveness of increasing
838.88 -> the dose or changing to another
841.839 -> is not well established there have been
844.16 -> a couple of uh
845.76 -> post hoc analyses of sps3 and chance
849.76 -> however
851.68 -> we need more data on this
854.16 -> and finally
855.519 -> continuous use of dual anti-platelet
857.92 -> therapy is not indicated and can cause
860.959 -> harm with excess risk of hemorrhage
862.8 -> without benefit
864.16 -> so we don't recommend and a dual
866.56 -> antiplatelet beyond 90 days
871.839 -> a really simple algorithm to help you
874.16 -> remember when to use dual is high risk
877.44 -> tia or
880.079 -> small stroke with a nih stroke scale of
882 -> less than three
883.36 -> reasonable to do dual antique platelet
885.68 -> for 90 days after which you go with
888.079 -> single antiplatelet and if you're not if
890.959 -> you don't have a high risk tia or a
893.279 -> small stroke then just go with single
895.199 -> antiplatelet
899.92 -> so um
901.839 -> with regards to risk factor management a
904.399 -> really important component is nutrition
907.12 -> and
908.079 -> um
909.44 -> so our nutrition uh data is really based
912.48 -> on primary stroke prevention
914.72 -> studies
916.32 -> we don't have data on secondary stroke
919.12 -> prevention
920.24 -> but the predimed
921.76 -> trial which used a mediterranean diet
924.88 -> with supplementation of extra virgin
926.959 -> olive oil or nuts versus a low-fat diet
930.48 -> showed a reduction in stroke for those
934.56 -> on the mediterranean diet this is
936.48 -> primary stroke
937.839 -> similarly the leon diet heart trial
941.12 -> looked at a mediterranean diet with
942.88 -> supplemental canola oil
945.199 -> in patients after an mi and found a
948.8 -> reduction in cardiovascular disease and
950.959 -> total mortality
952.8 -> and um with regards to salt um
957.04 -> again we're looking at uh primary uh
959.839 -> prevention data a one gram reduction is
962.959 -> associated with a twenty percent uh
965.519 -> reduction in cardiovascular events and
967.92 -> if you reduce it to 2.5
971.839 -> um gram sorry if you reduce it to 1.5
975.199 -> grams per day um you reduce blood
977.6 -> pressure by another five millimeters and
980.16 -> so the reason these are not class one
982.959 -> recommendations is because they're based
984.8 -> on um
986.16 -> uh primary prevention uh studies rather
988.639 -> than um
989.92 -> secondary prevention
993.759 -> now for physical activity uh
996.72 -> unfortunately there have not been that
998.8 -> many studies looking at physical
1000.639 -> activity and individuals with stroke
1003.519 -> however
1005.199 -> with
1006.24 -> limited data
1007.759 -> we
1008.56 -> are advising for moderate intensity
1010.72 -> activity for at least 10 minutes four
1013.44 -> times a week
1014.639 -> or vigorous intensity
1017.04 -> activity for 20 minutes twice a week
1019.519 -> this is based on
1021.279 -> a post hoc analysis of the sampras trial
1024.079 -> which was a medical management versus
1026.079 -> stenting trial for intracranial athero
1029.039 -> and they found that those who did not
1031.199 -> engage in that amount of activity
1033.36 -> had a five times higher risk of stroke
1035.919 -> mi or vascular death additionally we
1039.12 -> know that
1041.28 -> the two systematic reviews of exercise
1044 -> classes with counseling showed
1047.12 -> a reduction in cardiometabolic risk
1049.2 -> factors but not reduction in stroke
1052.64 -> um and the bust stroke trial is actually
1056.64 -> an important neutral that showed that if
1059.28 -> you break up sedentary activity
1062.48 -> everything 30 minutes with three minutes
1064.64 -> of light bouts of light activity there's
1067.36 -> an improvement in cardiovascular health
1073.679 -> with regards to uh smoking and substance
1076.24 -> news there's really nothing new here
1078.88 -> and patients who smoke they should be
1081.039 -> counseled to stop and um
1083.52 -> uh provided resources for counseling and
1087.12 -> or
1087.919 -> uh drug therapy with nicotine
1089.919 -> replacement bupropion or very various
1093.2 -> very clean
1094.96 -> um
1096.64 -> and um
1098.24 -> they should uh be advised to stop in
1101.2 -> patients with a history of stroke or ta
1103.52 -> they should also be a council to avoid
1105.76 -> passive smoking because there is an
1107.44 -> association between
1109.2 -> environmental smoke
1111.36 -> or secondary smoke and uh stroke
1115.28 -> with regards to alcohol there is a j
1118.16 -> shaped curve so that
1120.48 -> there is a lower risk at about
1124 -> two drinks a day for men and over one
1126.72 -> drink per day at one drink per day for
1129.2 -> women however because it's a j shaped
1131.679 -> curve
1132.48 -> the risk increases exponentially after
1135.36 -> that amount so if they're drinking that
1137.039 -> amount they should be cancelled to
1138.88 -> reduce or eliminate uh drinking
1142.559 -> additionally in individuals who
1145.28 -> are using stimulants or iv drug use they
1147.44 -> should be
1148.32 -> counseled to to stop and as you know
1151.039 -> it's not enough to just tell someone to
1152.96 -> stop uh referral to specialized services
1155.919 -> to help them with their dependency is
1157.84 -> critical
1160.88 -> um with regards to hypertension
1162.96 -> management so there are several trials
1165.2 -> which are not new um and systematic
1167.76 -> reviews that have shown that a thiazide
1170.08 -> diuretic ace inhibitor or angiotensin
1172.559 -> receptor blocker are associated with
1175.52 -> reduced risk of recurrent stroke in
1177.12 -> individuals with stroke
1178.799 -> however what is new is the blood
1180.799 -> pressure goal so meta-analysis of four
1183.44 -> randomized control trials respect past
1185.84 -> bp sps3 and podcast showed that an
1189.2 -> intensive goal
1190.96 -> of less than 120 or less than 130
1193.76 -> depending on which trial was superior to
1196.64 -> a goal of less than 140 or less than
1199.679 -> 150.
1201.52 -> therefore we have a class 1 br
1204.64 -> recommendation for a blood pressure goal
1206.88 -> of less than 130 over 80.
1209.76 -> in addition
1212.159 -> there's a recommendation to to
1214.88 -> choose medication based on patients
1216.72 -> comorbidities
1218.24 -> and in patients who do not have a
1220.159 -> history of high blood pressure but do
1222.32 -> have a blood pressure of over 130 over
1224.559 -> 80 we are recommending starting
1226.88 -> medications
1230.64 -> with respect to hyperlipidemia there are
1233.2 -> some new
1234.48 -> studies here
1235.76 -> so first of all the sparkle trial showed
1238.32 -> that a torba 80 versus placebo reduces
1240.72 -> risk of recurrent stroke however we did
1243.28 -> not know the target ldl so the tst study
1246.799 -> gave us that information
1248.48 -> they found that individuals with a
1250.159 -> target ldl of less than 70 had a reduced
1253.679 -> risk of recurrent stroke compared to
1255.44 -> those with a goal of 90 to 110
1257.919 -> and based on that we have a new class
1260.88 -> one 1
1262.159 -> a recommendation to treat to a goal of
1265.52 -> less than 70 using acetamide if needed
1269.52 -> in addition to a statin
1271.6 -> and in patients who are high risk
1274.88 -> defined as stroke plus another major
1278.12 -> atherosclerotic cardiovascular disease
1280.96 -> or stroke plus multiple high risk
1282.64 -> conditions
1284.24 -> there's a recommendation to also add
1286.72 -> psk9 therapy
1289.2 -> if a statin and azadomide
1292.48 -> do not reduce the the ldl to below 70.
1299.44 -> for
1300.44 -> hypertriglyceridemia we have new
1302.08 -> recommendations as well so the first is
1305.679 -> based on the reduce at trial where they
1308.32 -> randomize individuals with
1310 -> atherosclerotic cardiovascular disease
1313.52 -> including a history of ischemic stroke
1315.28 -> they had quite a few people with
1316.48 -> ischemic stroke in this trial
1318.48 -> and they randomized them to icosapentyl
1321.28 -> ethyl 2 grams vid
1323.84 -> plus statin versus statin alone and
1326.159 -> showed a reduction in the primary
1328.48 -> endpoint of adverse cardiovascular
1330.159 -> events therefore we have a 2a
1333.12 -> recommendation
1334.88 -> a 2a because it's not in a purely stroke
1337.2 -> population
1338.64 -> of um adding
1340.64 -> icosapentyl ethyl 2 grams bid for
1343.44 -> individuals who have high triglycerides
1346 -> but less than 500
1349.039 -> additionally we have a recommendation to
1352.559 -> address severe hypertriglyceridemia
1355.6 -> because it can cause multiple adverse
1358.48 -> effects including pancreatitis
1364.159 -> for glucose there's a few key points one
1367.12 -> is that the eight we recommend an a1c
1370.48 -> goal of less than seven percent with
1372.96 -> those who have diabetes
1375.2 -> and especially those who are less than
1377.28 -> 65.
1378.799 -> in addition the the treatment of
1381.039 -> diabetes should include a glucose
1382.96 -> lowering agent with proven
1384.4 -> cardiovascular benefit
1386.32 -> the glp-1 receptor agonists have been
1389.44 -> shown to have cardiovascular benefit and
1391.84 -> should be added in individuals with
1394.24 -> established cardiovascular disease
1397.2 -> as um
1399.039 -> as with any uh stroke uh there's a
1402.72 -> recommendation to include lifestyle
1404.559 -> counseling nutritional management
1407.12 -> diabetes self-management education
1410.08 -> and
1410.799 -> support and medications
1413.44 -> now with respect to the a1c level we do
1416.4 -> not know if a lower a1c goal is
1420.24 -> a benefit for reducing recurrent stroke
1423.679 -> the studies did show higher rates of
1426.32 -> hypoglycemia with
1428.72 -> more strict glucose
1430.32 -> control
1432.159 -> and then in
1433.919 -> individuals with pre-diabetes metformin
1436.4 -> can be
1437.919 -> beneficial for lowering the blood sugar
1440 -> and reducing the risk of diabetes
1442.559 -> and in individuals with insulin
1444.799 -> resistance pioglitazone can be
1448.08 -> considered this is based on the iris
1450.48 -> trial which showed a reduced risk of
1452.799 -> recurrent stroke
1454.4 -> in individuals treated with pioglitazone
1458.159 -> of note you uh
1460.559 -> patients with a severe congestive heart
1463.279 -> failure
1464.32 -> and
1465.12 -> bladder cancer would be excluded from
1467.279 -> pioglitazone treatment
1471.2 -> with regards to obesity obesity and
1473.6 -> sleep apnea we recommend weight loss and
1477.159 -> multi-component behavioral lifestyle
1479.44 -> interventions for individuals with
1480.96 -> obesity we also recommend checking a bmi
1484 -> at the time of the stroke and annually
1486.24 -> thereafter
1487.679 -> for individuals with sleep apnea we
1490.08 -> recommend positive airway pressure
1492.799 -> and
1493.6 -> it is reasonable to evaluate for sleep
1495.679 -> apnea during a stroke workup
1497.36 -> particularly in individuals who you
1498.96 -> think are at high risk for sleep apnea
1504.32 -> so now we move to the section uh by
1507.279 -> etiology and
1509.679 -> the section is a little bit dense um but
1512.84 -> uh i'll hope to
1514.96 -> i'll try to make it as simple as
1516.64 -> possible so we're going to start with
1518.76 -> intercranial large artery
1520.559 -> atherosclerosis
1522.559 -> so
1523.84 -> we know that individuals who have at
1526.48 -> least moderate stenosis of an
1528.08 -> intracranial artery aspirin 325 is
1531.12 -> recommended this was based on the wasat
1533.52 -> trial which looked at warfarin versus
1535.52 -> aspirin and found aspirin to be superior
1538 -> to warfarin
1540.64 -> in individuals with severe stenosis at
1543.44 -> least 70 percent
1545.52 -> addition of clopidogrel to aspirin for
1548.799 -> up to three months is reasonable now
1551.679 -> this is um not a based on randomized
1554.4 -> controlled trial data it's looking at
1556.48 -> the medical management arm of sampras
1559.279 -> which was a trial of medical management
1561.44 -> versus stenting
1562.96 -> and looking at the event rate in the
1564.799 -> sampras trial
1566.32 -> when
1567.36 -> medical management was clopidogrel plus
1569.039 -> aspirin and comparing that event rate to
1571.84 -> the wasat trial aspirin arm so aspirin
1575.52 -> arm in the watson trial versus aspirin
1577.6 -> was clever girl
1579.12 -> in the sampus trial and they found lower
1581.36 -> event rates in the sampus trial so
1585.2 -> it's an indirect comparison um but based
1588 -> on that it's reasonable to consider
1590.559 -> um dual antiplatelets for three months
1592.88 -> and somebody with symptomatic severe
1594.48 -> stenosis
1596 -> now if somebody has epsilon stenosis of
1599.36 -> at least 30 percent
1601.52 -> the thales trial showed that addition of
1604.24 -> ticagrelor plus aspirin might be
1606.88 -> considered
1608.48 -> and
1609.36 -> there have been numerous studies looking
1610.96 -> at celostazole plus aspirin
1615.52 -> or cellos dissolve plus clovida girl in
1618.32 -> patients with moderate to severe
1620.159 -> stenosis
1621.679 -> and the data has been
1623.84 -> mixed
1624.799 -> so there's a toss one tossed to
1626.48 -> catharsis and csps trials the csps trial
1630.88 -> showed a benefit of celostazol plus
1633.44 -> aspirin
1635.52 -> for reduction of recurrent events
1637.36 -> catharsis just showed a benefit for
1640.24 -> reduction of vascular events and silent
1642.72 -> brain infarcts and toss one and tossed
1645.12 -> it did not show a benefit so that's a 2b
1648.96 -> limited data recommendation i'd also
1651.36 -> like to point out that
1653.52 -> those trials were done in a
1655.039 -> predominantly asian population so it may
1657.279 -> not be generalizable
1659.52 -> and the last recommendation is
1662.08 -> in anyone with uh moderate to severe
1665.279 -> intracranial athero
1667.919 -> it's unknown
1669.36 -> whether to use clopidogryl
1671.36 -> agronox ticagrelor or celostazole alone
1675.12 -> because those have not been studied
1679.52 -> so
1680.32 -> bottom line
1681.679 -> moderate to severe stenosis aspirin 325
1685.2 -> if it's severe um symptomatic stenosis
1688.159 -> reasonable to add clopidogrel to aspirin
1691.2 -> for 90 days
1692.72 -> and um it's also reasonable to consider
1696.48 -> adding ticagrelor plus aspirin
1700.64 -> for up to 30 days but that
1703.279 -> data is not as convincing
1707.12 -> the other thing to keep in mind is in
1709.279 -> the past we often used to let the blood
1712.32 -> pressure ride a little bit higher in
1714.24 -> patients with symptomatic intracranial
1716.24 -> athero however post-hoc analyses from
1720 -> wasab sampras and the chinese
1722.24 -> intracranial athero registry
1724.399 -> showed that those who had a blood
1726.08 -> pressure of less than 140
1728.32 -> actually had a lower risk of recurrent
1730.159 -> stroke than those with a higher blood
1731.919 -> pressure
1732.96 -> so in anyone with moderate to severe
1735.039 -> intracranial athero we recommend high
1737.76 -> intensity statin antiplatelet systolic
1741.039 -> blood pressure less than 140 and
1743.84 -> physical activity to reduce risk of
1745.6 -> recurrent stroke
1750.159 -> with regards to angioplasty and stenting
1753.039 -> there have been three
1754.799 -> studies that have looked at um
1757.919 -> percutaneous transluminal angioplasty
1760.799 -> and stenting versus medical management
1763.44 -> in patients with symptomatic
1765.039 -> intracranial arthro
1766.88 -> and the um
1770.399 -> and there's harm to for in the stenting
1772.88 -> arm so there are there's a three harm
1777.12 -> recommendation for stenting in a
1779.76 -> symptomatic intracranial athero
1782.24 -> um that's based on those three studies
1784.799 -> and um
1786.559 -> that's where for symptomatic severe
1788.64 -> stenosis
1790 -> um since uh the event rates in moderate
1792.88 -> stresses are even lower we extended that
1795.44 -> to a three-harm recommendation for
1798.24 -> moderate stenosis
1800.08 -> even though there has not been a trial
1801.679 -> for that
1803.12 -> with regards to
1805.2 -> bypass um there have um
1809.84 -> there are higher higher rates of stroke
1811.6 -> with bypass in patients um
1814.799 -> who um
1816.399 -> had bypass
1818 -> for for symptomatic uh stenosis so
1820.559 -> there's no benefit for
1822.399 -> bypass either
1826 -> so we've talked about intracranial
1828.159 -> athero now let's talk about extra
1830.24 -> cranial large artery athero
1832.559 -> so
1833.76 -> numerous studies have shown that uh for
1836.799 -> symptomatic severe
1838.88 -> ica stenosis carotid endoderectomy is
1841.919 -> better than medical management provided
1844.559 -> the perioperative risk is less than six
1846.64 -> percent this is uh
1848.799 -> based on a rothwell meta-analysis dr
1851.679 -> rothwell did a meta-analysis which
1853.2 -> included nasa ecst and the va trial
1857.919 -> um
1858.799 -> the in this meta-analysis there was a 16
1861.36 -> absolute benefit over five years for
1862.96 -> severe stenosis
1864.399 -> and a five percent benefit over five
1866.64 -> years for moderate stenosis
1870.24 -> the peri procedural risk of six percent
1872.64 -> is based on those studies as well as
1874.88 -> crest and um statistical modeling
1879.279 -> now um
1881.519 -> anyone with symptomatic ic stenosis
1883.6 -> should be on antiplatelet statin that
1885.2 -> has their blood pressure management
1887.279 -> now the question of stenting versus ca
1890.399 -> is um
1891.6 -> discussed in a couple of recommendations
1893.76 -> so in those with who are at least 70
1896.08 -> years old it's reasonable to select cea
1899.36 -> over
1900.159 -> stenting
1901.84 -> to reduce the risk of the pair
1904.08 -> procedural stroke risk additionally if
1906.559 -> you're going to do it within one week
1908.399 -> it's reasonable to choose cea over
1910.32 -> stenting because there's higher risk
1911.919 -> with stenting
1916.08 -> if revascularizing with stenting or
1919.679 -> cea it's best to do it within two weeks
1922.88 -> of the index event this is do uh a 2a
1925.84 -> recommendation with limited data
1928.24 -> and if if somebody has anatomic or
1931.12 -> medical conditions that increase the
1932.64 -> risk of surgery it's reasonable to
1934.559 -> stenting over cea
1940 -> and it's also
1941.679 -> reasonable to choose stenting over cea
1944.24 -> in symptomatic patients who are at
1947.039 -> average or low risk of com of
1949.519 -> complications
1951.44 -> um the other uh recommendation that's
1954.399 -> new is uh there's a new procedure called
1957.44 -> trans-carotid artery revasculation
1959.919 -> vascularization or tcar we have limited
1962.88 -> data on this and so we don't know if
1965.279 -> this is beneficial in cardiac stenosis
1968.72 -> and
1969.919 -> we do know in patients
1972.72 -> with recent tia or stroke bypass is not
1976 -> recommended in
1978.64 -> patients who have an occlusion this is
1980.399 -> based on the cost trial
1983.519 -> if the
1984.799 -> if a patient has symptomatic ica
1986.88 -> stenosis of less than 50 percent
1989.679 -> cea or stenting is not recommended and
1992 -> that's based on a rothwell meta-analysis
1997.36 -> we did have a separate section of
1999.039 -> vertebral athero
2001.279 -> in patients with vertebral artery
2003.36 -> stenosis
2004.88 -> there's no benefit for stenting
2010.64 -> and aortic arch atheros so this has been
2013.2 -> a topic of conversation for many years
2016.08 -> unfortunately the arc study did not
2018.72 -> answer the question of aspirin
2020.96 -> of anti-platelet versus anti-coagulation
2023.12 -> as it was underpowered they had much
2025.519 -> fewer events in the study than they
2027.76 -> anticipated likely due to
2030.399 -> intensive medical management so at this
2033.279 -> time
2034.72 -> in patients with aortic arch athero we
2037.039 -> recommend
2038.159 -> uh intensive lipid management as well as
2040.799 -> antiplatelet therapy
2049.28 -> for small vessel disease there have been
2051.2 -> numerous studies looking at celostazole
2053.76 -> versus aspirin um actually two studies
2056.8 -> csbs and csbs2 these um and csps2 uh
2062.079 -> about two thirds of the patients had
2063.76 -> small vessel disease they looked at
2065.28 -> celostasol versus aspirin
2067.52 -> and although was a celostal was
2069.52 -> associated with a lower ischemic a lower
2072 -> risk of ischemic or hemorrhagic stroke
2074.32 -> when you only look at ischemic stroke
2076.079 -> there was a non-significant reduction
2078.96 -> therefore
2080.32 -> at this time it's still uncertain
2082.48 -> whether to use cellostazol for small
2084.8 -> vessel disease
2088.159 -> atrial fibrillation um we have a class
2091.119 -> one recommendation to use
2093.639 -> anticoagulation um for patients with
2095.919 -> atrial fibrillation and that includes
2098.4 -> either warfarin or doulac
2100.72 -> now we have another class one
2102.88 -> recommendation to use
2105.359 -> um
2106.4 -> anyone who is non-valvular afib to use a
2109.44 -> doc over warfarin
2112.079 -> and that's based on the four randomized
2114.16 -> trials aristotle rely engage af timmy 48
2117.839 -> and
2118.64 -> um
2120 -> rocket af
2122.96 -> the other two recommendations are that
2124.8 -> you should treat paroxysmal and
2127.44 -> persistent afib the same
2129.599 -> and that you should treat a flutter the
2131.28 -> same as a-fib
2134.24 -> in addition in patients who have uh
2137.2 -> contraindications to long-term
2138.8 -> anticoagulation you can consider
2141.2 -> watchmen device so it's a left atrial
2143.599 -> appendage
2145.04 -> occlusion device
2146.96 -> it has been shown to have a
2148.24 -> non-significant increase in thrombotic
2150.64 -> risk but a lower bleeding risk so in
2153.52 -> somebody who can tolerate short duration
2155.76 -> of anticoagulation of 45 days a watchman
2158.96 -> device is reasonable
2161.599 -> now the other thing is um when do you
2164.079 -> start anticoagulation after a stroke
2166.24 -> this is a question that comes up pretty
2168.16 -> often
2169.2 -> so let's say you have your stroke if
2171.839 -> it's a tia and the patient is bound to
2174 -> be an afib it's fine to start
2176.2 -> anticoagulation immediately if there's
2178.72 -> no evidence of stroke now if it's a
2181.28 -> small stroke
2182.8 -> with low risk for hemorrhagic
2184.24 -> transformation it's reasonable to start
2186.96 -> between days 2 and 14 and if it's a
2190.48 -> larger stroke or high risk for
2193.28 -> hemorrhagic conversion you're going to
2195.2 -> want to start anticoagulation after day
2197.76 -> 14 to reduce the risk of hemorrhagic
2200.32 -> transformation
2203.2 -> for valvular heart disease we divided it
2206.079 -> into three
2207.119 -> categories so patients with valvular
2209.76 -> disease plus afib
2211.839 -> patients who have valvular disease who
2213.52 -> are in sinus and patients who have
2215.359 -> valvular disease
2217.119 -> with endocarditis
2219.839 -> so in patients with afib
2223.68 -> if you have
2226.4 -> valvular afib which is defined as
2228.88 -> moderate to severe mitral stenosis or a
2231.599 -> mechanical valve warfarin is recommended
2235.28 -> non-valuable or a-fip we recommend a
2237.76 -> delac
2239.119 -> if you're in sinus rhythm
2241.359 -> the oh and you have non-rheumatic mitral
2244.4 -> valve disease aortic valve disease
2247.119 -> mitral valve or aortic valve prosthesis
2250.079 -> you're going to be on an anti-platelet
2252.48 -> and if you have a mechanical mitral or
2254.96 -> aortic valve we recommend warfarin
2258.16 -> now i'll talk a little bit about this in
2260.56 -> the next slide but generally
2262.8 -> mitral valve has a higher um goal a inr
2267.04 -> of
2267.839 -> 2.5 to 3.5 an aortic valve is two to
2271.599 -> three unless you have a stroke in which
2274.079 -> case it's reasonable to intensify the
2276.48 -> treatment goal to 2.5 to 3.5
2280.32 -> in patients with infected endocarditis
2282.72 -> the question is are you going to do
2284.72 -> surgery early or later now if there's a
2288.72 -> if the patient has interest
2291.119 -> a risk for
2292.8 -> hemorrhage has intracranial hemorrhage
2294.48 -> or a large stroke the recommendation is
2296.72 -> to delay surgery
2298.72 -> if they have a mobile vegetation
2301.68 -> or that's at least 10 millimeters or
2304.32 -> they're having recurrent strokes despite
2306.24 -> antibiotics early surgery is reasonable
2311.359 -> so this um algorithm goes back to what i
2314.88 -> was talking about the the inr goal so by
2317.839 -> prosthetic valve you're going to do
2319.04 -> anti-platelet mechanical valve if it's a
2322.4 -> mitral valve you're going to do an inr
2324.16 -> goal of 2.5 to 3.5
2327.04 -> if they had a stroke you're going to add
2328.8 -> aspirin to that
2330.88 -> and for a mechanical aortic valve if
2333.68 -> they have a stroke while they have their
2336.4 -> valve and they're on anticoagulation
2338.96 -> it's reasonable to either intensify the
2341.04 -> iron article to 2.5 to 3.5 or add a baby
2345.04 -> aspirin
2347.44 -> and there have been studies that showed
2349.359 -> that dabigatran should not be used in
2351.44 -> the setting of a mechanical valve
2355.599 -> for cardiomyopathy acute a few key
2358.8 -> recommendations um and also intracardiac
2361.92 -> thomas so
2363.04 -> lv or left atrial
2365.04 -> thrombus you're going to anticoagulate
2367.44 -> if there's an lvad
2369.359 -> then the recommendation is warfarin plus
2371.92 -> aspirin
2373.2 -> lv non-compaction
2375.119 -> warfarin
2376.32 -> and others it's going to be based on the
2378.48 -> individual condition
2381.599 -> now
2382.56 -> pfo is a relatively controversial topic
2386.24 -> there have been numerous different um
2389.28 -> guidelines with respect to pfo
2392.16 -> but i'm going to kind of give you
2394.72 -> our recommendations in a nutshell
2396.96 -> so first you have to look at the age of
2398.4 -> the patient so in individuals who are 18
2401.04 -> to 60 that's the age range in which
2403.28 -> these studies were done
2404.88 -> and they have a non-lacunar stroke and a
2407.28 -> pfo you're going to look for other
2409.359 -> causes if you don't find any other
2410.96 -> causes
2412.16 -> then it's possible that it's a
2413.68 -> paradoxical embolism
2415.839 -> now the two the things you should think
2417.68 -> about are is it a high-risk pfo or
2420.56 -> low-risk pfo high risk would be someone
2423.52 -> with either an atrial septal aneurysm or
2425.839 -> a large right to left shunt and this has
2428.4 -> been defined differently but in
2430.079 -> different studies but one
2432.24 -> example of a definition is at least 20
2434.56 -> micro bubbles so high risk pfo
2438.4 -> pf
2439.52 -> pfo closure is reasonable it's a 2a
2441.839 -> recommendation
2443.92 -> if it's a low-risk pfo
2446.8 -> then the benefit of closure is not well
2448.48 -> established and then you want to look at
2450.88 -> other things to help make your decision
2454.319 -> one really useful tool is the rope score
2457.839 -> which is the risk of paradoxical
2459.52 -> embolism score that tells you the
2461.52 -> likelihood that the pfo is related to
2463.76 -> the stroke
2468 -> the next slide is on dissection now
2470.8 -> there is a separate scientific statement
2473.52 -> on dissection but we have a short
2474.96 -> section here
2476.319 -> um
2477.28 -> so the main points are antithrombotic
2479.839 -> therapy for at least three months
2482.48 -> and the catas trial looked at
2484.72 -> anti-platelet versus anticoagulation
2487.839 -> and
2488.64 -> basically showed no difference in the
2490.24 -> primary endpoint at one year so it is
2492.88 -> reasonable to use either aspirin or
2495.04 -> warfarin to prevent recurrent stroke or
2497.119 -> tia
2498.4 -> now in patients who are having recurrent
2500.64 -> strokes despite maximal medical
2502.72 -> management it or if they develop a
2505.119 -> pseudoaneurysm it is reasonable to
2507.359 -> consider endovascular therapy but that's
2509.76 -> a 2b recommendation
2515.04 -> we have a new section on embolic stroke
2517.2 -> of undetermined source this has been a
2519.52 -> topic of active research now just
2522.8 -> remember the definition of esis is a
2525.28 -> cryptogenic stroke that looks symbolic
2528.56 -> um
2529.44 -> and uh so in patients with esis
2533.76 -> treatment with doax is not recommended
2536.24 -> and that's based on the navigate thesis
2538.16 -> and respect issues trials
2540.24 -> in addition uh treatment with ticagrelor
2543.2 -> is not recommended and that's based on a
2545.359 -> post-hoc analysis of patients with
2547.76 -> issues who are enrolled in the socrates
2549.92 -> trial
2552.16 -> this is the last section
2554.64 -> and it's the systems of care section
2557.2 -> so
2558.319 -> we divided it into health systems based
2560.72 -> intervention so
2562.8 -> interventions that are changing the way
2564.319 -> you deliver care in the health system
2566.319 -> versus uh behavior change interventions
2568.88 -> where you're expecting the
2570.88 -> patient to change their behavior
2573.04 -> and there have been numerous studies
2575.92 -> with really mixed results but a few
2578.64 -> things
2580.24 -> are being recommended one
2583.2 -> is that it's important for hospitals and
2586.64 -> outpatient clinics to
2589.28 -> look at quality and improvement programs
2591.68 -> to look at
2593.599 -> nationally accepted evidence-based
2595.52 -> guidelines for secondary stroke
2596.72 -> prevention
2597.92 -> the second which is based on some
2600 -> randomized controlled trials is to use a
2602.28 -> multidisciplinary team
2604.16 -> and what we mean by a multi-disciplinary
2606.16 -> team that can include advanced practice
2608.4 -> providers nurses and pharmacists to
2611.119 -> control vascular risk factors and on the
2613.92 -> left you can see a few of the studies
2615.92 -> that utilize multi-disciplinary teams
2619.04 -> the third is to use a decision support
2622.16 -> tool so the fastest trial looked at a
2624.8 -> electronic decision support tool for
2627.52 -> managing um
2630.64 -> secondary stroke prevention there are
2632.64 -> numerous trials that are currently
2634.56 -> underway um looking at strategies to
2637.28 -> optimize secondary stroke prevention
2639.359 -> it's an area of active research
2642.56 -> and then the second section is on
2645.76 -> behavioral oh sorry i skipped a slide
2651.44 -> so behavior change interventions
2654.079 -> so these are interventions where you're
2655.68 -> trying to help the patient change their
2657.68 -> behavior whether it's regards with
2659.76 -> regards to diet lifestyle medication
2662.64 -> adherence
2665.04 -> and so in order to do a behavior change
2667.76 -> intervention it's really important to
2669.52 -> use a
2672.319 -> model of behavior change
2674.88 -> the social sciences have very robust
2677.28 -> models of behavior change so our first
2680.56 -> recommendation is
2682.72 -> to to
2684.24 -> target
2685.44 -> stroke literacy lifestyle factors and
2687.04 -> medication adherence for cardiovascular
2689.04 -> events the second is that we don't know
2692.64 -> the optimal tools but motivational
2694.56 -> interviewing has been shown to be
2697.92 -> useful
2699.119 -> in the mistrial as well as a text
2702.24 -> messaging uh trial of sms for stroke
2705.52 -> showed that text messaging was helpful
2707.839 -> for medication adherence
2710.16 -> um a meta-analyses of lifestyle
2712.48 -> interventions have shown that you have
2714.64 -> larger effects if you combine
2716.88 -> a kind of counseling lifestyle
2718.72 -> intervention with an actual exercise
2721.839 -> based group exercise based intervention
2724.64 -> in addition several small cardiac rehab
2727.599 -> trials have shown evidence of
2729.68 -> improvement in cardiovascular risk
2731.76 -> factors but not secondary stroke
2734.72 -> and the one clear thing that we know is
2737.119 -> that it's not not enough to just give
2739.119 -> someone a pamphlet or handout
2741.599 -> in order to change their behavior you
2743.359 -> really need more robust behavioral
2745.52 -> intervention
2748.319 -> and finally we have a section on health
2750.079 -> equity um
2751.92 -> there have been numerous uh trial
2753.92 -> secondary stroke prevention trials
2755.76 -> trying to reduce disparities and stroke
2758.4 -> they've all had mixed results
2761.44 -> but there are a few key take-home points
2763.44 -> one is that it's critical to address
2765.52 -> social determinants of health
2767.68 -> the second
2768.8 -> is that it's it's helpful as mentioned
2771.2 -> earlier to monitor evidence-based
2773.92 -> performance measures
2775.599 -> the third and this is based on an aha
2778.4 -> scientific statement
2780.24 -> is to use the ahrq precautions toolkit
2783.359 -> for health literacy to ensure that your
2786.24 -> materials are appro appropriate
2789.839 -> um for individuals with limited english
2792.16 -> proficiency
2793.76 -> and finally
2795.52 -> in patients who are from vulnerable
2797.92 -> groups um the uh the
2801.04 -> the best model for reducing
2803.839 -> risk factors for stroke remains unknown
2806.56 -> and i included a few of these key
2808.96 -> knowledge gaps here
2813.359 -> so i'm just going to give you our top 10
2815.839 -> take-home messages i know that was
2817.92 -> really a lot of information i tried to
2820.16 -> give you the the key um
2822.96 -> the key messages but
2824.8 -> let's just summarize real quick
2827.2 -> so one
2828.319 -> your strategy for secondary stroke
2831.44 -> uh prevention depends on the etiology of
2833.599 -> the stroke the second is you need to
2835.68 -> manage vascular risk factors those
2837.359 -> include hypertension diabetes
2839.04 -> dyslipidemia
2840.559 -> diet and physical activity
2843.359 -> and that segways into number three that
2845.599 -> it's really critical to address
2847.2 -> lifestyle
2848.48 -> and that
2849.92 -> you can't change someone's behavior with
2851.839 -> just a handout you need to refer them to
2853.839 -> a more robust program that includes
2856.079 -> either motivational interviewing or some
2858.64 -> kind of group support or self-management
2861.119 -> support
2863 -> anti-thrombotics are recommended in most
2865.52 -> patients the only time you're going to
2867.2 -> use dual antiplatelets is for short-term
2869.599 -> use in either
2871.68 -> patients with
2873.359 -> small stroke or high risk tia for the
2876.24 -> first uh three months or in patients
2878.8 -> with symptomatic intracranial athero for
2881.2 -> three months
2883.28 -> in atrial fibrillation
2885.68 -> anticoagulation is recommended um in
2888.4 -> most cases you're gonna we're gonna
2890.079 -> recommend a doc over a warfarin and if
2893.2 -> somebody has embolic stroke fund
2895.2 -> determines us
2897.52 -> source it's um we recommend looking for
2901.599 -> occult afib with long-term rhythm
2903.92 -> monitoring
2905.359 -> for severe extra training extra cranial
2908 -> stenosis we recommend um
2910.8 -> either cea or stenting depending on
2913.76 -> patient circumstances
2915.68 -> and severe intracranial stenosis don't
2918.24 -> stent as first line use aggressive
2920.24 -> medical management which includes
2923.04 -> anti thrombotic
2925.2 -> statin therapy blood pressure control
2927.839 -> and diet and physical activity
2930.48 -> for pfos in certain circumstances it's
2933.68 -> reasonable to close the pfo particularly
2935.839 -> in those under 60 with a high risk pfo
2938.96 -> and finally essa should not be treated
2941.359 -> empirically with anticoagulants or
2943.28 -> ticagrelor
2944.72 -> and there are
2946 -> ongoing studies to determine the optimal
2948.559 -> management of esis
2951.28 -> um and so that leaves us some time for q
2954.64 -> and and we have about 10 minutes for
2956.96 -> questions
2959.68 -> thank you
2961.2 -> um anybody have any questions i do see
2963.92 -> one but feel free to type them into the
2966.96 -> chat box
2968.16 -> and dr taffigi will toffee sorry we'll
2972.559 -> answer those
2973.76 -> and um
2975.44 -> or you can star six to unmute yourself
2977.76 -> so the first question is can you further
2980.4 -> discuss aspects that influence which
2982.559 -> patient should have a tte or a tee to
2986.079 -> determine stroke etiology the 2019 aha
2990.079 -> ais guidelines state the benefit of
2992.24 -> routine use of echocardiogram is
2994.72 -> uncertain for example should lacunar
2997.2 -> strokes have cardiac structures imaged
2999.359 -> if the patient has known vascular risk
3001.28 -> factors
3004.079 -> um so that's a great question um so if
3007.119 -> we go back to
3009.04 -> the diagnostic slide one sec
3012.96 -> um
3014.079 -> so it's a 2b recommendation to look for
3017.359 -> cardiac sources of envelopes um with tte
3020.319 -> or t-e-e
3021.839 -> um and so i think you know you're gonna
3025.04 -> find different practices based on the
3027.92 -> institution where you work we um we
3031.2 -> don't have um great evidence
3034.319 -> but just because something hasn't been
3035.92 -> tried um you know there hasn't been a
3038.24 -> randomized controlled trial doesn't mean
3040.4 -> that it shouldn't be done
3043.119 -> and so
3044.079 -> in this case you're going to find
3045.52 -> different practices at different
3046.96 -> institutions
3052.64 -> okay thank you
3054.559 -> um any additional questions
3057.359 -> you can either star sticks to unmute
3059.28 -> yourself type them in or you can unmute
3062.48 -> yourself at the bottom of your screen
3073.2 -> okay so i'm not seeing any additional
3075.839 -> questions
3076.96 -> so
3077.76 -> i just want to thank you so much for
3079.52 -> this excellent presentation
3082.319 -> thank you everybody who joined us
3084.72 -> and we will be sending out a link to the
3086.96 -> presentation
3088.48 -> within the next week or so so that
3090.4 -> you'll have that available and if you
3092.72 -> have any further questions feel free to
3094.64 -> reach out anytime
3097.76 -> and i just want to point you to the
3099.28 -> guidelines on the go
3105.44 -> that's an excellent resource looks like
3107.599 -> we do have one more question here is
3110.4 -> there a reason that the new nursing
3111.92 -> guidelines did not use the same
3113.599 -> evidence-based criteria
3117.359 -> um i cannot speak to that um so the the
3121.68 -> do you mean the
3123.2 -> level of evidence and the strength of
3125.52 -> the recommendations
3132.319 -> yes she says okay um so
3135.359 -> the i'm not sure the um the aha um has
3139.76 -> pretty strict rules um about the
3143.119 -> using the level of evidence and circle
3145.44 -> recommendations so i would uh i don't
3148.16 -> know enough about the new nursing
3149.599 -> guidelines to to comment on that i'm not
3151.839 -> sure if someone else
3153.599 -> can comment on that
3162.16 -> i can look into it she said thank you
3165.44 -> and i can look into it donna for you and
3168.72 -> see if i can find any information and
3170.64 -> get back to you
3174.559 -> any additional questions
3180.16 -> okay again thank you so much for joining
3182.72 -> the presentation it's an excellent
3184.64 -> presentation and we really appreciate
3186.8 -> your time and expertise
3189.359 -> so thank you so much for having me
3191.76 -> yep have a great rest of your day
3193.44 -> everybody bye bye
Source: https://www.youtube.com/watch?v=PnZmDap57io