Recent Therapy of Acute Stroke / TIA in prime Time at Primary Care

[urrent

Upilates

ol

Initial

$h0rh attf, $ttohe

ilaltagenteltl

in

Primary

Care

CEE

DING

3(}(}1{

I

sEMfitAB

flASl0ilAL

SABTU,

I

APfrIL 2016

07.00

-

16.00

wtB

)

+'r* coNtttturxG IrrEDrcAL EDUcATrox

FAKULTAS KEDOKTERAN t}AIiI ILMU KESEHATAN UNIVERSITAS MUHATIMADIYAH YOGYAGARTA

q

I

DAFTAR

ISI

Kata

Pengantar...

...i Kala

5ambutan...

...r;

DaJiar

1si...

...vii

Clinicul Practice Guideline For Manageruent Stroke

Puticttts lrt Prinrary Health Cctre

(Phc:)

...1

Prut/'. Dr. dr. Rusdi Lamsudin, Sp S(K)., M.Med.Sc

Surgicul lnclic'ation For

Stroke.

...J rlr. Endro Basulci Sp.BS(K) M.Kes

Rccent Theraplt Of Autte Stroke

/

Tia In Prime Tirue

At

Priman,Cure...

...17

Dr. dr.

Tri

Wahyulictti Sp.S., M.Ka,s

Current Update Management And Rehabilitation Of Septic Shock In Printary Health

Care...

...61

dr. Rizka HumardewayantiAsclie, Sp. P D-KPTI

PenatalaksanaanShock : Therapy CairanDan

MonitoringHemodinamikTerkini...

...69 dr. Bhirow

o

Yudopranoto, Sp. An-KAKV

Syok Hipovolemik Pada

Anqk.

...73

Dr.nted.dr. Intan Fatah Kumara, MSc., Sp.A

dr. Nurnaningsih, SpA(K)

vii

Diagnosis Dan Terapi Syok Kardtogenik Pada Layanan Primer...

dr. Erika Maharani, Sp JP(K)

Resusitasi Cairan Pada Syok Akibat Trauma...

dr. Ardi Pramono, SPAn, M.Kes

Tatalaksana Keperawatan Pasien Shock Di Pelayanan Kesehatan Primer ...

Sttdiman, Ns., M.Kep Panitia Pelaksana

76

79

91

95

Ct r r a nt U p tl a t es o _{{ lt} i t i al 5h o ck a tzd S t r o i; r: i\,|il t t it _St t t t(. I i t

Ist {)rintriru

{lnrt

Recent

Therapy

of Acute

Stroke /

TIA

in prime

Time

at

Primary

Care

Dr. dr.

Tri

Wahyulioti Sp.S., M.Kes Departemen Neurologi

Fakultas Kedokteran dan llmu Kesehatan

Un iv ers it as Muhamm adiyah Yo gyak art a

Abstract

TIA, or

traruient ischemic attack,

is a

',mini stroke"

that occuls when

a

blood clot blocks an artery

for

a

shorl

tirne. The only difference between

a

stroke and

TIA

is that

with TIA

the

blockage

is

traruient (tenporary).

TIA

synlptoms

occtu rapidly

and

last

a

relatively short tinie.

Unlike

a

strokc, when

a TIA

is

ovcr, thorc's no permancnt

injury

to

thc brain. Thcrc's

no wily

to

tcll if- symptorns

of

a

stroke will lcad

to

a

TIA

or a major stroke. It's important to

managc imnrcdiately

for

any

TIA

sylptonrs.

Because, ln

peoplc wlro have

a

TIA,

the incidcnce

of

subsequent strokc

Saturday, April 9th 201 6

Asri Mcdical Ccntc.r of Yogyakart;r 1.7

i*

t"t:t:r'ti j: _{l..i tttitli::,;:'i' !iiiiiir! liiit:it. iuti! ,\lrtrl;r fvitit!tt ';'ttt t:!}

i t i i::' r i i t i.t.i t' t.i t...t t r i'

is as high as

l1o

over the next 7 days and 24-21)'Yt over lte following 5 ycars.

Effcctive

trcatment

of

stroke

can prcvcnt

long-term

disability and save lives.

The

spccific trcatmcnts

recommended

depend

on

whether

a

stroke

is

causcd by

a

blood clot

obstructing

the flow

of

blood

to

the

brain

(ischaemic stroke)

or

by

bleeding

in

or

around

the

brain

(haernonhagic slroke).

It

is

very

irportant

to

determaine a

diagnosi.s

of

an

ischaernic stroke

or

haemonfiagic sfl'oke

because

the lalsc

Ircdication

cart rnke

the

bleecling that

occurs in haeuronhagic strokes worse.

Key word :

TIA,

stroke. acute, therapy

Introducfion

A

transient

ischaemic

attack

(TIA)

or

"mirli

stroke"

is

caused by a temporary disruption

in

the blood

supply

to part of the

brain.The disruption in blood supply

results

in

a

lack

of

oxygen

to

the

brain. This can cause

sudden

syrptorns

similar

to

those

of

a

stroke, such as

speech and visual disturbance, and nrrnbness or weakness in

the face. arnrs and legs.However, a TIA does not last as long

Saturday,Aprij .,'i',116

i--*.i.rt:'L! Li :tiilNt:;ti

!tiiiili

,:iiitttl,

titti

.:::,i:i:i;t: lvl.tititii,i;;lii,')ii itt ilt iit:tt':: i.-;'i',

as

a

strokc. Thc effects often only last

lbr a

tbw minutes or hours and lirlly rcsolve within

24

hou's. But, in people who

have

a TIA,

the incidence

of

subsequent stroke is as high as I I o/o over the next

7

days and 24-29o/o over the following 5

years.

The incidence

of

TIAs

increases with age,

liom

l-3

cases per 100,000 in those yolmger than 35 years to as lrulny

as 1.500 cascs per 100,000 in thosc olilcr than [i5 years. The

incidence

of

TIAs

in

men

(101

cases

per

100,000

population)

is

significantty higher than

that in

wornen (70

per

100,000).The incidence

of

TIAs

in

blacks

(98per

100,000 population)

is

higlier than that

in

whites

(81

per 100,000 population).

The causes TIAs

Durng

a

TI{

one

of

the blood vessels that supply

your

brain

with

oxygen-rich

blood

becorres blocked.This

blockage

is

usually caused

by

a blood clot that has formed elsewhere

in

your

body

and fravelled

to

the blood vessels

sryptying the brain, although

it

can also be caused by pieces

of

fatty nraterial

or

air

bubbles.Certain things can increase

Saturday, Aprll 9 th 207 6

L'tirr*i!

Liyeiilt:s o{ btil-ial Sliack itttd Slrol;e kltncgemtnt

I tr. ]) r i rri s t' tl i.itre

your

chances

of

having

a TIA,

inch.rding:srnoking

hypertensiorl obese, higfu cholesterol levels, alcohol, atrial

ftrillatiorL

diabetes,

over

60

years

of

age,

ras

(people

ofAsiarq African

or

Caribbean are also

at

a

higlrer risk

of

having a TIA).

Preventing TIAs

ATIAis

oftena sigt

that

another one rnay follow and you are

at a

high

risk

of

having

a

flrll, life-threatening

stroke

in

the near flture.Regardless

of

whether

or

not you have had

a TIA or

stroke in the past, there are a nurnber

of

ways you can lower your risk

of

having either in the f,rture'

These include Lifbstyle changes:

.

maintaining a healthy weight

.

eating

a

healthy

diet-a

low-fit, rcdtrccd salt,

high-fibre

diet

is

usually recommended, includirrg plenty

of fi'esh fruit and vegetables

exercising rcgularly

-

for

most people. at lcast 150

minutes

of

nnderate-intensity aerobinc activity, such

as

cycling

or frst

walking,

every

week

b

recommended

o

Sat.r ' jay, Apn, .' L _101ir

a

a

C t r rt n I Ll p d a tes tti lr i t iitl Si r o tk a nd 5 i r tt it t: A,li] r t {t tt t t ii: !-t i

irr [)r'iittttt u {..o; ,,

stopping

smoking

-

if

you

srnoke, stopping may

significantly reduce

your

risk

of

having

a

stroke in

the future

cutting

dorvn

on

alcohol

-

you

should aim

not

to

exceed

the

recomrrended alcohollimits

ofthree

to

four rmits

a

day

for

rnen and trvo

to

tlree turits

a

day

for wornen

In

addition

to

lifestyle changes, nnst people who have had a

TIA will

need

to

take one

or

rtore

daily

medications

indefinitety

to

help reduce their chances

of

having

a

stroke or another TIA.

Diagnosis

Ruling

out

metabolic

or

drug-induced causes

of

syrptoms consistent

with

a

transient ischemic attack (TIA)

is

important.

lnitial

assessment

is

ainred

at

excluding

emergency

conditions

that can

mimic

a TIA

(eg,

hypoglycemia,

seizure,

or

inh'acranial henrorrhage).

A

lingerstick

blood

glucose

test

shoulcl

be

perfbrmed and

blood drawrr

lor a

complete bloocl court (CBC), coagulation

Sa turday, Ap ril 9rt 201.6

L..'.urrtniLirdati:soI IrtiIiitl 5!toi:kitrulStroke:Niittttlli'trl{'rrI

l*

1:lriinu rv i-'.i;rt

22

studies,

and

sertrr

electrolyte levels.

Obtain

a

l2-lead electrocardiogam (ECG) with rhythm strip, and evaluate for

synptorrntic

arrhyhmias

or

evidence

of

ischemia.Brain

inraging

is

recon'unended

within

24

hours

of

symptom

onset.Brain iuraging

can identifi an

area

of

ischemia

in

as

n'rany as 2501, ol'patients, and

TIA

mimics

nuy

be identified

as

well.

Vessel irnaging can identiff

a

stenosis

or

occlusion

that may

warrant

early

intervention.Elecffoencephalography

(EEG) may be indicatccl to evaluiate for seia:rc actffiy.

Signs and symptoms

The

main syrptoms

of a

TIAcan

be

renrembered

with the word FAST Face-Arms-Speech-Trne.

.

Face-

dropped

on

one side (not

be

able

to

srnile,

nrouth or eye rnay have droPPed)

.

Atms

-

weakness or nurnbness in one arm

.

Speech- shrred, garbled, not be able to talk at all

.

Time-

it

is tirne

to

take care furrnediatety

if

you see

any of these signs or synPtonr's

Saturday, April 9th 2016

l-rtrrntLipilittesoi

jii.it.iitlsiio,'i..riitiiii:.i:i;t: _{i\v.i.;.;;i:i.i;;1i;.1;1;}

:.r ' rjJ: r. i . .

lnitial vital signs should includc

the

following:Ten:perahre,

Blood

prossrx-c

,

Hcart

rate

and

rhythnl Respiratory rate and pattern, and Oxygen saturation.

The exarnincr should assess the paticnt's overall health and

appearance,

nuking

an

assessnrcllt

ol'

the

following: attentivcness, ability

to

interact

with thc

cxamincr, Ianguagc

and _{memory skills, hydration statm,} development.

Risk Stratilication Scores

In

pcople

who

have

a

TlA,

the

incidcnce o1.

subsecluent stroke is as high as 1l%o over the next 7 days ancl

24-29"/,,

over

the

following

5

yeal.s.Appropriate risk

strati{icatiou utust be employed

to

L.llsure that diagrostic and

thcrapcutic intcrventions

are

tar-gctcd

to

thc

highcst-risk

patients.A

nulber

of

risk

stratification scoles are available

to

assist

in

llis

task,

but thc

rnost widcly validated

is

thc

ABCD2 scorc.(See Table

I

below.)

Saturday, Ap r ll9,s 201. 6

Asri Medical Center of Yogvakarta 23

I

point

A: Age >60 years

1 point

B

:

Blood

pressue: Systolic

>140

nrn Hg

or

diastolic >90

nrn

Hg

Unilateral weakness with or without speech inpairment C: Clinical features

2 points

I

point

Speech inpairment without

unilateral weakness

2 points

D:Duration >60 min

I

point

l0-59 min

I

point

D: Diabetes

[image:11.462.30.448.40.575.2]

{'t s' r u

*

Li lt t}

il

ts a { It r i f iol 5h a ck n t ul St r o k e Mn nage rnant ltz l]rim*rtl Csra

Table 1.ABCD2 Score

ln<lividurls with an ABCD2 score

of

6

or

7

have

8% risk

of

stroke within

2

days, whereas those with

ABCD2 scorc lowcr than

4

havc

a l%

risk of strokc within

days.Some

of

thcsc paticnts

with

lowcr

scorcs nuy

have

non-TIA

events rather

than

ffue TIAs.lt

has

proposed

that this

scoring system

can

be

used to

stratiland

to

predict

the

severity

of

recurrent stroke

TIA.

24

Saturday, April 9th 201 6

L''trtr(iri

llr,ialt'qoi

ltriiiizl !,ittt,!,.irii iiri:i:r:iv,lii:titlt)?\{:t!i

i:i

Pt iiltis:t i.'il

r

Physical Examination

The goals

of

the physical examination are to urcover

any

neurologic

deficits,

to

evaluate

for

underlying

cardiovascular

risk

frctors, and

to

seck any

potential

thrombotic

or

embolic source

of

the

event. Global CNS depression

and

ainvay

or

cardiac compromise

are

not

[pically

features

of a TIA. In

filct,

the

level of

corsciousness

and

newologic

examination

findings

are

expected to be at the patient's baseline.

Ideally,

any

neurologic deficits should

be

recorded

with the aid

of

a

formal and reproducible stroke scale, such

as the National Institutes

of

Health Stroke Scale (NIHSS).

A

stroke scale prompts the examiner to be thorough and allows

different

examinem

to

repeat

the

examination reliably

during subsequent phases

of

the evaluation.

Any

neurologrc

abnormalities should suggest

the

diagnosis

of

sfroke

(or ongoing neurologic event) rather than TIA.

Sa ttr rday, Ap ril9il. 201,6

26

t-' r ir r,t

i!

Li t, ii tt l " c o I I n i ti nl 5i t it tk it r td St r o k e Mn n it

Sc fft( t i i

ln l:trirnarv Carr

N eurologic Examination

A

ncur:logic cxamination

is

the

forurdation

of

ttr

TIA

evaluation

and

should

focus

in

particular

on

the

neurovascular

distribution

suggested

by the

patient's

symptoms. Subscts

of

the

netnologic examination incfude

the

following:Cranial

nerve

testing,

Determination

somatic rnotor strength, Somatic sensory testing, Speech and

language testing.

.Assessment

of

the

cerebellar system @e

sure to watch the patient walk)

For

sonratic motor

testing

test

muscle

reflexes

of

the

biceps, triceps, brachioradialis, patellaq and

Achilles.

In

additioq inspect posture and

look for

tremors-Tcst

the

sfrength

of

the

shoulder girdle, upper extremities,

abdominal muscles,

and lower

exftemities.

Test

p

movement

of

major joints

to

look for

spasticity, clonts,

rigrdity.

Saturday, Aprii ,'Li' 2016

Cru'rtnt L[pdales ai lnit:ial Shotk tnrl Styr:i;t: Aikitnigjitt:rti itt I)rintnru {liit't'

Stroke Scale

The

National

Institutes

of

Health

Stroke

Scale

NIHSS)

(see Table

2

below) is used nrostly by stroke teams

lbr

quaffirying neurologic impairmcnt.

It

enables rapid

detemrination

of

the

severity and possible location

of

the

stroke.

A

patient's score on the

NlllSS

is str-ongly associated

with

outconrc, and

it

can help idcntdy thosc patients who

are

likely

to

benefit

from

thrombolyic therapy and those

who are

at

highe.

risk

for

developing hemomhagic

complications

of

tluombolytic use.The NIHSS

is

easily used

and

focuses

on

the

following

6

nrajor

areas

of

the

neurologrccxaurinationievel

of

corLsciousness, VisLal

liurction,

Motor

firnction, Sersation and neglcct, Ccrcbcllar

limctinn ancl Language.

Saturday, April 9il' 2016

28

tJ.rit'rtni Littiar,'. r:{ lnifia! 5ltack util|tyoke Mrtnrtgtrrtnt

fr.

itriir;

rry

{itrt

Table 2. National Institutes of Health Stroke Scale

(NTHSS)

Saturday, Aprii :t* 201,6

Asri Medical Cer,;er of Yogyakarta

Category Score

-Description

la

level of consciousness (LOC)

0 Alert

I

Drowsy

2 Stuporous

3 Coma

1b LOC qucstions

(rxrnt[

agc)

0 Answers both

corrcctly

I

Answcrs I

con'ectly

2 Incorrcct on

both

lc

LOC

comrrxnds (open and close eyes,

grip and release nonparetic hand)

0 Obeys both con'ectly

I

Obcys I

con'ectly 2 Incorrect on

both

2 Best gaze (follow finge0

0 Normal

1 Partial gaze

palsy

2 Forced

devration

., Best visual (visuiil lields)

0 No visual

loss

I

Paftial

hemianopia

[image:15.463.119.452.58.552.2]

\.' ! ! !' t' ( it i Li p d a t t:s o

i

l t r i t iai Si r a' i. ii i t,i :) i :i: i;i: it,i;i : ii!'ir? t

t

1 i !

it; {)t

irril-l

{-'iu't' hemianopia 3 Bilateral

hemianopia

4 Facial palsy (show tecth, raisc brorvs,

squeeze eyes shut)

0 Nornral

1 Minor 2 Partial

3 Completc

5

Motor

arm

left*

(raise 90o,

hold

10 seconds)

0 No drift

I

Drift

2 Cannot resist

gra\{ry

3 No effort

against

grauly

4No

movertent

6

Motor

arm riglrt* (raise 90o,

hold

10

seconds)

0 No drift

1Drift

2 Cannot resist

gravity

3 No ellbrt

agairst

grauty

4No

rnovement

7

Motor leg

left*

(raise

30", hold

5 seconds)

0 No drift

I

Drift

2 Cannot resist gravrty 3 No effot

against

graviry

Saturday, April 9th 2016

{', ts- r u

*

Li y }', _{t',-'' t' "} r i I ial Si r o r:k a r

rl

St rt:kt: M n t tit ! t t r i( fi t

ln l:trim*rq Ctrt'

4No

nrovement 0 No drift

1m

2 Cannot resist

Savity

3 No effort

against

gavity

4No

rnovernent

B

Motor

leg

riglrt*

(raise

30o, hold

5 seconds)

9 Limb ataxia (finger-nose, heel-shin)

0 Absent

I

Present

in

I

limb

2 Present in 2 limbs

10 Sensory

$inprick

to face, arrq leg)

0 Normal

I

Partial loss

2 Severe loss

0 No neglect

I

Partial

neglect

2 Conplete

neglect

11 ExtinctiorVneglect

simultaneous testing)

(double

0 Normal

articulation

l

Mild to

nnderate

dysarthria 2 Near to

txdntelligibl

e or worse

t2

Dysartkia

(speech clarity

to

'Ynarna,

baseball, huckleberry,

tip-top,

fifty-fiftv')

30 Saturday, April 9th 2015

l3

Best

languagex*

(name

items,

descnbe pictures)

0 No aphasia

I

Mild

to

moderate aphasia

2 Severe

aphasia

3 Mute

Total _0-42

*

_{For limbs with arrputation,}

joint

_fusion,

etc, score 9 and e4plain.

*x _{For intubation or other physical barriers to}

speech, score

9 and exphin. Do not add 9 to the total score

Cr*-rcnt Llpd.ales o{ }rit:iitl Sitotk

i*ul

St.roi;t: }vlattit!*tit:rti

l:t

{}rintnrst Ccrt

The NIHSS

is a

42-point scalc, rvith nrinor strokes

usually being corsidered

to

result

ilr

il

score lower than 5.

An

NII

ISS

score higher

than

l0

corrclatcs

with an

g0%

lkelihood

of

visual

flow

deficits

olt

angiography. yet,

discretion must

be med in

assessing the magnitude

of

the

clinical deficit;

for

instance,

if a

patient's

only

deficit is

being mute, the

NIHSS

score

will

be 3.

Additiornlly, the

scale

does

not

rrcasure

sonrc delicits

associatecl with

postcrkrr circulation strokes (eg, verligo and ataxia).

Saturday, April 9tt 2016

Currant Littdatcs sl ln)ticl Sltock cnd Stroke Mnrvtgemant {n l}yim'trv t)art

Managernent

The

following should

be

done

urgently

in

patients

with

TlA:Evaluation,

I{isk

stratification

(eg,

with

the

California

or

ABCID score), Initiation

of

stroke

therapy.

For

paticnts

with

a

rccent

(<l

wcck)

TIA"

guidelines reconrrrrcnd

a

timely

hospital

refi:nll

with

hospitalizetio

n

for the following:

.

Crescendo TIAs

.

Duation of symptons longer than

I

hour

.

Synptorrratic internal

carotid

stenosis greater

s0%

.

Known

cardiac

source

of

embolm

(eg fibrillation)

.

Known hypcrcoagulable state

.

Appropriate combination

of

the

Califomia score

ABCD score (category 4)

Afthough

the

symptoms

of

a

TIA

resolve

in a

few

minutes

or

hourswithout

any

specific

treatment you

Saturday, April 9th 2016

Asri Medical Center of Yogyakarta

t. !:;:'t'i!i Li::1i,ii;..,:.'i !;;tii,:t .1..,1]t1 t. ti;:r' .,; t,i;, \,,i;t:::t.t.,:|1t.. :

i1i !'" it:t,'t:1y tl. ; :

nccd

trcatmcnt

to

h.lp

prevent anotltcr

TIA

or a

fiJl

strckc happcning

in

the futule.

A

TIA

is

a

waming sign that

you arc

at

a

significantly increased

risk

of

_having

a

fi-rll

strokc

ur thc

near futu'e,

with the

higltcst risk

in

the days

and rveeks {bllowing _{the attack.A stroke is}

a

_{serious health}

condition

tlrat

can

causc

pcrnunont disability

arul

_can

be fatal in sorle cases, but appropriate treatnrcnt following a

TIA can

help

to

reducc

your risk of

having

one.You

treatment

will

depend

on your

individual

circunstances, such as your age and nredical history.In sonrc

cases, surgery may be needed

to

r.mblock the carotid afieries

(the

rrnin

blood vessels that supply the

brair with

blood).

The healthcare team can discuss treatment options with you. and tell you about possible benefits and risks.

Pharmacologic rnanagement

for

transient ischemtc

attacks

(TIAs)

is

aimed

at

reducing

both

short-term and

long-term

risk

of

stroke.

In

view

of

the high shorl-term risk

of

stroke

after

TIA,

antithnombotic therapy should be

initiated as soon as intracranial hemorrhage has been ruled

out.In view

of

the high short-term risk

of

stroke after TIA, antitluombotic

therapy should

be

initiated

as

soon

as

Saturday, April 9tt, 2016

C ur r _- r;t LI y ii c t i::; r t ! _{I n} i I inl 5l t o ck u rd St r oke Nfu urtge rnent

ln Priint rrt Cara

intracranial hemonhage

has

been nrled

out.

noncardioembolic

TIA,

the

following antiplatelet agents

all reasornble

frst-line

optiors for

ffiial therapy:

V

.

Aspirin (50-325 mg/day)

.

Aspirin

plm

extended-release dipyridannle

.

Clopidogrel

Stroke

prevention rnedication typicalty recornnrended

cardioembolic

TIA

is as follows:

.

For

patients

with

atrial fibrillation after

TIA,

long-term

anticoagulation

with

warfrrin international norrnalized

ratio

[fNR],

2-3);

325 m/day

for

those unable

to

take

anticoagulants

F

are

iefi

a

ln

acutc

myocardial

infirction

(MI)

with

ventricular

tlrombus,

oral

anticoagulation

warfirin

(targct

lN&

2-3;

concurrcnt asprin

up

to

162

mg/day

for

ischemic coronary aftery

tcADl)

34

Satur,iay,,.r,pril v ir 201 6

C*rran! Littti.i,stt:s af' jtr.itial 5ita* nizl 9!ri:i:t: lrlii:it:.,::i1ii:i'i!

itt {}rint*ry {.nrr'

.

In

dilated cardiomyopathy,

oral

anticoagulation with

warhrin (target INR, 2-3) or antiplatelet therapy

. In

rheumatic

mitral valve

disease,

oral

anticoagulation with warfarin (target

IN&

2-3)

For

patients

with

TIA

due

to

50-99% stenosis

of a

rrnjor intracranial afiery, the following is recommended:

.

Aspirin 50-325 rcrdday rather than

warhrin \-/

.

Maintenance

of

blood

pressure

below

140/90

mm

V

Hg and total cholesterol below 200

m{dL

t/

.

Angioplasty

or

stent placenrent

is

investigational and

of urknown

utility

t

/

Antiplatclots

Platclcts

are blood

cells

that

hclp

blood

to

clot

(thickcn).

lf a

blood

vessel

is

damaged, platelets stick

togethcr

to

form

a

blood

clot

to

prevent

bleeding.

Antiplatelet agents

inhfuit platelet

fi"rnction

by

blocking

cyclooxygenase

and

subsequent aggregation. Antiplatelet

rnec'licincs

work

by

reducing

the

ability

of

the platelets to

Saturday, April 9tr, 2016

Cur r u

*

Li _{it tl} a I t:s o I I r r i I ial 5l t o ck n nd St r o k e Nl {t t tit _Sl tw n t

ln Prirnct rtl C.ara

stick together and fbnn clots.

If

you have had

a TlA, it

b

likely that you

will

bc

olllred

antiplatelet rn:dication.

Two

comrron antiplatelets offered

to

pcoplc

have

had

a

TIA

arc aspirin and clopidogrcl. Aspirin

also

somctimcs

bc

takcn with another antiplatclct

called dipyridanrole because this can

be

more effective

taking these medications separately.

The

rnain side

effects

of

antbhtelet nredications

indieestion and an increased

risk

of

bleeding

-

for

examp

you may bleed

for

longer

if

you cut yourself, and you

bruise easily.Antiplatelet Agents are :

-

Aspirin. Aspirin

blocks

prostaglandin synthetase

and

this,

in

turn,

inhibits prostaglandin syitlrcsis

prevents fornration

of

platelet-aggregating

A2.

Aspirin

25

rE/dipyridannle

200

ntg

:

aspirin-dipyridamole therapy has been shown to

cardiovascular

events following

TIAs.

Each

contains

25 rrg

of

aspirin and 200 mg

of

Satr-rr iiay, April'; :'20'1.6

t--tii rttrl

ilpiiittt:so

liiitiiti !:liittrir rriti.i :\i ti)i;t.i.v,tiittit,itt;ft:r;!

it; {}t intr"nt {'rtt't,

for a daily total dose

of

50 mg

of

asplrin and 400 mg

of

dipyidamole.

Aspirin

ineversibly

inhibits

formation

of

cyclooxygcnase,

thus

prcvcnturg

Ibrmation

of

throrrboxane

N., a

platelet

agg€gator

and

vasoconstrictor. Platelet inhibition lasts

for

the life

of

a

cell (approximately

l0

days).

Dipyridanrolc

is a

platelct

adhcsion inhibitor

that

possibly inhibits

red

blood

cell

(RBC)

uptake

of

adenosine,

itself

an

inhibitor

of

platelet reactivity. ln

addition,

it

may

inhfoit

phosphodiesterase actMty.

leading to

increased

cyclic

3,,5,-adenosine

nnnophosphate

within

plateles

and

lbrmation

of

the

potent platelet activator thromboxane

N..

Clopidogrel

:

Clopidogrel selectively inhibits

the

binding

of

adenosine diphosphate

(ADP)

to

its platelet receptor

and

subsequent

ADP-mediated activation

of

_the

glycoprotein

GPIIbAIIa

corrple4

thereby

inhfoiting

platelet aggregation.

Saturday, Ap rilgtt 201,6

{'.tirr*,-! 'ri triin{rs

ol

lrrilial Slnck ntrl Strokc Mnnit.\ement

{tt l} r i i *,i t' tl l.^. i.t r'.'

-

Dipyridannle

:

Dipyridannle

is

administered to

conplement

usrnl warhrin

therapy.

It

inhfoits

adhesiorl which rnay inhfoit adenosine uptake

by

RBCs'

It

may

increase

cyclic

3'.5'-adenosine

(cAMP)

within

platelets

and

fonnation

of

the

platelet activator ttromboxane

42. In

addition, it reduce

the risk

of

stroke when

wed

as

instead of aspirin.

-

Ticlopidine

:

Ticlopidine

is a

second-line antip

therapy

for

patients

who

cannot tolerate

or

do

respond

to

aspirin therapy.

In

sorne circurnstances, it

be an altemative to clopidogrel Anticoagulants

Anticoagulant medicines

can

hep

to

prcvent

clots

by

changing the chemical conposition

of

the blood

a

way that prcvcnts clots.They are usually offcrcd to

who have had

a

TIA ifthc

blood clot that catscd your

originated

in

yoLrt' hcart. This

is

often due

lo

a

called

atrial

fibrillation,

which

causes

your

heart to

inegularly.Anticoagulants agents are :

Saturday,

Apri'

rih ₂₀₁₆

Asri Med-ica; C.-,

Jl.

t).ttirtn! Liptiitlt:s,;ti'ltriliiti Siri:;l; ituii

iiri:i:i:

i',.,iti:i,ititit,ti:

iit

1)t iillt tt,l i'_.'it:,,

Warfrrin

:

Warfrrin

interferes

with

hepatic synthesis

of

i,itamin K-dependent coagulation factors.

It

is

used for

prophylaxis

and

treatment

of

venous

thrombosis.

puknorary embolisrrg

and

thromboembolic disorders.

A

side effect

of

all

anticoagulants

is

the

risk

of

bleedng

caused by _{the reduction in the blood's ability}

to

_{clot. you} may need regular

blood

tests while taking warfarin, so

doctors can ensure your dose is not too high / low.

,

Antilrypertensives (blood _{pressure medication)}

If

you

have high blood pressue '(hvperlension), _you

will be

offered

a

t),pe

of

medication

called

an

antihypertensive

to

_control

it.

This

is

_{became high blood} pressure significantly increases yor.r risk

of

having

a TIA

or stroke. There are lots

of

different ty;es

of

'redicine that can help control your blood prcssrrc,

incluiling:

\A/

.

thazrdc diuretics

.

angiotensin-converting ev.)me (ACE) inhibitors

.

calcium channel blockers

.

beta-blockers

Saturday, April 9rr, 2016

40

{.|:ir r

*it

l !'/ ii rt t t:'; t 1 i t t i i ii tl Sl r tt r:k it r t d St r ttkt: NI it t t ii (('r,/{'ril

{n l}rit*ti rti

iitrr

Sorne people may be offered

a

combination

ol'two

or

three

differcnt rrcdications.

Paticnts

may

be

sigrrfficantly hlpertcnsivc. Unless

there

is

specific conccm

for

end-organ danragc

from

a

hlpertensive emergency, blood pressrne should

be

rnanaged

conseruatively while ischemic stroke is being ruled out.

For

acute ischemic stroke,

the

AHA

initiating antilrypefiensive therapy

only

if

blood

pressure

higher than 2201120 rnrn

Hg

or

if

mean arterial

exceeds 130 mrn Hg. Unless there is

a

cornorbid cardiac

other condition tlrat necessitates reduction

of

blood

allowing

the

patient's

blood

pressure

to

autoregulate at

higher level (during

the

acute phase) nray heS cerebral perfi"sion pressure.

Statins

If

you have high cholesterol, you

will be

advised

take a nredicine known as a statin. Statins reduce the level

cholesterol

in

your blood

by

blocking an enrynre in the

that

produces cholesterol Statins may also

hep

to

Saturday, April 9th 2015

t

trt'rt nt Ll pdtttt:s rtl lniiiei Siitti l, it r r:i i!i'iii:t: i\,1,i t :'t{Jirii , r l

I t t {}r. i ni ;i t.t! {l a t.,.

your

risk

of a

stroke whatever your cholcstcrol level is, so

you llray

bc

olli:rcd

a

statin even il'yorx' cholcstcrol level is

not

pafticularly high.Examples

of

statins

often

offered to

people who have had

a

TIA

include atorvastatin, simvastatin

and rosuvastatin.

Surgcry

In

son-rc cascs,

a

surgical proccdu'c callcd a carotid

enda(erectomy mrly

be

recommended alter having

a

TIA.A

carotid

crxlarterectomy

is an

opelation

that

ir-n.olves

renmving

pafl

of

the

lining

of

tlrc

carotid afiety. plus any

blockage that has brrilt

.p

in the artcry. The carotid arteries

deliver blood

to

your

brain. Whcn

htty

dcposits build up

inside

thc

caroticl arteries, they bcconrc hard and narow,

nnking

it

nyorc difficult

for

blood

to

flow

through them

This is known as atherosclerosis and

it

can lcad to TIAs and

strokes

if

the

blood

supply

to

thc

brain

becomes

disrupted.By unblocking the carotid arteries in people whose

afieries

ate

nroderately

or

severely

rnrowed,

a carotid

endafterectomy can significantly reduce the risk

of

having a

stroke or another TIA.

Saturday, Ap r il 9 a. 201. 6

42

C.urrant Llrrdntr.s o/ lrriticl Shack nnd Stroke hLcnogemant

{n l:'rirntt r.tl Cayt

Driving

after a

TIA

Although

a TIA

shouldn't have any long-term

on

your

darty

activities,

you mtst

stop

immediately.Ifyour doctor

is

happy that you have nnde

good

recovery

and

there

are

no

lasting effects after orc

month you can start driving again.

Prognosis

With passive reporting the early risk

of

stroke

TIA

is approximately

4%

at

2

days, 8o/o at 30 days, and

at 90

days.When

patients

with

TIA

are

prospectively, lrowever, the incidence

of

stroke is as high

l1o/o

at

7

days.Thc probability

of

strokc

in thc

5

following

a

TIA

is

rcporled

to

bc

24-290/,

lrt

patients

with TIAs

or

stroke have

an

incrcascd risk

coronary artery disease.

Patient Education

Before bcing discharged from

the

hospital,

who

have

been

diagnosed

with

TIA

mmt

receive

Saturday, April 9th 2015

C m' r en t L) p d a t cs oi Itti t

itl

Sh o & n nrl 5 t r o

k

Nl tt n a gt r nc n t

hr Printcry Cn't

instruction

to

ensure that they understand

the

need

for

a

conplete and rapid

workrp

tl,roWh close follow-up care.

Also essential

for

patients

is

education

on

stroke symptoms,

the

need

to

call

enrcrgency services inrnediately

if

any

of

these

synptorns

occur,

and

the

contact nurnber

for

ernergency services (911 in the United States and Canada).

Despite program efforts

in

public educatioq rnany

patients still

do

not seek nredical attention after experiencing

TIA

synptoms.

A

2010 population-based study found that

3l% of

all

patients

who

experienced

a

recurrent stroke

within

90

days

of

their

frst TIA

or

minor stroke had not sought nredical attention after the initial event.

Public health professionals

and

physicians need to

do

ff)ore, such

as

promoting

and

participating

in

medical

scrccning

frirs

and

public otrtreach prograrns.

In

additioq

patients need

to

be educated about lifestyle nrodffication and

cardiovascular risk fictors

Saturday, April 9th 2016

-44

C w' r

tnl

L I y ti * t cs r: _{{ ln} i t:isl 5h o ck u

ti

St r * f; e klit n n g: rn* n!

{n Prirusrq {ara

Noncardioembolic transient ischemic attack

Antiplatelet agents, rather

than

oral

anticoagulants,

are reconrlrcnded as initial therapy. Aspirin 50-325 mg/da1;

a

combination

of

aspirin and extended-release diplridarnoh, and clopidogrel are

all

reasonable fost-line optiors (class I

reconnnendation).

The AHA/ASA

guidelines state that

the

combination

of

aspirin and clopidogrel might

be

considered

for

initiation

whhn

24

hours

of a

minor ischemic stroke

or TIA

and lbr contiruration

for

2l

days.

However,

the

combination

aspirin and clopidogre[ when initiated days

to

years after a

minor stroke

or TIA

and continued

2 to 3

years, increases

the

risk of

hemonhage relative

to

either agent alone and b

not

recomnrcnded

for

routine

long-term

prevention after ischemic stroke or TIA.

Cardioembolic transient ischemic attack

In

patients

who

have atrial fibrillation

in

associatbn

with

a

TIA,

long-term anticoagulation

with

warfrrin

to

a

Saturday, Ap t il 9 th 20'1, 6

l'ii.i ri:rt! i-i tt!itii:g r:1" ltt.ii titi 5!r r.:r'k l tzri Sirtti;t: i"4ti*i7t;i:tttt:fi|

)it {riutnrry {.'rit't

target

intemational nonnalized

ratio

(lNR) of 2-3

is

typically

recorrncnded.

Aspirin

325

n'dduy

is

recornnrended

for

patients

unable

to

take

oral

anticoagulants. However,

the

addition

of

clopidogrel to aspirin therapy, conpared

with

aspirin therapy alone, might be reasonable. For most patients with

a

stroke or TIA in the

setting

of

AF,

it

is

reasonable

to

initiate oral anticoagulation

within

14

days after

the

onset

of

neurological synptorns'

Anticoagulation

can

be

delayed

beyond

14

days

in

the

presence of higfu risk for hernonhagic conversion'

The

2014 AHA/ASA

guidelines

also

state

that

bridging

therapy

with

subcutaneou low-rnolecular-weight

heparin

(LMWH)

is

reasonable

for

patients

with

atrial

fibrillation

who

require

tenporary

intemrption

of

oral

anticoagulation but are at high risk for stroke.

In

acute myocardial

infirction

(MI)

with

left

venfricular thrombus, oral anticoagulation with warfarin (target

IN&

2-3) is reasonable.

ln

dilated

cardiomyopathy,

either

oral anticoagulation

with

warfarin (target

IN&

2-3)

or antiplatelet therapy rnay

be

considered.

In

rheurrntic mitral

Saturday, APril 9th 201 6

46

Ct*'rtnt Ll p$ nir.s cf' lnif kil Sltock ntzd Str':i,:e Mitnagtrnrn!

{n Frimcrry Care

vahe

disease,

oral

anticoagulation

with

warfrrin

(target

IN&

2-3)

is

reasonable. Antblatelet agents

would

nor

normally

be

added

to

warhrin

urless patients experience

recunent embolism despite

a

therapeutic

INR.

The beneft

of

warfrrin after

sfoke or

TIA

in patients with sinus rhythm

and

cardiomyopathy clnracteized,

by

systolic dysf,mction has not been established.

In

mitral

valve

prolapse, long-term

antiplatelet

therapy

is

reasonable.

In

mitral anrular

calcification,

antiplatelet therapy can

be

considered. Patients with mihal

regurgitation can

be

considered

for

warfrrin

or

antiplatelet therapy.

In

aortic valve disease, antiphtelet therapy rnay be

considered.

For

patients

with

mechanical prosthetic vahes,

oral

anticoagulation

witlr

warfrrin (target

IN&

2.5-3.5) b

recomnrended.

For

those

who

experience

TIAs

despite

therapeutic

IN\

aspirin 75-100 rrrdday can be added to the

regimen. Patients

with

bioprosthetic

vahes

and no

other

source

of

thromboembollsm

who

experience

TIAs

can be

corsidered

for

oral

anticoagulation

with

warbfo.

(target

rN&

2-3).

Saturday, April 9th 2016

C.wrent Llp'lutes ctl

hitinl

Slrccknnr! Strake hlrtn*gerncnt

ht l>rinmrtlCrrt

Intracranial

atherosclerosis

The

2014

AIWASA

guidelines state

the

following

for patients wittr stroke

or TIA

due

to

50-99% stenosis of a

nnjor intracranial artery:

,./ .

Aspirin

50-325

@day,

rather than

warhrin,

is

recorrrnended

,/ .

Maintenance

of

blood

pressure

below

140/90

nm

Hg

and total

cholesterol

below

200

mddL

is

recornrnended

.

Exffacranial

or

intracranial bypass surgery

is

not

reconnnended

.

Angioplasty

and

stent placement

are

investigational

and of unknown utility

A

randomized

trial

has

shown

that

aggressive rnedical

rBnagement (antiphtelet therapy combined

with

intensive

rnanagement

of

vascular

risk

fictors)

is

safer

than

percutaneou translurninal angioplasty

and

stenting (PTAS)

in

patient

with

70-99%

stenosis

of

a

major

intracranial

a(cry. Enolkncnt in this trial was stopped after 451 patients

rurderwent randomization because the 30-day rate

of

stroke

Saturdav, April9th 201,6

Asri Mc.j..cal Ce- .el of Yogyakarta

I

Currcnt Llpttliles of lttilinl Shock nnd Stroke Managerrrcnt

[fl Primarv Cart

or

death

was

l4.7Yo

in

the PTAS grorp and 5.8% in the

medical-management goup.

Long-Term Monitoring

Patients selected

for

outpatient care should have a

clear follow-rp plan and

stroke

prevention initiated as

described, including antiplatelet medicatbn

and

risk-rnodification Antblatclet agents

Spically

should

initiated

as

soon

as

intracranial bleeding

is

nrled out.

noted (see above),

the

agent

to

be

used varies with patient and the specific indication

The

following rrrcasures should

be

included

in

any

term rrrcnitoring of TIA patients:

.

Anhhyperlensive

control

should

be

optimized

patients with hlpertersion

. Lipid

control

should

be

initiated,

including a statin agent

.

Blood

glucose

conffol

should

be

optimized

patients with diabetes

Saturday, April 9th 2016

Asri Medical Center of Yogyakarta

t'.rs'rtnt Llp'lntcsol {rtif irt" Slratk itnd Stroke Manugtrncnt

ltt

?rinnry Cwt

A

snroking-cessation stratery,

which

may

inchrde

medicatioq shouid be initiated

Heavy drinkers should eliminate

or

reduce alcohol

consunption

Overweight patients should

be

encouraged

to

lose

weight

All

patients should be encouraged to exercise

Recommendations

These guidelines cover

both

ischaemic stroke and

trarsient ischaemic attacks (TIAS). Separate guidelines exist

or

are

being prepared

for

intracerebral haernorrhage and

subarachnoid haenronhage.

The

classes

of

evidence and

levels

of

reconrnendations used

in

these guidelines are defi

ned according

to

the criteria

of

the Euopean Federation

of

Neuological Societies

Saturday, April 9th 201 5

Asri Medical Center of Yogyakarta

o

a

a

a

Currcnt Llptd tlcs aj'

lnitkil

Sltock nnd Stroke Monogernent

[n Priynsrv Care

tiG s:

iEs

_PU6

'=-U

S$a

E8E_{, or}

a.E I

EH5

E.:l

E;l

t

*'88

E ; AA

F

:bE

g

_U EEP EEII

o oOO c uv=

I

u TE

r

i;"

c

a-E sa-E

_{c !E}

Eb,

qtr: i oft!r.i!

!

? e q E --E

'

.ge&ro=E6E

t:;tXEE;

b;PEETEE

EEEEE,*tg.

E HEEE E

I;

- u"ic " o? E

5 S E

e*

x€

3

hq=od-i-g.T _E

E;

_E

;;

Ef;EEEXHg

raptu*=b"

EEEEEg;E

_{o r d tr'v hq c}

*o*;EiE9

fi i c o -e q o o o d c 8t p a c D s ? g E E o o E

F $g

E aP

.Qo5

Eli

EgE EES .sEE E14U

$t

E

E EE

EiE

EEE

E

E"8

E 6E

= -'Q

b a-_!l?o

*En

t u;

EEg !t! LYU o Ell eId_o;o ioH fi -9_o:c >to

t;E_{x >r}

Yoy aat

{

E

.HE

fr

3BE

A

EE:;

a

$;ii

: FE i i9

r

e fl

I $9

9ptre".E

qrU^-C.Y

e$h8EEE

p;:E5e:

H

3€

!

E H _E

IEEiEflE

oBEh'E2c

EtE

EEfiE

dts,i*j..tti q E f o o E I E 8_N E o r? c a fi q ( o o E o u o E

,

!

q E

:

o g E a E * E o E E o t

EE f,E gEEE =E ip

f;88

E€Eg

"€uP

Ir€*

$!::

ob = I

ssEh

EEEfi

E i tr il E n o q c e u -f g E T o o i! r b e E H r.l

;

D

Saturday, April 9th 2016

Asri Medical Center of Yogyakarta

Table 9.2 De{initions {or levels of recommendation (from [583]).

o

an

(,

v\)

x-(^

ea,

:t-.jv

>

\t

^=

Level A Established as usefuTpredictive or not usefullpradictive for a diagnoslic measure or established as

effective, ineffective or harmful for a therapeutic intervention; requires at least one convincing Class I

study or at least two consistent, convincing Class ll studies

Established as usefuUpredictive or not uselu,lredictive for a diagnostic measure or established as effective, ineffective, or harmful {or a therapeutic rntervention; requires at least one convincing Class ll

study or ovenvhelming Class lll en/idence

Established as usefu7predictive or not usefuUpredlctive for a diagnostic measure or established as

effective, ineffective or harmful for a therapeutic interventron; requires at least tr,!o Class lll studies Recommended best practice based on the axperience of the guideline development group. Usually based

on Class lV evidence indicating large clinical uncertainty, such GCP points can be useful for health workers

Level B

Level C

Good Clinical Practice (6CP) points H

7

9-.)

Ai LD

*'!) rDE o!) ts\<

hJ>

<'o

31

I'N,

tD o\

ffiuli

l:r P il

\-52

Curt'ent Llpttielcs r:l'iirificl S!nck tnd Strol;e Mitnngernent

ln Primartt Carc

Sroke services and stroke unit

Recommendations

.

lt is recornrnended that all stroke patients should be

treated in a stroke unit (Class l, Level A).

.

lt is recornmended that lrealthcare systems ensure that

acute stroke patients have access to high technology

medical and surgical stroke care when required (Class lll,

Level B).

.

The developrnent of clinical networks, including

telemedicine, is recommended to expand access to

high-technology specialist stroke care (Class ll, Level B).

Diagrostic innging

Recommendations

r

ln patients rvilh suspected TIA or stroke, urgent cranial CI

{Class l), or alternativety MRI (Class ll), is ncommended (Level A).

.

_lf fulRl is used, the inclurion of diffusion-weighted irnaging

(DW) and T2t*veighted gradient echo sequences 1s

re(ommended (Class lt, LevelA).

'

ln patients with TlA, minor stroke, or

recovery immediate work-up, urgent vascular imaging or MR angiography) is ((lass l, A),

Saturday, April 9th 201.6

Ctrrcni

Ll.ttlates oj

btitid

Sltock anri Sirake Manogernt:nt

lit Prinnry Cwt'

Other Doagnosis Tests

Rerommendations

r

!n patients with acute stmke and Tl,{ early dinical

evaluation, including physiological parameters and routine

blood tests. is recommended (Class _l, Level A).

.

For all stroke and TIA patients, a sequence of blood tests is recornmended (table 9,3, table 9.5).

o lt is recornmended that all acute stroke and T[,A patientr

should haw a 1Z-lead ECG, ln ddition continuous E(G

recording is recomrnended for ischaemic stroke and TIA

patient: (Cla:s t, Letel A).

.

[t is recornmended that for stmke and TtA patients :een

after the acute phase, 24-h Holter ECG rnonitoring should

he pe#ormed when anhythmias are suspected and no

other causes of stroke are found (Class _{l, Lerel A).}

.

Echocardiography ir recommended in selected patients

(Class _{lll, Lercl} B).

Satur.rlay, April 9th 2016

Curr

u*

Lllt d n t e s o f ln i t'ktl Sl t o ck n nd St r o ke Mit n t ge meut

In Primurv Care

Managenent of Vascular Rlsk

Eecprrrnendethns

' Blgcd pEsaire sfEukt hE clucfieo rEgulrry. tt ts

feromnErE€d uElt hlgh EBd Frscjfe $Euld E nanrgEd Qlrh ilfusryE lTEdtca$rn ir6 h{r}rtrluJlred

Fnrmradog(al lhEraFy LE E{ lri drnlrE at

mnnrl ler€ls gf 14

fPdrt tillurB dlnbEtsE,ar cfrunlf, rxld

anlil?ErtEmhE m€dlatE{r E lntlclted tcts l, LRH _4.

r EIEECI _{EuEose stro{:lu} be chB(Hl rErylarly. It b rffirnnreDJed trlat daDetEs ghflJld be marraqed vl,tth lfesty'e mEdltEto[ arld ltddl:UellDe.l _{Fhilrnafffogl{al}

tner+I {ga5r lv Lerd ci. h d3e[c paenls, htgh bhsd

FrEsurE lls"rE EB ,rt;lnaEd htefEl$eu {€ta55 l, Lelel {l

atrnlng ior lsrg! bgril# l3offilrflml{q Flass l4 LsfEt rl. wnere _FerHe tEatrmnt stsjld lrl|lucle !n Bt. lorEngn cofterur€ ErrlTrfle lrfilHto] or sngb&n{n rece@r rntrJsnlrt {clars I, l-sl€l A}

r Blaod rhdc6teml shauE E ElErXEd r€gulxly. I ls

reffimtEffil$Ihet hlgh blffid {ndE5terol (E.9. tot}

l50r€tt l3.gmnsuD snoukr bE rnfi4ed ${fi $ttrqle

flEdtfl(3Itrr (cless lY LEtcl q trrd a ltaIn itrla5 1.

l-fi,td Al.

. lt E rsEEmn€ndE{t tfiitclgErstG rmoxtEg bE dlsEuJralEd

trlss lll, L€t el E).

. lt E rEEomrEr{rErl fint hem,y lrse of iholEl bE

clssrraged (oE ll. LErsl E).

t R€qur phyrlcal aEt[lty E resmr€ldEd {ElEs lll, Ls\E q.

. a EtEt l$r' h satard 5ltjt3ted f.t htgl ln liut afrd \ESFEot€s 3rd rLtr lll llre E rEmm]r€nu€{r {o& ll, L€r€ _E.

. lubJerts wlEl 3n €lalBlEd Eodf rlrralB lrr:lg are

reomnErroed to tete r urggrrt-rE[tuchg dlgt (El6 lt, Lere E.

r Antrqrldnnt vttamh $JpplEm€BE a{e not rtrsrnrnsrlEd {ClsE l, lrrg Al.

. HoTTEIE r€pE0Elmnt tntr#t ls nst lEtrIrnEnded iff tne pflrrsy praEnflon of strd{E _iEl6 t. tB€t A).

54

Saturday, April 9th 2016

Cts'rcnt Llpilatcsof

[nitki

Slro*

l*d

Strok MsvrLt4ttncnt

ltr Prinut"rtl Crn'e

Prinnry Prevention - Anfithrpntbic Therapy

" Lorl-dcce arpirin is rBcsmfi?rded in r.Em€n aged 45 !.aar: flr rnore wtlo re rtot Et increaged dd< for lntrecerebrd haerylsrrh€e and who hav* good gastrrJntectinal _tdrance; ho!.,Errerr its effect is very srnall (Class l, Lerrpl A).

.

lt is recsnmerrded that lorv-dcre aspirin rrry be

rsrsi&red in rnBn fs fte primsy prerrerxlrr of

rnyoerdid hrfarction; trowwer. it does nct rpduce the risk

of isdraernk 5tulte (Cks 1. terre{ A},

. Afltidratrht EsEflts otlnr tfran aspitn am not recomnrended

for primary shtg{<e pr*rent}rn {Chs,V, 6Cp}"

.

Asfrdrin nry be recorrrrended lor pxients with ncn-vakr.rler AF who are yo.rnger than 65 yean and frce of vrcula risk factss (Chs l, Lerrel A.

.

lhlees *wrbaiir$<ated. eitlpr aspirin or aa oral

anlimaguhr.rt {nt€matimal ncrmaked ratio flf{Rl t.A-3.0}

is rxonxner#Bd for patientr with non-vaha.dar AF r+ho

are aged 65-75 yean md fee af rrascuhr risk fartor,s (Class _I tsvel A).

.

Lhles: contrairdcated, an oral antiroagul*nt tf{R 2.0-3.0}

i: reromrnended far patients wifi non-rrahaJar AF wfro are agrd >75. or wtro are ya"rrger but hane risk lartors

ardr al higt| bhod prer*nq [eft _{rrrnficular d6function.}

q dabeter rrpilihJs (Clar l, t-srel A).

,

lt ic rscsmendsd that patients !v,i6 AF u*ro are unahle

to receive ord anticaa$,iants shoutd be sffsrcd asphin

(flarr L Levd A).

.

lt h rxornmendcd *rat paient5 wifi AF who hatre

mxhmkal prosth*tic h*art vahrcs shcr.rld receive

[ongrterm antiroeryrlatic* r+ith a target INB based om rtre

prosltr*i: {ype. but nd less than INR 2-3 {Clnss ll, Lor*l B}"

.

Lour<Jpse xpirin is reronrrended for patients u4th aqrnptcrnati< inp'nal ramtid art€ry (lCA) stenoris >5016

to rpdure th*ir drk of vascular e\rents (Clss 11, LorEl E).

Saturday, April 9th 201 6

56

C. urr e nt Ll _trt d t l t s t: !' l i i i t ktl Sl i o

*

ri n.d St r o k c Nliut fi q t rrrc nt

ln Primarv Care

Secondary Prevention

Optimal rnanagement of vascular risk frctors

Rerommendetlons

. lt is recrynmended rltat blood prrrsui€ b€ che<ked regrlorly" Blood prerure lcniveriqg ir reronnflsfided aftei'

tte acute phase, includng in patieflts with nornral blood prersure {Ckss t, ta/el A).

" tt i: reromrnended that blood glueos* lhould be rhe<ked reElularly. 11 ie recorrrnerded drat diabetes drould be

nranaged widr li{estyle moditi(Eti,on and individualEed pharrmr,:l,rgieal therapy {Class l\4 CCP).

. ln patienls with type 2 diabetea who do not need insulin, traatment witt| f,ioglitarnnE is rpcornrrerd*d after stroke {f,ltsss lll. Lev*l B).

. statin theraty is rerorrurended in subj*ds with

nsr-cardir:*mbalic stroke (Cln55 l, Lscel Al.

. lt is r*commended that rigarette sEnohinq be drcnr:raged (Class lll, Leirel C],

. it is rec,:nrmended that healy u*e ol alcohol be di:couraged (Class tV. GCP).

. ftequlo,r phryncd activity b recomrnended {Claas lS GCP}.

. A diet lerw in sah ard seturated fat high in fruit and veg€tnbles. and ri<h io fibre is re(ffnm*adsd ({lass _l{ GCPi.

. Subiects with an elevated hody mass indeot are recomnrended to ddopt a weight-reducing diet (da5s lV,

Lelsl (i.

. Antioxidant vitamin s-rpple.rnents ar* not rec(}nrn]Ended (Class l, level A].

. Hormonp reSa<ement th*raFry i! n$t recomnr*nded for

rhe secondary p{evprnion of stroke {Cless l, Level A},

. h is recrrnrrnended that deep-clis,:nCered breathing aurh as obrtru.tive sle*p aFnoea be trentFd rrvith continuous pr: itive airwqy Frplstre breathing {Claso tll. Laiel G(P}.

. lt i: recemrnended thgt €ndovascular cls*re of FFO b*

con*dered in p*tients with <rlptogenic stroke and high risk PFO {llass M GCP}.

Saturday, Ap r il 9 th 20L 6

Asri Medical Center of Yogyakarta

Ctu'rent Llp'lates ai

hiticl 5ln&

itnrl Strakc Mn na*etncnt

ilt

l>i'inrcry Cnre

Antithrombotic therapy

R€(ommendetlons

. lt b rc<a*rmended $al patients re<eirre antithronrb<dk tlerapy {Class l, Loel $.

r h k reco*vnended that patienB not req.rhng

antkoaErlation shquld receirE antiplx*let therapy (Cfa* l,

Lercl A)- Where possible, combined aspririn and dipyridannle, or dopidogpd alone, should be giwn. Ahernatimly, aspirin alooe or triffusal done rnry be u:*d

(Ctass l, Lnrel A].

. Ihe cnmbination of aspirin and <lopidogrel ir not recomm+nded in patients with recent isfraernic strc&e,

exceFt in $niipnts with specific indcations (e.9. un*able angina or non-Q-ware Ml ff rpcenl stpntiflg); traatrEent sh*.rld be qiven for r*p to 9 months alter thp eryent Klass l, Le\ipl A),

. tt ts re(rrmrnended that patients r*-ho harn a stroks fli antiplatelet therapy shorld be re-evduated for pathophy:iology and risk Iirtors (Clasr _I{ 6CF}.

r Oral antiroagulation {lNR 2.0-3,0} is reconrmended afler i:<haemic atrol<e areodated with Af tClass l. Lelel A]. Oral anticoagulation h not recomrnended in patients \.r,ith con"rorbid conditions such as falls, poor <onplian<e. urrontrCled epileply, r gastrointesinal bleedng {Class

Itl, lelel C)" lncrea$ng age alone is not a conraindication to oral antkoagulation {Chss l, Lelel AI

. ft is re(offan€fided that patimts nith cardoernboli< sboke r.nrelated to AF:hou,ld reeive antico.gulaftts {lNR

2.0-3.0) if thp rhk of recunence is hiEh (Cla:s t{, LE /el C).

e lt k rxamrnendsd that aflti.oa$Jlation *mrtrd not be u:+d after ncn-cardio+mb,o{i< isdramic stro&e, except in tom€ spe{ific 5ltuatiom, such as aortir ath.eromas"

fusiform aneurysnrs of the basilar ortery cer,vkal artery dsaectiol't. or patent feranren crrah in lhe presence of proven deep vein thrombo,sb (DMO or arrial septal aneurysm (Class lV GCPI

r tt is recsrilnerd€d that <omtrined low dme apirin ard dipyridrnole *ouH be giwn if oral anticoagdation is

contdrdicated (Class lV, GCP).

Saturday, April9th 201,5

58

C ur r

tnt

Llpt d a t es o,f ln i tinl Sl rc ck t n.d S t r o k e M a n n gr: ment

{n Primarv Carc

Conclusion

Pharmacologic managenrnt

for

transient ischemic

attacks

(nAs) is

ainrd at

reducing

both

short-term and

long-term

risk

of

stroke.

In

view of the higlr short-term risk

of

stroke after

TIA,

antithrombotic therapy should be

initiated as soon

as

intracranial hennnhage has been ruled out.

Saturday, April 9th 2016

Cttrr*tt

Llprllttr:s oi htitial Slrrst"k nnd StT oke iv'lftntt4i:n{nt

ltr l'rinr.nty Cnrt References

l.

Ringleb, M.G. Bousser, G. Ford,

P.

Bath,

M.

Brainin, V.

Caso,

A

Cervera, A.1 Chamorro, Charlotte Cordonnier, L.

Csfua,

A.

Davalos,

H.

-

C. Diener, J. Ferro, W. Hacke, M.

Hennerici,

M.

Kaste,

P.

Langhorne,

K.

Lees,

D.

Leys, J.

Lodder, H. S. Markus, J. - L. Mas, H. P. Mattle, K. Muir, B.

Norrving,

V.

Obach, S. Paofucci, E.

B.

Ringelstein, P. D.

Schellinger,

J.

Sivenius,

V.

Skvortsova,

K.

Stibrant

Sunnerhagen,

L.

Thomassen, D. Toni, R.r von Kummer, N.

Gunnar Wahlgren,

M. F.

Walker,

J.

Wardlawm

20ll

-Ischaemic stroke and transientischaemic attack

-

European

Handbook of Neurological Management: Volume 1, 2nd EditionEdted by N. E. Gilhus, M. P. Barnes and M. Brainin

201 1 Publishing Ltd. ISBN: 978-l-405-18533-2

2.

William

J.

Powers, MD, FAHA, Chair; Colin P. Derdeyn,

MD, FAHA, Vice Chair;Jos6 Biller, MD, FAHA; Christopher S. Coffey, PhD; Brian L. Hoh, MD, FAHA;Edward C. Jauch,

MD, MS, FAHA; Karen C. Johnston, MD, MSc;S. Claiborne

Johnston, MD, PhD,

FAHA;

Alexander

A.

Khalessi, IvfD,

MS,

FAHA;Chelsea

S.

Kidwe[ MD,

FAHA;

James F.

Meschia, MD, FAHA;Bruce Ovbiagele.

MD,

MSc, MAS,

FAHA;

Dileep

R.

Yavagal,

MD,

MBBS,

2015.

AHA/ASGuidelines

for

the Early Management offatients

Saturday, April 9th 201 6

Asri Medical Center of Yogyakarta 59

60

Cun'ent Llyrtiaics t:! )rritktl Sltotk r,"ttd StrokcMtriitgtttwnt

In l!rimurq Carc

With

Acute

Ischemic Stroke Regarding Endovascular

Treatment.

A

Guideline for Healthcare Professionals From

the

American

Heart

Association/AmericanStroke

Association. Stro k e. 2015;46:000-000.

3.

Ashish Nanda,Niranjan N Singh, Robert E O'Conno, 2015

-

Transient Ischemic Attack, Treatment and Management

Medscape Medical News. Updated:Dec 01,2015

4.

[Guideline] National Institute

for

Health

and

Excellence

(NICE)

Stroke

Guidelines. Available

http//zuidance.nic e. ore.uk/CG68/Guidance/pdf/Enslish.

Accessed: September 22, 2010.

5.

Wu CM, Mclaughlin K, Lorenzetti DL, Hill MD, Manns

Ghali WA. Early risk of stroke after transient ischemic

a

systematic review and meta-analysis. Arch Intern

2007 Dec 10. 167 (22):2417 -22.

6.

Amarenco

P,

Goldstein

LB,

Sillesen

H,

Benavente

Zweifler RM, Callahan

A

3rd, et aL Coronary heart

risk in patients with stroke or transient ischemic attack and

known coronary heart disease: frrdings from the

Prevention by Aggressive Reduction

in

Cholesterol

(SPARCL) tr'nL S tro k e. 201041(3) :426-30.

Saturday, April 9th 2016

Asri Medical Center of Yogyakarta

Cw"rent Llp,lutes a{

lrif

kti Slratk nnd Strai:t: M*n*gtrtrcnt lit l>rinutril Crirt

7.

Chandratheva A, Lasserson DS, Geraghty OC, Rothwell PM.

Population-based

study

of

behavior immediately after

transient ischemic

attack

and

minor stroke

in

1000

consecutive patients: lessons

for

public education. Stroke.

2010 Jun. al (6):1 108-14.

8.

Bos MJ, van

Rln

MJ, Witteman JC, Hofman A, Koudstaal

PJ,

Breteler

MM.

Incidence and prognosis

of

transient

neurological attacks. JA M A. 2007 D ec 26. 298(24):2877-85.

9.

Giles MF, Ahers GW, Amarenco P, Arsava EM, Asimos AW,

Ay H, et al. Early stroke risk and ABCD2 score performance

in

tissue-

vs

time-defned

TIA:

A

multicenter strdy.

Neurology. 2011 Sep 27 . 77(13):1222-8.

10. Shcchan OC, Mcrwick A, Kelly LA, Hannon N, Marnane M,

Kync L, et al. Diagnostic usefulness of the ABCD2 score to

distinguish transient ischemic attack and minor ischemic

strokc from nonccrebrovascular events: the North Dublin TIA

Study. Stroke. 2009 Nov. 40(Il):3449-54.

ll.

Tsivgoulis

G,

Stamboulis

E,

Shamra

VK,

Heliopoulos I, Voumvourakis

K,

Teoh

HL,

et

al.

Multicenter external

validation

of

the ABCD2 score

in

triaging

TIA

patients.

Neurology. 2010 Apr 27 . 74(17):1351-7.

Saturday, April 9th 2016

Cur r ent LI p d a t r,s a { }r t i

titl

Sl rc ck nnd S t r o ke Mn n c gu nant

{n Prirnarv Carc

12. Asimos

AW,

Johrson

AM,

Rosamond WD.

evaluation of the ABCD2 score accuracy for predicting

ischemic stroke in admitted patients with transient ischemb

attack. Ann Emerg Med. 2010:201-210

13. Chandratheva

A,

Geraghty

OC,

Luengo-Fernandez

Rothwell PM. ABCD2 score predicts severity rather than

of

early recurrent events after trarsient ischemic a

Strok e. 2010 May. 4l(5):85 1-6.

14. Stead LG, Suravaram S, Bellolio MF, Enduri S, Rabinstein

Giknore RM, et al. An assessment of the incrementalvalue

the ABCD2 score in the emergency departrnent evaluation

transient ischemic atlack.

Ann

Emerg

Med.

2011 J

57( I _):46-51.

15. Fothergill A, Christiarson TJ, Brown RD Jr, Rabinstein

Validation and refinement of the ABCD2 score: a popula

based analys its. S n"o k e . 2009 Aug. 40(8):2669 -7 3.

16. Amarenco P, Labreuche J, Lavall6e PC, Meseguer E,

L,

Slaoui T, et al. Does ABCD2 score below 4 allow

time to evaluate patients with a transient ischemic attac

Stroke. 2009 Sep. 40(9):3091-5.

17. Merwick

A,

Albers GW, Amarenco P, Arsava EM, Ay

Calvet D, et al. Addition of brain and carotid imaging to

Saturday, April 9t'. 2016

Asri Medical Center of Yogyakarta

t...-. i ; r r * *

i

L i ;L, i, t l t:s tt

i

i t t.i t i a i 5h ts i :k t t ui 5 i t' o k i: ;\'4 i;i n t tt t r *: ri t

Jti iltint*r:1

{.trt

ABCD'zscoretoidentifypaticntsatearlyriskofstrokeafter

transient ischaemic attack: a multicentre observational study.

Lancet Neuro

l.

2010 Nov. 9( 1 1):1060-9.

18. Wu CM, Manns BJ,

Hill MD,

Ghali WA, Donaldson C,

Buchan

AM.

Rapid evaluation

after

high-risk

TIA

is

associated with lower stroke risk' Can J Neurol Sci _' 2009 Jul'

36(a):450-5.

19. [Guideline] Furie

KL,

Kasner SE, Adams

RJ,

et

aL

Guidelines for the prevention of stroke in patients with stroke

or

transient ischemic

attack

a

guideline

for

healthcare

professionals from the american heart association/american

stroke associa tion. S tro k e. 20 1 1 Jan. a2Q):227 -7 6'

SaturdaY, APtil9th 2016