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Robert Dachs, MD, FAAFP 8 Board Review Express® February 19-22, 2020 Houston, TX geor Day 3 Friday, February 21 7:00 – 8:00 am Breakfast Provided 8:00 – 8:30 am Acute CVA & TIA – Robert Dachs, MD, FAAFP 8:30 – 9:00 am Adult Pulmonary Disease – Dana King, MD, MS, FAAFP 9:00 – 9:30 am The Surgical Abdomen – Robert Dachs, MD, FAAFP 9:30 – 10:00 am Asthma: Pediatric and Adult – Dana King, MD, MS, FAAFP 10:00 – 10:15 am Q&A 10:15 – 10:30 am Break 10:30 – 11:15 am Selected Issues in Women’s Health – David Weismiller, MD, ScM, FAAFP 11:15 – 11:45 am Musculoskeletal Medicine – Joseph Garry, MD, FACSM, FAAFP 11:45 am – 12:30 pm COPD, Lung Cancer, OSA, Sarcoidosis – Dana King, MD, MS, FAAFP 12:30 – 12:45 pm Q&A 12:45 – 1:45 pm Lunch Provided 1:45 – 2:15 pm Behavioral Medicine I: Major Depression – Stanley Oakley, MD, DLFAPA 2:15 – 2:45 pm Fracture Care in Family Medicine – Joseph Garry, MD, FACSM, FAAFP 2:45 – 3:15 pm Behavioral Medicine II: Bipolar & Anxiety Disorders – Stanley Oakley, MD, DLFAPA 3:15 – 3:30 pm Q&A 3:30 – 3:45 pm Break 3:45 – 4:15 pm Sports Medicine – Joseph Garry, MD, FACSM, FAAFP 4:15 – 4:45 pm Behavioral Medicine III: ADHD, Autism, & OCD– Stanley Oakley, MD, DLFAPA 4:45 – 5:15 pm Pediatric Orthopedics – Joseph Garry, MD, FACSM, FAAFP 5:15 – 5:30 pm Q&A Acute CVA and TIA Robert Dachs, MD, FAAFP Clinical Associate Professor Ellis Hospital Family Medicine Residency Program Albany Medical College, Albany, New York Disclosure Statement It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. Learning Objectives 1. Identify patients with underlying risk factors for stroke. 2. Employ cost-effective measures to decrease stroke in patients at risk. 3. State the 2009 AHA/ASA definition of TIA and describe the recommended evaluation. 4. Propose appropriate treatment options to improve outcomes in patients who suffer a stroke. In 30 Minutes … The Plan • CVA risk factors and 1° prevention • Acute CVA care • 2° prevention • TIA – everything has changed Stroke Pathogenesis 1. Acute stroke events are most often the result of which of the following pathological processes? A. Acute thrombosis B. Acute embolic event C. Acute intracerebral hemorrhage D. Acute subarachnoid hemorrhage Stroke Type/Subtypes Large-vessel Thrombotic (50%) (20-25%) Ischemic (80%-85%) Small-vessel Embolic (30%) (20-25%) Intracerebral (10%) Hemorrhagic (15%-20%) Subarachnoid (6%) What is a “cryptogenic stroke”? Stroke Type/Subtypes Large-vessel (20-25%) Thrombotic (50%) Ischemic (80-85%) Small-vessel (20-25%) Embolic (30%) But the underlying cause is undetermined What is a “cryptogenic stroke”? Stroke Risk Factors • Modifiable vs. Non-modifiable – Age – Family Hx – Ethnicity Modifiable Risk Factors and CVA 70 60 50 Accounts 40 for 90% 30 of all 20 strokes 10 0 HTN Afib DM Physical Smoking inactivity Add in: hyperlipidemia, excessive alcohol use INTERSTROKE study, Lancet 2016 Stroke Type/Subtypes and Risk Factor: HTN Large-vessel (20-25%) Thrombotic (50%) Ischemic (80-85%) Small-vessel (20-25%) Embolic (30%) Intracerebral (10%) Hemorrhagic (15-20%) Subarachnoid (6%) If you can control BP, can you reduce CVAs? Stroke Type/Subtypes and Risk Factor: HTN Large-vessel Thrombotic (50%) (20-25%) Ischemic (80-85%) Small-vessel Embolic (30%) (20-25%) Intracerebral (10%) Hemorrhagic (15-20%) Subarachnoid (6%) If you can control BP, can you reduce CVAs? YES! * Supporting Evidence: Control HTN (the Placebo-Controlled Trials) Population Treatment NNT/yrs MRC, 1985 17,354 pts a) Bendrofluazide or 90/5.5yrs Age: 36-64 b) Propranolol vs. 192/5.5yrs Diastolic: 90-109 placebo 43/4.5yrs 4,736 pts Chlorthalidone vs placebo SHEP, 1991 Age: 60+ BP:160-219/90+ 34/4.0yrs STOP, 1991 1,627 pts a) B-Blocker, or Age:70-84 b) HCTZ + amiloride, or BP: 180-230/90+ c) ACE-I vs. placebo MRC-2, 1992 4,396 pts a) HCTZ + amiloride, or 53/5.8yrs Age: 65-74 b) Atenolol vs 103/5.8yrs BP: 160-209/<115 placebo Stroke Type/Subtypes and Risk Factor: DM Large-vessel (20-25%) Thrombotic (50%) Ischemic (80-85%) Small-vessel Embolic (30%) (20-25%) Intracerebral (10%) Hemorrhagic (15-20%) Subarachnoid (6%) Stroke Type/Subtypes and Risk Factor: Afib Large-vessel (20-25%) Thrombotic (50%) Ischemic (80-85%) Small-vessel Embolic (30%) (20-25%) Intracerebral (10%) *if anticoagulated Hemorrhagic (15-20%) Subarachnoid (6%) Atrial Fibrillation and Stroke 8 7 6 5 4 3 CVA rate 2 (% per yr) 1 0 < 65 yrs 65-75yrs > 75 yrs • Anticoagulation decreases absolute annual risk from 4.5% -> 1.4%(NNT=30) • The older the patient with atrial fibrillation, the higher the risk of cardioembolic stroke • Strokes due to Afib have higher mortality and morbidity. Afib and CVA risk stratification: CHA2DS2-VASc Score CHA2DS2-VASc 1 CHF Risk Category 1 HTN 0: Low-risk (ASA) 2 Age >75 yrs 1: Women: (ASA or DOAC > warfarin) 1 DM 1: Men: (ASA or DOAC > warfarin)* 2 Prior Stroke or TIA 2+: High-risk (DOAC > warfarin)* 1 Vascular disease 1 Age 65-74 yrs 1 Female sex *2019 AHA/ACC guideline changes Note: DOAC noninferior to warfarin, improved safety profile Atrial Fibrillation: Anticoagulation Potential Harms vs. Potential Benefits • Decreases CVA – approx. 3% per yr • Best calculator: www.afib.ca • Rate of ICH 0.1-0.6% –Increased with advanced age, HTN • Major bleeding rates: 1.2% per yr Which of the following new oral anticoagulants is approved for the management of non-valvular Afib? 1. Dabigatran (Pradaxa) – BID 2. Rivaroxaban (Xarelto) – qd 3. Apixaban (Eliquis) – BID 4. All of the above Which of the following new oral anticoagulants is approved for the management of non-valvular Afib? 1. Dabigatran (Pradaxa) – BID 2. Rivaroxaban (Xarelto) – qd 3. Apixaban (Eliquis) – BID 4. All of the above If you were asked… Which of the following new oral anticoagulants is approved for the management of DVT/PE? 1. Dabigatran (Pradaxa) 2. Rivaroxaban (Xarelto) 3. Apixaban (Eliquis) 4. All of the above If you were asked… Which of the following new oral anticoagulants is approved for the management of DVT/PE? 1. Dabigatran (Pradaxa) 2. Rivaroxaban (Xarelto) 3. Apixaban (Eliquis) 4. All of the above Modifiable Risk Factors and CVA 70 60 50 Accounts 40 for 90% 30 of all 20 strokes 10 0 HTN Afib DM Physical Smoking inactivity Add in: hyperlipidemia, excessive alcohol use INTERSTROKE study, Lancet 2016 AHA/ASA Guideline for Primary Prevention of Ischemic Stroke (2014) • Obesity: recommend weight reduction Class I, Level of evidence B • Physical Activity: recommend it Class I, Level of evidence B (moderate to vigorous aerobic activity 3-4 x/week) • Hypertension: annual screen, treat if >140/90 Class I, Level of evidence A • Diabetes: control HTN, Class I, Level of evidence A -start statin if > 1 risk factor Class I, Level of evidence A • Smoking: Stop Class I, Level of evidence A AHA/ASA Guideline for Primary Prevention of Ischemic Stroke (2014) • Alcohol: for those who choose Class IIb, Level of evidence B - ≤2 drinks/day for men and ≤1 drink/day for women “might be reasonable” • A fib: anticoagulate if CHA2DS2-Vasc > 2 Class I, Level of evidence A • Lipids: see 2018 lipid guideline in Cardiology lecture* reproduced in Supplemental slides at end of lecture What about aspirin for primary prevention of CVA/CVD? USPSTF 2016 Recommendations Aspirin for 1° Prevention for CV/Stroke The Big 3 randomized trials… •ARRIVE trial (Lancet, Sept 22, 2018) −12,546 pts (55yrs+), Ave CV risk score (17% over 10yrs) – followed 5 yrs −No difference in Composite CV endpt, or mortality − 0.5% increase bleeding with ASA •ASPREE trial (NEJM, Oct 18, 2018) −19,114 pts (70yrs+), no hx of CV disease – followed for 5 yrs −No difference in death, dementia or disability, 1% increase in bleeding •ASCEND trial (NEJM, Oct 18, 2018) −15,480 pts with DM but no CV disease, Ave age 63, – followed 7.4 yrs −1.1% decrease in first vascular event, 0.9% increase in bleeding Published Online, March 2019 Arnett et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease 4.6. Aspirin Use Recommendations for Aspirin Use Referenced studies that support recommendations are summarized in Online Data Supplements 17 and 18. COR LOE Recommendations IIb A 1. Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among selected adults 40 to 70 years of age who are at higher ASCVD risk but not at increase bleeding risk (S4.6-1—S4.6-8) III: B-R 2. Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the Harm primary prevention of ASCVD among adults >70 years of age (S4.6-9). III: C-LD 3. Low-dose aspirin (75-100 mg orally daily) should not be administered for the primary Harm prevention of ASCVD among adults of any age who are at increased risk of bleeding (S4.6-10). Aspirin for 1° prevention for CV/Stroke USPSTF 2016 Vs. AHA/ACC 2019 IIb III Stroke Risk Factors • Traditional vs.
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