Prevention of Recurrent Stroke: An EvidenceBasedKorinne Approach Novak

Prevention of Recurrent Stroke: An EvidenceBasedKorinne Approach Novak

Prevention of Recurrent Stroke: An EvidenceBasedKorinne Approach Novak APRN, CNP Michelle Ullery DNP, APRN, CNP Uche Amajuoyi APRN, CNP Mark Ringo DNP, APRN, CNP April 15th, 2016 Objectives 1. Recognize risk factors for recurrent stroke. 2. Apply current guidelines to manage risk factors for recurrent stroke in the sub-acute and primary care

setting. 3. Learn how to support health-promoting behaviors among high risk groups. 2 Stroke > 790,000 adults experience ischemic stroke each year in the

3 United States, 185,000 are recurrent strokes 2nd most common cause of mortality and 3rd most common cause of disability Incidence decreasing in high income countries, increasing in low income countries Recurrent Approximately 240,000 will experience a TIA- focal neuro symptoms lasting <24 hours without imaging evidence of infarction. TIA increases risk for future stroke Annual risk for future stroke after initial is 3-4%. 4 5 6 7

Ischemic Stroke- 80% of all strokes Thrombosis Large Vessel Disease including common carotids and intracranial arterial system Small Vessel Disease- intracerebral arterial system. Distal vertebral and basilar arteries Atherosclerosis most common cause Embolism Common risk factors Afib, valve replacement, recent MI

Hypoperfusion 8 Hemorrhagic 32% incidence globally Intracranial hemorrhage HTN, trauma, drug abuse Subarachnoid hemorrhage Ruptured aneurysm, vascular malformation

9 Non Modifiable Risk Factors Age >80 Ethnicity. Black higher risk compared with white Sex. Men higher risk than women with exception of ages 35-44 and >85 Family History 10 Modifiable Risk Factors

Smoking- doubles stroke risk. Risk disappears 2-4 years after quitting HTN- most common stroke risk factor, severe HTn with increased rish for ICH Diabetes- increase incidence of ischemic stroke Hyperlipidemia Heart disease A fib, valve disease, endocarditis, MI Obesity 11

Case Study Mr. H 68 year old Caucasian male PMH: DM type 2, HTN, Paroxysmal A-fib, hyperlipidemia, BPH, osteoarthritis PSH: left TKA, cataract surgery, removal of colon polyp, cardiac stent 5 years ago, cardioversion for A fib SH: married, 3 adult children, retired

bar owner, current smoker 40 packyear history, 5-6 beers/week 12 Medications Lisinopril 20 mg daily Metoprolol 25 mg BID ASA 81 mg Rivaraxiban 20 mg daily Tamsulosin 0.4 mg daily Vitamin D 2,000 units

daily Metformin XL 2000 mg daily MR. H 2:30 pm. Patients wife returned to home and found Mr H. lying on the floor. He had difficulty generating words and unable to lift his right arm and leg off of the floor

EMS was called and transported patient to ER 13 Upon arrival to ER BP 190/110 ECG showed normal sinus rhythm CT revealed Left MCA ischemic stroke

Mr. Hs Hospital Course Patient was hospitalized due to stroke Stable recovery course Regained partial use of arm and leg Blood pressure optimized and discharged on additional antihypertensives Transferred to acute inpatient rehabilitation x 3 weeks prior to discharge home with his wife Upon discharge, able to ambulate with cane and assistance 14

Current Guidelines AHA/ASA 2014 Prevention of Stroke ADA 2016 Diabetes ACC/AHA 2013 Dyslipidemia CDC 2014 Immunization 15 Primary Prevention

Immunizations Annual influenza Tdap/Td Varicella Zoster MMR Pneumococcal 13 Pneumococcal 23 (CDC, 2016) 16 Secondary Prevention

Screen sleep apnea Depression Atrial fibrillation? (ACA/ASA, 2014) 17 Tertiary Prevention Dependent on the underlying condition(s), know the

1. Numbers 2. Medications 3. Lifestyle recommendations 18 Know the Numbers Blood pressure Hemoglobin A1C Body mass index

19 Know the Medications High potency statins (AHA/ACC, 2013) Antiplatelet agents Warfarin Novel anticoagulants (AHA, ASA, 2014)

20 Know the Recommendations Nutrition Physical activity (AHA/ASA, 2014) Sleep 21

(NSF, 2015) Secondary Stroke Prevention: Modifiable Factors 22 Stroke. 3 cause of death

rd worldwide Results in mortality or disability in every 3

patient at the end of the first year following an acute cerebrovascular rd event. 23 5 Most Common Risk Factors

High blood pressure Smoking Abdominal obesity Diet Lack of physical activity Life Style Modification A feature of stroke is recurrence 3040% within five-years following first

transient ischemic attack/ stroke. A consistent, systematic assessment of stroke risk factors is lacking in clinical practice. 24 Life Style Modification Helping patients commit to lifestyle changes that they themselves have selected have shown positive results

Interview Motivational Patient Centered 25 Modifiable Risk Factors 26 Life Style Modification: DIET

27 Life Style Modification: PHYSICAL ACTIVITY Engage in Physical Activity Each Day : o Total of 60 minutes for children o 30 minutes for adults 28

Life Style Modification: Smoking Cessation Smoking can.. Raise triglycerides Lower "good" cholesterol (HDL) Cause thickening of blood, making likely to clot Increase the buildup of plaque in blood vessels Thicken and narrow blood vessels 29

Mindfulness-Based Interventions: Stress Management Emerging evidence demonstrates an association between self-perceived psychological stress and ischemic stroke Goal: Equipping patients with skills and coping strategies to help manage perceived psychological stress

30 Mindfulness-based stress reduction (MBSR) & mindfulnessbased cognitive therapy (MBCT) BP in arteries Intestinal muscles relax Heart Rate

STRESS HORMONES Pupils dilate blood sugar blood flow to skeletal muscles

breathing rate 31 Supporting Health Promoting Behaviors

Physician-centered care relies on the physician who makes the healthcare decisions and it relies on a hierarchical relationship between the physician and the patient. Patient-centered care changes this relationship from whats the matter to what matters to you. This type of care empowers the patient to take a more active role in their health care. 32 Motivational Interviewing Motivational interviewing is a technique that elicits from the patient their own motivations

for making behavioral changes which can have a beneficial impact on their overall health (Rollnick, Miller, & Butler, 2008). Motivational interviewing, grounded in patient-centered care, focuses on what the patient thinks, wants, and feels. 33 Motivational Interviewing in Action

34 Six Steps of Instance Influence Step 1: Why might you change? Step 2: How ready are you to change- on a scale from 1/10, where 1 means not ready at all and 10 means totally ready? Step 3: Why didnt you pick a lower number? (Or if they picked a 1, either ask the second question again, this time about a smaller step toward change, or ask, what would it take for that 1 to turn into a 2?)

35 Six Steps of Instant Influence Step 4: Imagine youve changed. What would the positive outcomes be? Step 5: Why are those outcomes important to you? Step 6: Whats the next step, if any? 36 Literature Review

Positive evidence in addiction Results mixed in chronic health conditions New studies in using MI after stroke Need more RCTs 37 Questions? 38 References

American Diabetes Association. (2016). Standards of medical care in diabetes- 2016. The Journal of Clinical and Applied Research, 39(1) CDC. (2016). Adult immunization schedule. Retrieved from The Centers for Disease Control and Prevention (2016). Smoking and heart disease and stroke. Retrieved from: Healthteam Works Videos. (2009, 10,9). Motivational Interviewing: Evoking Commitment to change. [Video file]. Retrieved from Lawrence, M., Booth, J., Mercer, S., & Crawford, E. (2013). A systematic review of the benefits of mindfulness-based

39 interventions following transient ischemic attack and stroke. International Journal of Stroke, 8(6), 465-474. doi:10.1111/ijs.12135 Mayo Clinic .(2016). Secondary stroke prevention: Toward a new model of care. Clinical Updates. Retrieved from

National Sleep Foundation. (2015). National sleep foundation recommendations new sleep durations. Sleep Health: The Journal of the National Sleep Foundation. Niewada, M., & Czlonkowska, A. (2014). Prevention of ischemic stroke in clinical practice: A role of internists and general practitioners. Polskie Archiwum Medycyny Wewnetrznej, 124(10), 540-548. Pantalon, M. (2011). Instant influence: How to get anyone to do anything fast. New York, NY: Little, Brown, and Company, Hatchette Book Group. Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational interviewing in health care. New York, NY: The Guilford Press. Stone, N.J. et al. (2013). ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the american college of cardiology/american heart association task force on practice guidelines. Circulation. 01, doi:10.1161/01.cir.0000437738.63853.7a

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