Transcript Diapositiva 1

Impacto del control de
los distintos Factores
de Riesgo en la fase
aguda del AVC:
Objetivos.
Vicente Giner Galvañ.
Unidad de HTA y Riesgo Cardiometabólico.
Servicio de Medicina Interna.
Hospital Verge dels Lliris.
Alcoi. Alacant.
Valencia, 8 y 9 de Junio de 2012
Arterio-arterial
Gran vaso
Hemorrágico
Trombótico
Cardioembólico
Pequeño vaso
Idiopático
Lacunar
Isquémico
Arritmias (FA)
Disglucemia
HTA
Dislipidemia
SAHS
Arterio-arterial
Gran vaso
Hemorrágico
Trombótico
Cardioembólico
Pequeño vaso
Idiopático
Lacunar
Isquémico
Introducción
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Ictus: entidad vascular altamente heterogénea
Al contrario de lo que ocurre en otras
enfermedades vasculares, el ictus es una
entidad heterogénea tanto en sus diferentes
formas de presentación clínica como en su
etiopatogenia diversa.
Sus factores de riesgo y su pronóstico a
corto y largo plazo también varían según el
subtipo de ictus.
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Introducción
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Ictus: entidad vascular altamente heterogénea
La mortalidad intrahospitalaria fue del
12,9%, dentro de los márgenes de la
mayoría de las series publicadas.
La hipertensión arterial (HTA) se presentó
en el 55,5%, seguida por la fibrilación
auricular (FA) (29,8%) y la diabetes mellitus
(DM) (23,4%).
Arboix A. Rev Esp Cardiol. 2008;61:1020-9.
Arboix A. Rev Esp Cardiol. 2008;61:1020-9.
Arboix A. Rev Esp Cardiol. 2008;61:1020-9.
Arboix A. Rev Esp Cardiol. 2008;61:1020-9.
Introducción
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Ictus: entidad potencialmente curable
El tratamiento agudo del ictus se puede subclasificar en 2
partes:
1.- Medidas generales y de control de
complicaciones (Control PA, glucemia,
infecciones/temperatura, arritmias…).
2.- Tratamiento recanalizador.
Introducción
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Ictus: entidad potencialmente curable
 En el paciente no subsidiario de trombolisis
 En el paciente subsidiario de trombolisis
Presión arterial
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Por cada 10 mmHg de incremento de
PAS por encima de 180 mmHg el riesgo
de
deterioro
neurológico
se
incrementa un 40% y de mal pronóstico
global un 23%.
Robinson T. Cerebrovasc Dis. 1997;7:264 -72.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Es común la detección de elevación de la
PA en las primeras horas de evolución del
ictus, de tal forma que valores de
PAS>160 mmHg son detectables en el
60% y atribuibles a estrés, dolor,
retención urinaria… (HTA reactiva).
Robinson T. Cerebrovasc Dis. 1997;7:264 -72.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Toyoda K et al. Stroke 2006;37:2637-2639
Toyoda K. Stroke 2006;37:2637-9.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Acute SBP values between
12 and 36 hours
postadmission, but not those
on admission or at 6 hours,
were predictive of
neurological deterioration
within the initial 3 weeks of
ischemic stroke, particularly
for cardioembolic stroke
patients.
Toyoda K et al. Stroke 2006;37:2637-2639
Toyoda K. Stroke 2009;40:2585-8.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Acute SBP values between
12 and 36 hours
postadmission, but not those
on admission or at 6 hours,
were predictive of
neurological deterioration
within the initial 3 weeks of
ischemic stroke, particularly
for cardioembolic stroke
patients.
Toyoda K et al. Stroke 2006;37:2637-2639
Toyoda K. Stroke 2009;40:2585-8.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Toyoda K et al. Stroke 2006;37:2637-2639
Vemmos KN. J Hum Hypertens. 2004;18:253-9.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Registro FINAPRES
Toyoda K et al. Stroke 2006;37:2637-2639
Dawson S. Stroke 2000;31:463-8.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Registro FINAPRES
Toyoda K et al. Stroke 2006;37:2637-2639
Dawson S. Stroke 2000;31:463-8.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Registro FINAPRES
Toyoda K et al. Stroke 2006;37:2637-2639
Dawson S. Stroke 2000;31:463-8.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Registro MAPA
Toyoda K et al. Stroke 2006;37:2637-2639
Tomii Y. Strroke. 2011; 42: 3511-17.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Registro MAPA
Mean ambulatory BP monitoring values
changed from 150.5±19.5/85.7±11.3 mmHg
on Day 1 to 139.6±19.3/80.0±11.7 mmHg on
Day 7.
Toyoda K et al. Stroke 2006;37:2637-2639
Tomii Y. Strroke. 2011; 42: 3511-17.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA
Registro MAPA
After multivariate adjustment, mean values of systolic BP
(OR, 0.63; 95% CI, 0.45–0.85), diastolic BP (0.61; 0.37–
0.98), pulse pressure (0.55; 0.33–0.85), and HR (0.61; 0.37–
0.98) recorded on Day 1 as well as mean HR on Day 7
(0.47; 0.23–0.87) were inversely associated with
independence.
Toyoda K et al. Stroke 2006;37:2637-2639
Tomii Y. Strroke. 2011; 42: 3511-17.
Factores de riesgo en el AVC agudo
Hospital Verge dels Lliris.
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Presión arterial / HTA
Toyoda K et al. Stroke 2006;37:2637-2639
Tomii Y. Strroke. 2011; 42: 3511-17.
Factores de riesgo en el AVC agudo
Hospital Verge dels Lliris.
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Presión arterial / HTA: Manejo en fase aguda del ictus
There are several questions about the management of arterial
hypertension in the setting of acute stroke.
Should patients previously taking antihypertensive medications continue taking
them during the first hours after stroke?
Are some of these medications contraindicated or indicated?
Should new antihypertensive agents be started?
What level of blood pressure would mandate initiation of new antihypertensive
treatment?
Which medication should be administered in this situation?
AHA/ASA Guideline. Stroke 2007; 38: 1655-711.
Factores de riesgo en el AVC agudo
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Presión arterial / HTA: Manejo en fase aguda del ictus
There are several questions about the management of arterial
hypertension in the setting of acute stroke.
Should patients previously taking antihypertensive medications continue taking
them during the first hours after stroke?
Are some of these medications contraindicated or indicated?
Should new antihypertensive agents be started?
What level of blood pressure would mandate initiation of new antihypertensive
treatment?
Which medication should be administered in this situation?
Unfortunately, definite answers to these questions are not available.
AHA/ASA Guideline. Stroke 2007; 38: 1655-711.
PA en la fase aguda del ictus
Hospital Verge dels Lliris.
Alcoy.
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Estudios disponibles
Acrónimo
Referencia
ACCES
Stroke. 2003;34:1699.
Muestra
Intervención
Resultado final
500
Estudio de seguridad
Candesartán vs.
Placebo
a 24h del ictus para ↓
PAS 15-20%.
Menor morbimortalidad en
candesartán al año (RR 0,475).
Captopril vs.
Amlodipino
a las 24h del ictus
Pequeñas reducciones de PA
produjeron beneficio a corto plazo.
37 ictus isquémicos
Bendrofluazida vs.
Placebo
en 24h del AVC durante
7 días
No efectiva en reducción de PA
clínica ni latido a latido (FINAPRES).
40
hipertensos con ictus
isquémico
Lisinopril vs. Placebo
en las primeras 24 h
Sin diferencias funcionales a los 90
días.
Rodríguez-García JL
Am J Hypertens.2005;18:379.
Eames PJ
Cerebrovasc Dis. 2005;19:253.
Eveson DJ
Am J Hypertens.2007;20:270-7.
PA en la fase aguda del ictus
Hospital Verge dels Lliris.
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Estudios disponibles
Acrónimo
Referencia
CHHIPS piloto
Lancet Neurol. 2009; 8:48.
COSSACS
Lancet Neurol. 2010;9:767-75.
SCAST
Stroke. 2011;42:2995-8.
PIL-FAST
Trials 2011; 12:152
Muestra
Intervención
Resultado final
179 hipertensos con
AVC isquémico o
hemorrágico
Labetalolo vs.
Lisinopril
vs. Placebo
en las 36 h iniciales
Reducción de mortalidad a tres
meses (RR 0,40)
763 pacientes con
antiHTA y AVC
isquémico
“mantener antiHTA
habituales” vs.
“suspenderlos”
en las 48 h
Lower blood pressure levels in
those
who
continued
antihypertensive treatment after
acute mild stroke were not
associated with an increase in
adverse events.
2029
Pacientes con AVC
isquémico o
hemorrágico
Candesartán vs.
Placebo
a las 24h del ictus.
Sin diferencias a 6 meses
(Tendencia a efecto negativo
funcional y morbimortalidad con
candesartán a corto plazo)
60 hipertensos con
ictus isquémico en
fase pre-hospital
(piloto)
Lisinopril vs. Placebo
en las primeras 3 h si
PAS >160 mmHg
En marcha
PA en la fase aguda del ictus
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Momento de inicio de tto antiHTA
Effect of change in blood pressure during the first 2 days
of stroke on the risk of early adverse events and poor
outcome.
2029 patients presenting within 30 hours of acute stroke and
with systolic blood pressure (SBP) ≥140 mm Hg. Treatment
was given for 7 days.
Change in blood pressure was defined as the difference in
SBP between baseline and Day 2.
Scandinavian Candesartan Acute
Stroke Trial (SCAST).
Sandset EC. Stroke 2012 May 24. [Epub ahead of print]
PA en la fase aguda del ictus
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Momento de inicio de tto antiHTA
OUTCOMES:
Early adverse events (recurrent stroke, stroke progression,
and symptomatic hypotension) during the first 7 days.
Secondary effect parameters were neurological status at 7
days and functional outcome at 6 months
Scandinavian Candesartan Acute
Stroke Trial (SCAST).
Sandset EC. Stroke 2012 May 24. [Epub ahead of print]
PA en la fase aguda del ictus
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Momento de inicio de tto antiHTA
Patients with a large decrease or increase/no
change in SBP had a significantly increased risk
of early adverse events relative to patients
with a small decrease (OR, 2.08; 95% CI, 1.193.65 and OR, 1.96; 95% CI, 1.13-3.38,
respectively).
Scandinavian Candesartan Acute
Stroke Trial (SCAST).
Sandset EC. Stroke 2012 May 24. [Epub ahead of print]
PA en la fase aguda del ictus
Hospital Verge dels Lliris.
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PA y fibrinolisis
Patients who have elevated blood pressure
and are otherwise eligible for treatment of
rtPA may have their blood pressure lowered
so that their systolic blood pressure is <185
mmHg and their diastolic blood pressure is
<110 mmHg (Class I, Level of Evidence B)
before lytic therapy is started.
AHA/ASA Guideline. Stroke 2007; 38: 1655-711.
PA en la fase aguda del ictus
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PA y fibrinolisis
If medications are given to lower blood
pressure, the clinician should be sure
that the blood pressure is stabilized at
the lower level before treating with rtPA
and maintained below 180/105 mmHg
for at least the first 24 hours after
intravenous rtPA treatment.
AHA/ASA Guideline. Stroke 2007; 38: 1655-711.
PA en la fase aguda del ictus
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PA y fibrinolisis
Butcher K. Stroke 2010;41:72-7.
PA en la fase aguda del ictus
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PA y Fibrinolisis
HI: petechial hemorrhagic infarction.
PH: parenchymal hematoma.
HT: Hemorragic transformation
Butcher K. Stroke 2010;41:72-7.
PA en la fase aguda del ictus
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PA y fibrinolisis
Because the maximum interval from
stroke onset until treatment with rtPA
is short, many patients with sustained
hypertension above recommended
levels
cannot
be
treated
with
intravenous rtPA.
AHA/ASA Guideline. Stroke 2007; 38: 1655-711.
PA en la fase aguda del ictus
PA en la fase aguda del ictus
Hospital Verge dels Lliris.
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PA en la fase aguda del ictus
Hospital Verge dels Lliris.
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PA y fibrinolisis
AHA/ASA Guideline. Stroke 2007; 38: 1655-711.
PA en la fase aguda del ictus
Hospital Verge dels Lliris.
Alcoy.
http//alcoi.san.gva.es
PA y fibrinolisis
AHA/ASA Guideline. Stroke 2007; 38: 1655-711.
Glucemia
Factores de riesgo en el AVC agudo
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Glucemia
Hyperglycaemia occurs in 30-40% of patients with acute ischaemic
stroke, also in individuals without a known history of diabetes.
Luitse MJ. Lancet Neurol. 2012;11:261-71.
Factores de riesgo en el AVC agudo
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Glucemia: Hiperglucemia inducida por el ictus agudo
Nyika D. Nature Reviews Neurology. 2010; 6,145-55.
Factores de riesgo en el AVC agudo
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Glucemia
Hyperglycaemia occurs in 30-40% of patients with acute ischaemic
stroke, also in individuals without a known history of diabetes.
Admission hyperglycaemia is associated with poor functional
outcome, possibly through aggravation of ischaemic damage by
disturbing recanalisation and increasing reperfusion injury.
Luitse MJ. Lancet Neurol. 2012;11:261-71.
Factores de riesgo en el AVC agudo
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Glucemia
Hyperglycaemia occurs in 30-40% of patients with acute ischaemic
stroke, also in individuals without a known history of diabetes.
Admission hyperglycaemia is associated with poor functional
outcome, possibly through aggravation of ischaemic damage by
disturbing recanalisation and increasing reperfusion injury.
Uncertainty surrounds the question of whether glucose-lowering
treatment for early stroke can improve clinical outcome.
Achievement of normoglycaemia in the early stage of stroke can be
difficult, and the possibility of hypoglycaemia remains a concern.
Luitse MJ. Lancet Neurol. 2012;11:261-71.
Factores de riesgo en el AVC agudo
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Glucemia: Ensayos clínicos de control de la glucemia
Kruyt ND. et al. Nat. Rev. Neurol. 2010. doi:10.1038/nrneurol.2009.231
Factores de riesgo en el AVC agudo
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Glucemia: Ensayos clínicos de control de la glucemia
Kruyt ND. et al. Nat. Rev. Neurol. 2010. doi:10.1038/nrneurol.2009.231
Factores de riesgo en el AVC agudo
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Glucemia
Insulin for glycaemic control in acute ischaemic
stroke.
Squizzato A, Romualdi E, Dentali F, Ageno W.
Cochrane Database Syst Rev. 2011 Sep 7;(9):CD005346.
We included seven trials involving 1296 participants (639
participants in the intervention group and 657 in the control
group).
Outcomes: death, disability and dependence, hypoglicemia.
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Glucemia
We found that there was no difference between treatment and
control groups in the outcome of death or disability and dependence
(OR 1.00, 95% CI 0.78 to 1.28) or final neurological deficit (SMD 0.12, 95% CI -0.23 to 0.00).
The rate of symptomatic hypoglycaemia was higher in the
intervention group (OR 25.9, 95% CI 9.2 to 72.7).
In the subgroup analyses of diabetes mellitus (DM) versus nonDM, we found no difference for the outcom
Squizzato A. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD005346.
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Glucemia en la fase aguda del ictus
Persistent hyperglycemia (>140 mg/dL)
during the first 24 hours after stroke is
associated with poor outcomes, and
thus it is generally agreed that
hyperglycemia should be treated in
patients with acute ischemic stroke.
AHA/ASA Guideline. Stroke 2007; 38: 1655-711.
PA en la fase aguda del ictus
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Glucemia en la fase aguda del ictus
The minimum threshold described in
previous statements likely was too high,
and lower serum glucose concentrations
(possibly >140 to 185 mg/dL) probably
should trigger administration of insulin,
similar to the procedure in other acute
situations
accompanied
by
hyperglycemia
Class IIa, Level of Evidence C
AHA/ASA Guideline. Stroke 2007; 38: 1655-711.
PA en la fase aguda del ictus
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Glucemia en la fase aguda del ictus
Close
monitoring
of
glucose
concentrations with adjustment of
insulin doses to avoid hypoglycemia is
recommended.
Simultaneous administration of glucose
and potassium also may be appropriate.
AHA/ASA Guideline. Stroke 2007; 38: 1655-711.
Lípidos
Factores de riesgo en el AVC agudo
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Lípidos
Choi KH. J Neurol Sci. 2012. [Epub ahead of print]
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Factores de riesgo en el AVC agudo
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Lípidos
Functional Neurology 2011; 26:133-9.
Factores de riesgo en el AVC agudo
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Lípidos
Statin treatment for 4 days may increase circulating EPC (Endothelial progenitor
cells) levels, probably by NO-related mechanisms.
Sobrino T. Eur J Neurol 2012 May 28. doi: 10.1111/j.1468-1331.2012.03770.x. [Epub ahead of print]
Factores de riesgo en el AVC agudo
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Lípidos
The purpose of the present review is to systematically evaluate the effectiveness
of statin pretreatment on functional outcome of acute ischemic stroke and to assess
potential adverse events associated with statin use.
Recurrence of stroke in patients who had suffered from a previous stroke was
analyzed with and without statin therapy.
Incidence and severity of adverse reactions was reviewed.
Lakhan SE. Int Arch Med. 2010; 3::22.
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Lípidos
Pretreatment with statins was associated with a favorable outcome in acute
ischemic stroke, with few incidences of adverse reactions.
Lakhan SE. Int Arch Med. 2010; 3::22.
Factores de riesgo en el AVC agudo
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Lípidos
The beneficial effects of prior statin therapy in acute ischemic stroke were shown to
be especially profound in whites, diabetics, elderly patients with hypertension
and other vascular diseases, and in patients with ideal low density lipoprotein
(LDL) levels.
Lakhan SE. Int Arch Med. 2010; 3::22.
Factores de riesgo en el AVC agudo
Lípidos
Statins for acute ischemic stroke.
Squizzato A, Romualdi E, Dentali F, Ageno W.
Cochrane Database Syst Rev 2011 Aug 10;(8):CD007551.
SELECTION CRITERIA:
We included all randomized controlled trials (RCTs) comparing statins (any type
and dosage) versus placebo or no treatment, administered within two weeks of
the onset of acute ischemic stroke or TIA.
The primary outcomes were mortality from ischemic stroke and mortality from
adverse drug effects, bleedings and infections.
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Factores de riesgo en el AVC agudo
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Lípidos
Statins for acute ischemic stroke.
Squizzato A, Romualdi E, Dentali F, Ageno W.
Cochrane Database Syst Rev 2011 Aug 10;(8):CD007551.
MAIN RESULTS:
We included eight RCTs involving 625 participants. Only one study was judged as
'low risk' of bias.
AUTHORS' CONCLUSIONS:
Insufficient data were available from randomized trials to establish if statins are
safe and effective in cases of acute ischemic stroke and TIA.
SAHS
Arch Bronconeumol 2004;40:196-202.
Factores de riesgo en el AVC agudo
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SAHS e ictus
RC: Roncopatía crónica.
HS: Hipersomnia diurna.
Arch Bronconeumol 2004;40:196-202.
Factores de riesgo en el AVC agudo
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SAHS e ictus
Antes del ictus, el 64,7% de los
pacientes eran roncadores, el
21,6%
presentaba
apneas
nocturnas repetidas y el 35,6%,
somnolencia diurna.
Arch Bronconeumol 2004;40:196-202.
Factores de riesgo en el AVC agudo
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SAHS e ictus
Arch Bronconeumol 2004;40:196-202.
Factores de riesgo en el AVC agudo
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SAHS e ictus
Stroke of respiratory centers can lead to apnea.
Dyken ME. Chest. 2009;136:1668-77.
Factores de riesgo en el AVC agudo
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SAHS post-AVC
Dyken ME. Chest. 2009;136:1668-77.
Factores de riesgo en el AVC agudo
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Alcoy.
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SAHS e ictus
Stroke of respiratory centers can lead to apnea.
Snoring preceding stroke, documentation of apneas
immediately prior to transient ischemic attacks, the
results of autonomic studies, and the circadian pattern of
stroke, suggest that untreated OSA can contribute to stroke.
Dyken ME. Chest. 2009;136:1668-77.
Factores de riesgo en el AVC agudo
Hospital Verge dels Lliris.
Alcoy.
http//alcoi.san.gva.es
SAHS e ictus
Stroke of respiratory centers can lead to apnea.
Snoring preceding stroke, documentation of apneas
immediately prior to transient ischemic attacks, the
results of autonomic studies, and the circadian pattern of
stroke, suggest that untreated OSA can contribute to stroke.
Dyken ME. Chest. 2009;136:1668-77.
Factores de riesgo en el AVC agudo
Hospital Verge dels Lliris.
Alcoy.
http//alcoi.san.gva.es
SAHS e ictus: Mecanismos patofisiológicos
 OSA has variably been reported to increase the odds of having the
metabolic syndrome anywhere from fivefold to ninefold.
 OSA elevates sympathetic nerve activity (SNA) as a result of the reflex
effects of hypoxia, hypercapnia, and decreased input from thoracic stretch
receptors.
 Autonomic effects may also explain the high prevalence of cardiac
arrhythmias reported in up to 48% of apneic individuals.
In patients with atrial fibrillation, the risk of OSA has been estimated to be 49%,
and noncompliance with CPAP has been associated with a greater recurrence
rate of atrial fibrillation after cardioversion.
 The elevation of catecholamines and platelet activation associated with
OSA may further increase thrombus and embolus formation, and stroke risk
Dyken ME. Chest. 2009;136:1668-77.
Factores de riesgo en el AVC agudo
Hospital Verge dels Lliris.
Alcoy.
http//alcoi.san.gva.es
SAHS e ictus: Mecanismos patofisológicos
Netzer N. Stroke 1998;29:87-93.
Factores de riesgo en el AVC agudo
Hospital Verge dels Lliris.
Alcoy.
http//alcoi.san.gva.es
SAHS e ictus
Stroke of respiratory centers can lead to apnea.
Snoring preceding stroke, documentation of apneas
immediately prior to transient ischemic attacks, the
results of autonomic studies, and the circadian pattern of
stroke, suggest that untreated OSA can contribute to stroke.
Although cohort studies indicate that OSA is a stroke risk
factor, controversy surrounds the cost-effectiveness of
the screening for and treatment of OSA once stroke has
occurred.
Dyken ME. Chest. 2009;136:1668-77.
Factores de riesgo en el AVC agudo
Hospital Verge dels Lliris.
Alcoy.
http//alcoi.san.gva.es
SAHS e ictus
 Positional sleep apnea (OSA that is worse in the supine position secondary
to gravitational effects on the oropharynx) appears to be a prominent feature
in acute stroke.
In a study of 43 subjects with acute stroke or TIA, the mean AHI determined with
patients in the supine position of 17.7±20 was significantly higher than the
mean AHI of 8.4±14.6 determined with patients in other than the supine
position (p<0.001).
Wierzbicka A. J Physiol Pharmacol. 2006; 57:385-90.
55 subjects were assessed within 72 h of stroke, and after 6 months, by using
cardiorespiratory polygraphy. Initially, 78% of patients had OSA (AHI ≥10), with
65% demonstrating positional apnea. After 6 months, the prevalence of OSA
was only 49% (33% with positional apnea).
Dziewas R. Neurol Res. 2008;30:645-8.
Dyken ME. Chest. 2009;136:1668-77.
Hospital Verge dels Lliris.
Alcoy.
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Hypercapnia due to sleep apnea is assumed to contribute to early
neurological deterioration by causing cerebral vasodilatation in arteries
unaffected by ischemia with a subsequent steal of blood from ischemic and
peri-ischemic areas of the brain.
CPAP therapy improves neurological outcome and may reduce the mortality of
patients with stroke with obstructive sleep apnea.
CPAP therapy, however, might be beneficial as “acute prophylactic”
treatment in the first night after stroke because hemodynamic disturbances
due to sleep apnea have markedly detrimental effects at this stage.
Stroke. 2012;43:295-6.
Factores de riesgo en el AVC agudo
Hospital Verge dels Lliris.
Alcoy.
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SAHS en la fase aguda del ictus: recomendaciones
En todo ictus valorar posibilidad de SAHS previamente no conocido (cuatro
peguntas a familiares).
En todo ictus evitar decúbito supino (cabeza incorporada).
En SAHS ya conocido mantener CAPP* previa. En sospecha de SAHS no
conocida valorar CPAP*.
*Valoración individual según estado neurológico del paciente.
Conclusiones
Factores de riesgo en el AVC agudo
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Alcoy.
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Conclusiones
Muy escasa evidencia.
La moderación y la vigilancia parece ser la clave
(Unidad de ictus).
Es absolutamente necesaria la individualización de las
actitudes (Unidad de ictus).
Valorar nuevos abordajes aunque no probados poco
invasivos (SAHS).
Estricta necesidad de cambio conceptual
(Código Ictus).