Transcript Mini-Strokes

The Big Deal About Mini-Strokes:
Treating TIA
2012. 12. 07
Andre Douen MD, PhD, FRCPC, FAHA
Director West GTA Regional Stroke Program,
Chief, Division of Neurology,
Trillium Health Centre, Mississauga
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Bayer
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document without the express written consent of Innovate
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Development
So…what is the big deal ?
Or
Should there be a big deal ?
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Transient ischemic attack
• A forthcoming stroke is often announced by a
transient ischemic attack (TIA)
• Like ischemic strokes, TIAs are caused by
vessel occlusion or reduction of blood flow
• The symptoms are the same as stroke
symptoms, and may include: Impaired vision,
speech disruption, weakness and numbness
• TIAs are brief due to early
revascularization/reperfusion
Johnston et al. National Stroke Association. Ann Neurol 2006; 60: 301–13.
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The work-up and management is
similar to a stroke
• Etiology not different from definite stroke
• Clinically < 24-hour duration, but....
• New MRI lesions seen in up to 80% of patients
with clinical course of TIA
• Frequently followed by more severe stroke
• TIA and stroke have a similar risk for early
recurrent stroke, ~ up to 14% within the first 2
weeks
• Opportunities for prevention – Rapid W/U in SPC
Johnston et al. JAMA 2000; 284: 2901–2906.
Warach, Kidwell. Neurology 2004; 62: 359–360.
Mohr. Neurology 2004; 62 (8 Suppl 6): S3–S6.
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Case 1 Mrs W.S., LLM
• 62 y/o obese lawyer with GERD
• PMH:
– Smoking 1ppd x 30 yrs
– No HTN, No DM, No Cholesterol at her last visit in
Jan 2010
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Douen
Case 1 Mrs W.S.
• HPI
 Speaking with niece regarding a legal matter
when..
 Slurred speech  Loss of speech
 Right facial droop, Right arm weak and
incoordinated
• EMS
– Symptoms resolved with 15 min
– Patient declines transfer to ER
– Elects to way overnight and call fam doc in AM for a
quick visit and head to office after to prepare for
prosecuting a medico-legal case
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Douen
Case
Examination in office the next day:
BP = 160/90 ; HR 90 and regular. No neurological deficits,
but with right carotid Bruits.
Current Meds: Losec, Tylenol prn for back pain
Next steps:
– DDX ? [Is this a TIA, if not what could it be ?]
– If TIA, what’s her risk of recurrent stroke ?
– Is there a tool that can help assess this ?
– What investigations is needed now ?
– What should I do...panic ? [Will I get sued if I make
the wrong decision ? ]
– Should I start Meds ?
– Maybe the ER might be a safe bet ?
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Stroke Mimics
•
•
•
•
•
•
•
•
•
•
•
•
Migraine (aura)
Vertigo
Syncope (vaso-vagal, cardiogenic, metabolic)
Seizure (simple, CPSz, grand mal with “Todd’s”)
Structural brain lesions (tumors, AVM, subdurals,
abscess)
Carpal tunnel (focal numbness)
Radiculopathies (focal numb/weak)
Neuropathies (more diffuse numb +/- weak)
Dementia (confusion)
Neuroses
Stress/Anxiety
Malingering
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Case 1 Mrs W.S.
• Needs to get back to office ASAP
• Thinks this “TIA” thing is non-sense, as she feels
she was a bit stressed over the case and that
caused her symptoms
• Not keen on extensive investigations for such a
minor episode
• She might comply if she can schedule these in
between her practice over the next 2 months
• If it was a “TIA” (she is skeptical) then she
wants to estimate her risk of recurrence
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Douen
1. What do you think her stroke risk might
be within the next month:
a.
b.
c.
d.
e.
~ 2%
~ 8%
~ 20%
She’ll almost certainly re-stroke
Her risk can only be measured over 3 months
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1. What do you think her stroke risk might
be with in the next month:
a.
b.
c.
d.
e.
~ 2%
~ 8%
~ 20%
She’ll almost certainly re-stroke
Her risk can only be measured over 3 months
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Stroke Recurrence
• Antecedent stroke/TIA is the most
significant indicator of a possible recurrent
stroke
• High incidence of early recurrent stroke
following either TIA or minor stroke
• Early recognition and treatment
significantly reduces the risk of stroke
recurrence
Johnston et al. JAMA 2000; 284: 2901–2906.
Warach, Kidwell. Neurology 2004; 62: 359–360.
Mohr. Neurology 2004; 62 (8 Suppl 6): S3–S6.
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Stroke patients: risk of recurrent event
20
TIA patients: risk of recurrent event
18.5
20
17.3
TIA patients (%)
Stroke patients (%)
15.0
15
11.5
10
5
0
7-day
stroke risk
30-day
stroke risk
3-month
stroke risk
15
11.5
10
8.0
5
0
7-day
stroke risk
30-day
stroke risk
3-month
stroke risk
Coull et al. BMJ 2004; 328: 326.
Nearly 1 in 5 stroke/TIA patients is at risk of a recurrent
event within 3 months
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The ABCD2 Score
Indicator
Criteria
Score
A
Age
1 point for age 60
B
Blood pressure
1 point for BP >140/90 mmHg
C
Clinical features
2 points for focal weakness or
1 point for speech disturbance
D
Duration of symptoms 1 point for duration 10-59 minutes
2 points for duration >60 minutes
/2
D
Diabetes
/1
1 point for presence of diabetes
Total Score
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/1
/1
/2
/7
The ABCD2 Score
Indicator
Criteria
Score
A
Age
1 point for age 60
B
Blood pressure
1 point for BP >140/90 mmHg
C
Clinical features
2 points for focal weakness or
1 point for speech disturbance
D
Duration of symptoms 1 point for duration 10-59 minutes
2 points for duration >60 minutes
1 /2
D
Diabetes
0 /1
1 point for presence of diabetes
Total Score
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1 /1
1 /1
2 /2
5 /7
Risk Factors for Stroke Within 90 Days of a TIA
The ABCD2 Score
High
Risk
25
20
2 Days
7 Days
30 Days
90 Days
Intermediate
Risk
Stroke 15
Risk
(%)
10
Low
Risk
5
0
0
1
2
3
4
5
ABCD2 Score
Lancet 2007;369:283-92.
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6
7
Case 1 Mrs W.S.
• After reviewing ABCD2 and showing her these
charts, she is now more agreeable to comply
with investigations
• She wants to know, how do stroke and TIA
occur, and also what investigations she would
need
• She also wants to know about how soon she can
have the studies completed
• She will reluctantly cancel appointments to
attend these investigations
• What can she take to prevent this from
recurring?
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Douen
Pathophysiology:
Multiple Mechanisms
requiring urgent W/U
Antiplatelet
(Anticoagulation)
Douen
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Case
Next steps:
– DDX ? [Is this a TIA, if not what could it be ?]
– If TIA, what’s her risk of recurrent stroke ?
– Is there a tool that can help assess this ?
– What investigations are needed now ? How soon ?
– What should I do...panic ? [Will I get sued if I make the
wrong decision ? ]
– Should I start Meds ?
– Maybe the ER might be a safe bet ?
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What investigations would you
consider for this patient (why,
when)?







ECHO (TEE,TTE)
Routine labs
Carotid doppler
CT scan
ECG, Echo (TTE/TEE)
Holter
Angiogram (CTA / MRA)
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4. What priority would you give these
investigations?
a) ECG > ECHO> Telemetry/Holter>Carotid Doppler>CT
b) CT>Telemetry/Holter>ECHO>Carotid Doppler> ECG
c) ECHO > Holter > CT>Carotid Doppler > ECG
d) CT> Carotid Doppler = ECG > Holter > ECHO
e) CT = ECG = Carotid Doppler > Holter > ECHO
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4. What priority would you give these
investigations?
a) ECG > ECHO> Telemetry/Holter>Carotid Doppler>CT
b) CT>Telemetry/Holter>ECHO>Carotid Doppler> ECG
c) ECHO > Holter > CT>Carotid Doppler > ECG
d) CT> Carotid Doppler = ECG > Holter > ECHO
e) CT = ECG = Carotid Doppler > Holter > ECHO
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Case
Next steps:
– DDX ? [Is this a TIA, if not what could it be ?]
– If TIA, what’s her risk of recurrent stroke ?
– Is there a tool that can help assess this ?
– What investigations are needed now ? How soon ?
– What should I do...panic ? [Will I get sued if I make
the wrong decision ? ]
– Should I start Meds ?
– Maybe the ER might be a safe bet ?
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3. Which of the following statements about the
management of patients with TIA or minor stroke are
correct:
a. If possible work-up should be completed within 2-3
days
b. Early treatment and intervention could reduce stroke
recurrence by 80%
c. Early management through a stroke clinic is likely
superior to routine out patient management.
d. For those with ipsilateral severe stenosis
revascularization is recommended within 2 weeks
e. All of the above
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3. Which of the following statements about the
management of patients with TIA or minor stroke are
correct:
a. If possible work-up should be completed within 2-3
days
b. Early treatment and intervention could reduce stroke
recurrence by 80%
c. Early management through a stroke clinic is likely
superior to routine out patient management.
d. For those with ipsilateral severe stenosis
revascularization is recommended within 2 weeks
e. All of the above
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EXPRESS
Urgent treatment of TIA and minor stroke
Outcome
Time to clinic visit Time to prescription90 day risk of stroke-
Phase 1
Phase 2
3 days ( 2 -5)
*20 days (8 -53)
~10.3%
1 day (0-3)
1 day (0-3)
2.1%**
*No prescriptions given. Patients advised to see family MD
**80% reduction in risk of recurrent stroke
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Timeliness of Care In Patients with TIA
The OXVASC Study
Neurology 2005;65:371-5.
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The Consequences of Delaying Access to Care
The OXVASC Study
Stroke
Patients
Neurology 2005;65:371-5.
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Timing of Surgical Intervention
The NASCET and ECST Studies
5 Year ARR
In Stroke
(%)
40
30
70-99% Stenosis
50-69% Stenosis
30.2
20
17.6
14.8
11.4
10
0-2
2-4
3.3
8.9
4
4-12
>12
0
-2.9
Time From Event to Randomization (weeks)
-10
Lancet 2004;363:915-24.
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Case
Next steps :
– DDX ? [Is this a TIA, if not what could it be ?]
– If TIA, what’s her risk of recurrent stroke ?
– Is there a tool that can help assess this ?
– What investigations are needed now ? How soon ?
– What should I do...panic ? [Will I get sued if I make
the wrong decision ? ]
– Should I start Meds ?
– Maybe the ER might be a safe bet ?
www.educatehealth.ca
2.
Following and ischemic stroke it is best to wait 3 - 4
days before initiating antiplatelet therapy because of
increased risk of bleeding.
a. True
b. False
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2.
Following and ischemic stroke it is best to wait 3 - 4
days before initiating antiplatelet therapy because of
increased risk of bleeding.
a. True
b. False
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Stroke / TIA
Interventional
Medical
Revascularization
CEA vs Stent
Risk factor
management
Antithrombotic
Antiplatelet
Anticoagulant
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5.
In an ASA naive patient which of the following Antitrhombotic
agents is recommended for secondary prevention of NonCardioembolic stroke
a.
b.
c.
d.
e.
f.
g.
ASA
ASA/ER Dipyridamole
Clopidogrel
Clopidogrel + ASA
Warfarin
Either b) or c)
Any of a) , b) or c)
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5.
In an ASA naive patient which of the following
Antitrhombotic agents is recommended for secondary
prevention of Non-Cardioembolic stroke
a.
b.
c.
d.
e.
f.
g.
ASA
ASA/ER Dipyridamole
Clopidogrel
Clopidogrel + ASA
Warfarin
Either b) or c)
Any of a) , b) or c)
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Prevention of Vascular Events in Stroke/TIA Patients with ASA Following
First Stroke
ASA Dose
Relative Risk of Vascular Events**
1,000 – 1,300 mg/d
300 mg/d
50 – 75 mg/d
Overall
0.8†
ASA better
Placebo better
ASA vs. Placebo: Efficacy by Dose*
* A meta-analysis of 10 controlled trials comparing acetylsalicylic acid (ASA) with placebo.
** Vascular events comprise stroke, MI, or vascular death.
† Signifies a 20% relative risk reduction
Adapted from Albers GW et al. Neurology. 1999; 53(suppl 4): S25-S38.
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6.
For patients already on ASA which of the following
Antitrhombotic agents is recommended for secondary
prevention of Non-Cardioembolic stroke
a.
b.
c.
d.
e.
f.
g.
ASA
ASA/ER Dipyridamole
Clopidogrel
Clopidogrel + ASA
Warfarin
Either b) or c)
Any of a) , b) or c)
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6.
For patients already on ASA which of the following
Antitrhombotic agents is recommended for secondary
prevention of non- cardioembolic stroke
a.
b.
c.
d.
e.
f.
g.
ASA
ASA/ER Dipyridamole
Clopidogrel
Clopidogrel + ASA
Warfarin
Either b) or c)
Any of a) , b) or c)
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MATCH: Bleeding Complications Increased Significantly
Clopidogrel + ASA (n=3,759)
p<0·0001
Clopidogrel + Placebo (n=3,781)
Number (n/%) with event
120
100
120 (3%)
p<0·0001
96 (3%)
p<0·0001
73 (2%)
80
60
49 (1%)
39 (1%)
40
22 (1%)
20
0
Life-threatening
bleeding
Major
bleeding
Minor
bleeding
Diener et al. Lancet 2004; 364: 331–337.
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0.04
Major Bleeding
2.4 %/year
RR = 1.06
Cumulative Hazard Rates
0.03
P = 0.67
0.02
2.2 %/year
0.01
OAC
0.0
Clopidogrel+ASA
# at Risk
C+A
OAC
0.0
0.5
1.0
1.5
3335
3371
3172
3212
2403
2423
914
901
Years
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7.
For patients already on Plavix which of the following
Antitrhombotic agents is recommended for secondary
prevention of Non-Cardioembolic stroke
a.
b.
c.
d.
e.
ASA/ER Dipyridamole
Clopidogrel
Clopidogrel + ASA
Warfarin
Either a) or b)
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7.
For patients already on Plavix which of the following
Antitrhombotic agents is recommended for secondary
prevention of Non-Cardioembolic stroke
a.
b.
c.
d.
e.
ASA/ER Dipyridamole
Clopidogrel
Clopidogrel + ASA
Warfarin
Either a) or b)
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8. In terms of the efficacy for non-cardioembolic prophylaxis which
of the following are true:
a)
b)
c)
d)
e)
f)
ASA/ER Dipyridamole > ASA > warfarin
Clopidogrel >ASA > warfarin
Warfarin > Clopidogrel = ASA/ER Dipyridamole
Warfarin = ASA
Clopidogrel = ASA/ER Dipyridamole
D) and e) correct
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8. In terms of the efficacy for non-cardioembolic prophylaxis
which of the following are true:
a)
b)
c)
d)
e)
f)
ASA/ER Dipyridamole > ASA > warfarin
Clopidogrel >ASA > warfarin
Warfarin > Clopidogrel = ASA/ER Dipyridamole
Warfarin = ASA
Clopidogrel = ASA/ER Dipyridamole
d) and e) correct
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Secondary prevention- Which
Antiplatelet ?
• Physician’s choice
• Compliance
• Cost
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Case
CT brain: Nil acute.
ECG: AF with HR of 95
Is a Doppler still required ??
Meds: …. ???
what is incidence of AF in acute stroke ??
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Case
CT brain: Nil acute.
ECG: AF with HR of 95
Is a Doppler still required ?? YES
Meds: …. ???
what is incidence of AF in acute stroke ??
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Cardioemboli
• AF:
– High incidence of paroxysmal AF in acute stroke
– 13.5% detection of new onset AF
– Overall ~20 % of acute stroke patient with AF.
(Douen et al, Stroke 2008)
• Up to 3 million people worldwide suffer strokes related to
AF each year1-3
1. Atlas of Heart Disease and Stroke, World Health Organization, September 2004. Viewed at
http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf
2. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 2.
1991:22(8);983-8
3. Lin HJ, Wolf PA, Kelly-Hayes M, et al. Stroke severity in atrial fibrillation: the Framingham study. Stroke 1996;27:1760-4
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AF increases the risk of stroke
• AF is associated with a pro-thrombotic state
– ~5- 17 fold increase in stroke risk
• Risk of stroke is the same in patients with chronic
of PAF2,3
• There is a high 30-day mortality (~25%) following
cardioembolic stroke4
• AF-related stroke has a 1-year mortality of ~50%5
1. Wolf PA, et al. Stroke 1991;22:983-988; 2. Rosamond W et al. Circulation. 2008;117:e25–146; 3.Hart RG, et al. J Am Coll Cardiol 2000;35:183-187;
4. Lin H-J, et al. Stroke 1996; 27:1760-1764; 5. Marini C, et al. Stroke 2005;36:1115-1119.
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Stroke Severity in Patients with AF
Effect of first ischemic stroke in patients with AF (n=597)
60%
59.7%
% of patients
50%
40%
30%
20%
20%
10%
0%
Disabling
(discharge mRS ≥ 2)
mRS=modified Rankin Scale
AF=atrial fibrillation
Gladstone DJ et al. Stroke. 2009; 40:235-240
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Fatal
Ischemic Stroke Associated With AF is Typically
More Severe Than Stroke due to Other Etiologies
% bedridden patients
on admission (mRs* = 5)
50
41.2%
40
30
23.7% (P < 0.0005)
20
10
0
With AF
Without AF
Odds ratio for bedridden state following stroke due to AF was
2.23 (95% CI, 1.87-2.59; P < 0.0005)
*mRS=modified
Rankin Scale
AF=atrial fibrillation
Dulli DA, et al. Neuroepidemiology. 2003;22:118-123.
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CHADS 2
• 1 point for Congestive Heart
•
•
•
•
Failure
1 point for Hypertension
1 point for Age ≥ 75 years
1 point for Diabetes Mellitus
2 points for Prior Stroke or
TIA
CHADS2 Score*
Stroke rate
0
1.9 (1.2 -3.0)
1
2.8 (2.0-3.8)
2
4.0 (3.1-5.1)
3
5.9 (4.6-7.3)
4
8.5 (6.3 -11.1)
5
12.5 (8.2-17.5)
6
18.2 (10.5-17.4)
*Score
0: Patients can be administered aspirin
*Score 1: Patients can be on aspirin and anticoagulant therapy
*Score ≥2: Patients should be on anticoagulant therapy
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CHA2DS2-VASc Score
• 1 point for Congestive Heart
Failure/LV Dysfunction
CHA2DS2-VASc
CHA2DS2-VASc
Score
Score*
One year event rate (95% CI)
Cl) of
hospital admission and death due to
thromboembolism†† per 100 person
year
year
• 2 points for Age ≥ 75 years
0
0.78 (0.78 – 1.04)
• 1 point for Diabetes Mellitus
1
2.01 (1.70 – 2.36)
2
3.71 (3.36 – 4.09)
3
5.92 (5.53 – 6.34)
4
9.27 (8.71 – 9.86)
• 1 point for Vascular Disease3
5
15.26 (14.35 – 16.24)
• 1 point for Age 65-74 years
6
19.74 (18.21 – 21.41)
• 1 point for Sex category
(female gender)
7
21.5 (18.75 – 24.64)
8
22.38 (16.29 – 30.76)
9
23.64 (10.62 – 52.61)
• 1 point for Hypertension
• 2 points for Prior Stroke or
or TE2
TIA1
CHA2DS2-Vasc score Mrs W.S. = 4
(hypertension, age 65-74 yr, female)
1TIA
= Transient ischemic attack; 2TE = Thromboembolism
myocardial infarction, peripheral artery disease, aortic plaque
1. Lip GY et al. Chest 2010;137:263-272
3Prior
*Score 0: Patients can be administered aspirin
*Score 1: Patients can be administered aspirin or anticoagulant therapy
*Score ≥2: Patients should be administered anticoagulant therapy
†Includes peripheral artery embolism, ischemic stroke, and pulmonary embolism
2. Olesen JB, et al. BMJ 2011;342:d124
3. Task Force or the Management of Atrial Fibrillation of the ESC.
Eur Heart J 2010;31:236902429
CCS 2012 Update to AF Guidelines
Assess Thromboembolic Risk (CHADS2)
CHADS2 = 0
CHADS2 = 1
CHADS2 ≥ 2
Increasing stroke risk
No antithrombotic
No
additional
risk factors
for stroke
ASA
Either
female
sex or
vascular
disease
OAC*
Age ≥ 65 yrs
or combination
of female sex
and vascular
disease
OAC*
*Aspirin is a reasonable
alternative in some as
indicated by risk/benefit
OAC*
Consider stroke risk vs. bleeding risk
Only when the stroke risk is low and
bleeding risk is high does the risk/benefit
ratio favor no antithrombotic therapy
*OAC = Oral anticoagulant
ASA = Aspirin
1. Skanes AC, et al. Can J Cardiol 2012;28:125-136.
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Case - Paul
Mrs W.S. Risk:
62-year-old - < 75
HTN
No h/o CHF
No DM
TIA symptoms
:0
:1
:0
:0
:2
CHADS Risk = 3
CHADS-VASC Risk = 4 (HTN, F, Stroke symptoms)
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Stroke / TIA
Interventional
Medical
Revascularization
CEA vs Stent
Risk factor
management
Antithrombotic
Antiplatelet
Anticoagulant
www.educatehealth.ca
9. The patients who benefit the most from warfarin therapy are
those with AF in the age group 65-75 and with no other
medical issues.
–
–
True
False
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9. The patients who benefit the most from warfarin therapy are
those with AF in the age group 65-75 and with no other
medical issues
–
–
True
False
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10. Recent studies have shown that ASA+Plavix is equally
efficacious to warfarin for cardio-embolic stroke prophylaxis
in patients with AF
–
–
True
False
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10. Recent studies have shown that ASA+Plavix is equally
efficacious to warfarin for cardio-embolic stroke prophylaxis
in patients with AF
–
–
True
False
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11. Patients with AF who has spontaneous intracranial
hemorrhage while using OAC should never be placed back
on OAC
–
–
Ture
False
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11. Patients with AF who has spontaneous intracranial
hemorrhage while using OAC should never be placed back
on OAC
–
–
Ture
False
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12. For patient with cardioembolic (AF) stroke/TIA which of the
following Antitrhombotic Agents is recommended for
secondary prevention
a.
b.
c.
e.
f.
g.
Warfarin
Dabigatran (Pradax)
Rivaroxaban (Xaralto)
Apixaban (Eliqus)
Clopidogrel + ASA
ASA/ER Dipyridamole
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12. For patient with cardioembolic (AF) stroke/TIA which of the
following Antitrhombotic Agents is recommended for
secondary prevention
a.
b.
c.
e.
f.
g.
Warfarin
Dabigatran (Pradax)
Rivaroxaban (Xaralto)
Apixaban (Eliqus)
Clopidogrel + ASA
ASA/ER Dipyridamole
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13. Because older patients (> 80 yrs old) with AF are generally
at high risk of falls and spontaneous bleeding and so should
not in general be treated with OAC
–
–
True
False
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13. Because older patients (> 80 yrs old) with AF are generally
at high risk of falls and spontaneous bleeding and so should
not in general be treated with OAC
–
–
True
False
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AF prevalence increases with
age
9
AF prevalence (%)
8
7
6
5
4
3
2
1
0
General
population
>60 years
Age
1. Go AS, et al. JAMA 2001;285:2370-2375.
>80 years
AF prevalence increases with
age
9
AF prevalence (%)
8
7
6
5
4
3
2
1
0
General
population
>60 years
Age
1. Go AS, et al. JAMA 2001;285:2370-2375.
>80 years
INR control: clinical trials v. clinical
practice
INR* control in clinical trial versus clinical practice (TTR**)
% of eligible patients
receiving warfarin
66%
Clinical trial1
Clinical practice2
44%
38%
25%
18%
9%
<2.0
*INR = International normalized ratio
2.0 – 3.0
>3.0 INR
** TTR = Time in Therapeutic Range (INR2.0-3.0)
1. Kalra L, et al. BMJ 2000;320:1236-1239 * Pooled data: up to 83% to 71% in individualized trials; 2. Matchar DB, et al. Am J Med 2002; 113:42-51.
INR control: clinical trials v. clinical
practice
INR* control in clinical trial versus clinical practice (TTR**)
% of eligible patients
receiving warfarin
66%
Clinical trial1
Clinical practice2
44%
38%
25%
18%
9%
<2.0
*INR = International normalized ratio
2.0 – 3.0
>3.0 INR
** TTR = Time in Therapeutic Range (INR2.0-3.0)
1. Kalra L, et al. BMJ 2000;320:1236-1239 * Pooled data: up to 83% to 71% in individualized trials; 2. Matchar DB, et al. Am J Med 2002; 113:42-51.
New OAC
• Dabigatran Etexilate (Direct Thrombin Inhibitor) in Atrial
Fibrillation (RE-LY)
• Rivaroxaban (Factor Xa inhibitor)
in Atrial Fibrillation (ROCKET-AF)
• Apixaban (Factor Xa inhibitor)
in Atrial Fibrillation (AVERROES; ARISTOTLE)
Pros : No Monitoring
Rapid onset of action
Similar or better bleeding profile to warfarin
Con : No antidote, no clear way of measuring effect
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Recent Oral Anticoagulation Trials:
Stroke or Systemic Embolism
The new oral anticoagulant agents are consistently associated with a numerically
lower risk for stroke or systemic embolism compared to warfarin†
†Not
intended as cross-trial comparison
Data obtained from intention-to-treat analysis
1. Connoly SJ, et al. N Engl J Med 2009;361:1139-1151.
2. Patel MR, et al. N Engl J Med 2011;365:883-891.
3. Granger C, et al. N Engl J Med 2011;365:981-992
www.educatehealth.ca
Recent Oral Anticoagulation Trials:
Hemorrhagic Stroke
The new oral anticoagulants are consistently associated with a numerically
lower risk of hemorrhagic stroke compared with warfarin†
†Not
intended as cross-trial comparison
Data obtained from intention-to-treat analysis
1. Connoly SJ, et al. N Engl J Med 2009;361:1139-1151.
2. Patel MR, et al. N Engl J Med 2011;365:883-891.
3. Granger C, et al. N Engl J Med 2011;365:981-992
www.educatehealth.ca
Recent Oral Anticoagulation Trials:
Major Bleeding
HR (95% CI)
New Agent Better
†Not
intended as cross-trial comparison
Warfarin Better
Data obtained from intention-to-treat analysis
1. Connoly SJ, et al. N Engl J Med 2009;361:1139-1151.
2. Patel MR, et al. N Engl J Med 2011;365:883-891.
3. Granger C, et al. N Engl J Med 2011;365:981-992
www.educatehealth.ca
Stroke / TIA
Interventional
Medical
Revascularization
CEA vs Stent
Risk factor
management
Antithrombotic
Antiplatelet
Anticoagulant
www.educatehealth.ca
Antiplatelet choices – Summary
Non-cardioembolic stroke
ASA naive patients vs those previously on ASA
a. ASA
b. ASA/ER Dipyridamole
c. Clopidogrel
________________________
d. Warfarin
e. Clopidogrel + ASA
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Stroke / TIA
Interventional
Medical
Revascularization
CEA vs Stent
Risk factor
management
Antithrombotic
Antiplatelet
Anticoagulant
www.educatehealth.ca
For patient with cardioembolic (AF) stroke/TIA
a. Dabigatran (Pradax)
b. Apixaban (Eliqus)
c. Rivaroxaban (Xaralto)
d. Warfarin
_______________________
e. Clopidogrel + ASA
f.
ASA
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Recommendations - Antithrombotic

We recommend that patients at very low risk of stroke
(CHADS2 = 0) should receive aspirin (75-325
mg/day). (Strong recommendation, High Quality
Evidence). We suggest that some young persons with
no standard risk factors for stroke may not require ay
antithrombotic therapy. (Conditional recommendation,
Moderate Quality Evidence).
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Recommendations - Antithrombotic

We recommend that patients at low risk of stroke
(CHADS2 = 1) should receive OAC therapy (either
warfarin [INR 2 – 3] or dabigatran). (Strong
recommendation, High Quality Evidence). We
suggest, based on individual risk/benefit
considerations, that aspirin is a reasonable
alternative for some. (Conditional recommendation,
Moderate Quality Evidence).

We recommend that patients at moderate risk of
stroke (CHADS2 ≥ 2) should receive OAC therapy
(either warfarin [INR 2 – 3] or dabigatran). (Strong
recommendation, High Quality Evidence)
www.educatehealth.ca
Recommendations - Antithrombotic

We suggest, that when OAC therapy is indicated, most
patients should receive dabigatran in preference
to warfarin. In general, the dose of dabigatran 150
mg po bid is preferable to a dose of 110 mg po
(exceptions discussed in text).
(Conditional recommendation. High Quality Evidence).
www.educatehealth.ca
Rich Multimedia
Simple Navigation
R e g is t e r a t w w w.e D u c at eh e a lth .c a
Peer Reviewed Content
Interactive Models
Interactive Design
Simple Navigation
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In-depth Content
Medical Models and Images
What is eDucate™
(www.educatehealth.ca)
eDucate is a unique e-learning portal specifically designed to
address the current challenges of retrieving pertinent, userspecific information from an ever expanding diffusely
disseminated body of literature currently available to healthcare
professionals.
eDucate is an on-line repository of disease specific information
that has been comprehensively reviewed by key opinion leaders
in their respective fields and presents users with a standardized
review of core disease information, as well as an approach to
patient care, as it relates to data gleaned from landmark trials
and current guidelines. Quick review (executive summaries), and
lecture slides are currently available. Audio, video, and high
resolution images are forthcoming.
Main landing page:
Left control panel shows main user types. “Start Living” icon provides brief tutorial
of website.
Example of drop down menu functionality.
Main disease detail page showing the icon based approach to selective data retrieval. Top 5
icons provides background disease information and remains constant among user types. The
bottom 7 icons provides specfic information for a given user type. The “Quick Review”
opens the executive summary. “User Tools” provides additional learning material by way of
lecture slides, graphs etc. “Interactive medicine” allows disease search with an organ.
Interaactive Medicine: Allows a search within an organ. Clicking on any of the red dots
generates a list of diseases associated with the corresponding organ, from which the
disease of interest could be selected.