1.22: In the stroke of time- pharmacist roles in the management of cerebrovascular accident
At the end of this case, students will be able to:
- Recognize stroke symptoms and when to initiate the emergency care system
- Assist a stroke response team in determining a patient’s eligibility for alteplase
- Identify risk factors for stroke and implement strategies to mitigate those risks
Introduction
Stroke is a disease affecting cerebrovascular blood flow, representing the fifth leading cause of death in the United States. 1 According to the Centers for Disease Control and Prevention (CDC), more than 795,000 Americans fall victim to stroke each year, resulting in an estimated $46 billion in related costs. 2,3 However, it is believed that 80% of strokes are preventable, 1 leading public health efforts to focus heavily on prevention and awareness. A stroke occurs when blood flow to the brain is impeded, resulting in decreased oxygen, damage to brain cells, and even death. 4 Strokes are broadly of two major types: hemorrhagic, the result of a leaky or ruptured artery, or more commonly, ischemic, resulting from blockages that prevent blood flow to the brain in the form of a plaque or clot. 5 Ischemic strokes can be caused by cardiac conditions, atherosclerosis, or small vessel disease.
Several key factors play an important role in an individual’s risk of stroke. Pre-existing medical conditions such as hypertension, diabetes, and hyperlipidemia account for 91% of stroke risk. Since lifestyle influences many of these disease states, lifestyle factors such as smoking, sedentary lifestyle, and unhealthy diet account for 74% of an individual’s stroke risk. 3,4 One specific example – nonvalvular atrial fibrillation – increases the risk of stroke by five-fold. Demographics also represent a key indicator in the risk of stroke. While a stroke can occur at any age, the risk of stroke significantly increases with age, and women are more likely to experience them than men. Additionally, race and ethnicity are distinguishing factors in both incidence and mortality, largely due to structural racism and social determinants that have put communities of color at higher risk. Stroke is experienced by Black patients at higher rates than white patients, resulting in the highest rate of stroke-related deaths across all racial groups. While stroke related deaths overall have declined in recent years, Hispanic patients have seen an increase. 3,4
As healthcare professionals continue to emphasize the modifiable risk factors associated with the disease as a preventative strategy, public health efforts have focused on the quick recognition of signs and symptoms. Survival and extent of disability is dependent on expedient care. To assist the public in quick recognition of symptoms, the acronym FAST has been utilized: F (face drooping), A (arm weakness), S (speech), and T (time) to call 911. 6 Knowing, recognizing, and acting on the warning signs can be the difference between life and death. Time matters in the acute treatment of stroke, as nearly two million neurons are lost each minute and the brain ages approximately 3.6 years each hour it remains untreated. 7 Once a patient receives emergency care, they can be evaluated for lifesaving and life-improving medications and procedures, such as alteplase and endovascular thrombectomy.
Since time matters in both the recognition of symptoms and initiation of stroke care, several organizations have established goals and encouraged best practices. 8,9 In particular, these guidelines aim to reduce door-to-needle times (time from hospital entrance to alteplase administration) and door-to-puncture times (time from hospital entrance to initiation of endovascular thrombectomy). One specific goal is “ Arrive by two, treat by three ,” which implies that a patient should be admitted within two hours and receive treatment within three hours of symptom onset. For the first part of this goal to be possible, community awareness of stroke symptoms and an established system of stroke care between EMS and local hospitals are required. Subsequently, for patients to receive treatment by hour three, hospitals must have an efficient process for determining eligibility and initiating treatment with alteplase or thrombectomy. Pharmacists can and should contribute to timely patient care at each step.
Case (part 1)
You are the community pharmacist at a local, independent pharmacy. While filling and checking prescriptions, you are called to the consultation window.
CC: “All of a sudden… I can’t…. speak…. right.”
Patient: CM is a 67-year-old African American woman who is visiting the pharmacy to pick up her monthly medications and to receive her annual influenza vaccination. The pharmacist calls CM to the consultation window to discuss the addition of a pneumonia vaccine, due to her diagnosis of diabetes and her age. As CM begins to answer, the pharmacist notices slurred speech and a slight droop to the right side of CM’s face.
PMH: T2DM; HLD; obesity
SH:
- No alcohol or drug use
- Currently smokes one pack per day
Medications:
- Atorvastatin 20 mg daily
- Metformin 1000 mg daily
Allergies: NKDA
SDH: The patient is a retired schoolteacher who lives with her husband and has reliable insurance coverage.
Case Questions (part 1)
- What are the key risk factors that CM has for stroke?
- What action step(s) should you as the pharmacist take in this scenario?
Case (part 2)
You are now an emergency department (ED) pharmacist. You are verifying medication orders when your pager goes off, signifying a code stroke. You grab your stroke response box and head to meet the team and the patient.
Patient: CM (65 in, 94 kg) arrives at the hospital via EMS at 11:15am, approximately 38 minutes since the community pharmacist first recognized the stroke symptoms. EMS pre-alerted the hospital, so CM arrived as a code stroke. The stroke team, including the neurologist, meets the patient at the door and determines the patient’s National Institutes of Health Stroke Scale (NIHSS). While the phlebotomist is drawing labs, the neurologist determines her NIHSS is 14. Meanwhile, you confirm home medications with EMS. CM is immediately taken to “imaging” and receives a CT head and a CTA head and neck.
Vitals:
- BP 148/92 mmHg
- HR 88 bpm
- RR 16/min
- Temp 99.6°F
Labs:
- INR: 1.1
- Platelets: 176 x 10 3 cells/mL
- Glucose: 132 mg/dL
Imaging:
- CT head (11:28am): New loss of gray-white differentiation in the right MCA/PCA watershed territories
- CTA head (11:36am): Right PCA calcified occlusion; proximal right MCA M1 occlusion
- CT perfusion (11:42am): Ischemia in the right MCA territory
Case Questions (part 2)
- The physician asks for your help determining if the patient is a candidate for alteplase. Does CM meet criteria to receive alteplase?
- What are the risks and benefits of alteplase?
- Once the decision is made to administer alteplase, the team asks for the pharmacy to mix and administer the alteplase. What dose should the patient receive, and by what time should CM receive the alteplase?
Case (part 3)
You are now the clinical pharmacy specialist with the stroke team at a comprehensive stroke center. You are working up your patients ahead of rounds.
Patient: Unfortunately, the first hospital did not have mechanical thrombectomy capabilities, but it did have a relationship with a nearby comprehensive stroke center with a neuro-interventionalist who can offer those services. CM was transported to your center where she was met by the neuro-intensivist team. She had a successful endovascular thrombectomy procedure (TICI 2B) and is taken to the Neurocritical Care Unit to recover. The stroke team determines that her stroke was cardioembolic, secondary to new onset atrial fibrillation.
Vitals:
- BP 142/88 mmHg
- HR 82 bpm
- RR 16/min
- Temp 98.8°F
Labs:
- LDL: 120 mg/dL
- HgbA1c: 8.1%
- TSH : 1.54 mIU/L
- RPR: non-reactive
- SCr: 0.8 mg/dL
Imaging and procedures:
- MRI brain without contrast: large acute infarction involving the right MCA territory; echocardiogram is recommended to evaluate for central thromboembolic source
- EKG: new onset atrial fibrillation diagnosis
- ECHO/TTE: Left ventricular systolic function is reduction with ejection fraction = 45%; global hypokinesis of the left ventricle
Case Questions (part 3)
- What modifiable risk factors does CM have for a second stroke?
- What medications should be initiated?
- Upon discharge, what actions should the pharmacist take to ensure an appropriate transition of care from the hospital?
Author Commentary
Patients who experience stroke may move through different systems and levels of care created to support timely and appropriate treatment. Pharmacists can play an important role at each of these levels of care – from initiation of stroke care to acute treatment, and finally to preventative care. Integral to these systems of stroke care is the timely identification of symptoms and triage of stroke care. The acronym FAST can be utilized to raise public awareness about the most common symptoms of stroke and the importance of immediate emergency care. 6 While FAST is a helpful tool, patients should also be educated on the risk of comorbid conditions like hypertension, smoking, and obesity that increase the risk of a stroke, even in younger patients. While educating on the symptoms of acute ischemic stroke, pharmacists should also educate on the importance of timely treatment and utilization of EMS. Overall, only 60% of stroke patients use EMS, which results in earlier ED arrival, improved door-to-imaging and door-to-needle times, and more eligible patients receiving alteplase. 10 Timely alteplase administration improves morbidity, mortality, and disability. Unfortunately, national alteplase treatment rates range from 3-5% of acute ischemic stroke patients, with the most common reason for failure to give alteplase being delay in presentation. 11
Stroke awareness and likelihood of EMS utilization is lower among Black and Hispanic patients, resulting in increased risk of prehospital delays in these populations. 10 Disparities in stroke awareness and EMS utilization mimic ethnic disparities in stroke mortality outcomes. It is important to understand that these disparities are rooted in socio-economic disparities that drive health literacy, access to care, and trust in the medical system. As a result, interventions should be geared towards the community’s specific needs, with forethought on how to reach these at-risk patients.
Patient Approaches and Opportunities
Pharmacists can provide care at several steps within the stroke systems of care. As the most accessible healthcare providers, pharmacists can educate their patients on risk factors for stroke and stroke symptoms using the FAST campaign. 6 They can also help to identify stroke symptoms in their patients and initiate emergency care when indicated. Quick initiation, creating opportunity for alteplase administration and other potential interventions, can save important brain function. In the ED, pharmacists must stay abreast of current guidelines to contribute to safe and timely decisions regarding alteplase administration. In particular, pharmacist involvement has been demonstrated to improve door-to-needle times. 12
While pharmacists must be ever cognizant of the ticking clock, pharmacists helping patients to recover face a long-term battle to reduce secondary event risk and aid in recovery. Stroke recovery and secondary prevention carry their own difficulties. Rehabilitation can be extensive and often only offers medications to reduce risk or to target symptoms. Identification of stroke etiology can help individualize treatment. A pharmacist, supported by clinical evidence, can assist treatment teams in determining anticoagulation versus antiplatelet therapy and selection of the best agent for the individual stroke patient. The pharmacogenomics of stroke is further enabling the individualization of antiplatelet treatment for patients. Secondary prevention should also include lifestyle changes that targets modifiable risk factors. Both medication and lifestyle recommendations require a pharmacist to consider cultural and socioeconomic barriers.
Related chapters of interest:
- Smoke in mirrors: the continuing problem of tobacco use
- Sweetening the deal: improving health outcomes for patients with diabetes mellitus
External resources:
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Websites:
- American Stroke Association. https://www.stroke.org/
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Journal articles:
- Warner JJ, Harrington RA, Sacco RL, Elkind MSV. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke. Stroke 2019;50(12):3331-2.
- Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45(7):2160-236.
- Davis SM and Donnan GA. Secondary prevention after acute ischemic stroke or transient ischemic stroke. N Engl J Med 2012;366:1914-22.
- Herpich F and Rincon F. Management of acute ischemic stroke. Crit Care Med 2020;48(11):1654-63.
References
- American Stroke Association. About stroke. https://www.stroke.org/en/about-stroke . Accessed February 2, 2021.
- Centers for Disease Control and Prevention. Stroke facts. Published September 9, 2020. https://www.cdc.gov/stroke/facts.htm . Accessed February 2, 2021.
- Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation 2020;141(9).
- National Heart, Lung, and Blood Institute. Stroke. https://www.nhlbi.nih.gov/health-topics/stroke . Accessed February 2, 2021.
- Centers for Disease Control and Prevention. Types of stroke. Published January 31, 2020. https://www.cdc.gov/stroke/types_of_stroke.htm . Accessed February 2, 2021.
- American Stroke Association. Stroke symptoms. https://www.stroke.org/en/about-stroke/stroke-symptoms . Accessed February 2, 2021.
- Saver JL. Time is brain—quantified. Stroke 2006;37(1):263-6.
- American Heart Association. Get with the guidelines® – stroke. https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke . Accessed February 2, 2021.
- American Heart Association. Target: stroke – when seconds count. https://www.heart.org/en/professional/quality-improvement/target-stroke/learn-more-about-target-stroke . Accessed February 2, 2021.
- Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019;50(12).
- Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2016;47(2):581-641.
- Rech MA, Bennett S, Donahey E. Pharmacist participation in acute ischemic stroke decreases door-to-needle time to recombinant tissue plasminogen activator. Ann Pharmacother 2017;51(12):1084-9.