TD is a 48 yo M with PMH of HTN, T2DM, and obesity presents to the ED with facial drooping, right sided weakness, and slurred speech. Symptoms began to manifest approximately an hour ago and was promptly admitted for non-cardioembolic ischemic stroke. The team decided on administration of tPA after reviewing TD's head CT scan of and he received a bolus followed by continuous infusion. On hospital day 5, the patient is doing well with no residual symptoms or bleeding and the patient is preparing for discharge home. The patient's vitals/labs are the following:
Height: 6’1’’ Weight: 133 kg
BP: 150/92 mmHG
HR: 85 bpm
Temp: 98.7 ᵒF
Hemoglobin A1c: 6.7%
ECG: Normal sinus rhythm
ECHO: EF of 60%, mild aortic stenosis
NIHSS score of 13
Metformin 1000 mg PO BID
Lisinopril 10 mg PO QD
ASA 81mg PO daily
Which of the following medications would be recommended for secondary prevention of stroke long-term for TD?
A. Atorvastatin 20 mg QD
B. Aspirin 325 mg QD
C. Aspirin 81 mg QD + Clopidogrel 75 mg QD
D. Prasugrel 10 mg QD
E. Rosuvastatin 20 mg QD
Answer with rationale:
Answer E is correct.
Secondary stroke prevention is key to patients with history of stroke. Adequate management of blood pressure, blood cholesterol, and co-morbid states such as diabetes and obesity can reduce the risk for recurrent strokes. Alongside these management strategies, antiplatelet therapy is used for secondary prevention as well. All these management strategies and therapies account for up to an 80% risk reduction in recurrent strokes.
Answer choice A is incorrect as atorvastatin (Lipitor) 20 mg QD is inadequate in intensity. The 2018 AHA/ACC guidelines for management of blood cholesterol define high intensity atorvastatin as 40 – 80 mg QD, the 2021 AHA/ASA guideline for prevention of stroke preferring atorvastatin 80 mg QD.
Answer choice B is incorrect as low dose aspirin (81mg daily) is a key therapeutic in the risk reduction of recurrent strokes in the 2021 AHA/ASA guidelines. The 325mg dose is not associated with any reduced stroke prevention and may increase the risk for bleeding. The mechanism behind stroke prevention is aspirin irreversibly binds to platelets, decreasing the blood’s ability to form clots. Aspirin is given within 24 – 48 hours of stroke onset and is given 24 hours after the administration of tPA.
Answer choice C is incorrect as dual antiplatelet therapy (DAPT) is not indicated in this patient. DAPT is indicated when given early in stroke onset (within 24 hours) and when the NIHSS score is 3 or less. Otherwise, the patient is only indicated for single antiplatelet therapy, mainly low dose aspirin only. If the patient cannot take aspirin, then clopidogrel (Plavix) may be used as a single antiplatelet therapy.
Answer Choice D is incorrect as prasugrel (Effient) is contraindicated in patients with history of stroke or transient ischemic stroke (TIA). Patients on prasugrel have a higher risk of serious bleeding, mainly intracranial hemorrhage. Alternatives in the same class as prasugrel that can be used are ticagrelor and clopidogrel.
Answer choice E is correct as rosuvastatin (Crestor) 20 mg QD is considered a high intensity statin as per AHA/ACC 2018 guidelines for cholesterol management as well as the 2021 AHA/ASA guidelines for secondary stroke prevention. The patient could also be given 40mg daily as this is an acceptable high intensity statin dose for rosuvastatin per the AHA/ACC 2018 guidelines.
In the case of blood pressure management, the patient’s home medication can be titrated up to reach a blood pressure goal of less than 130/80 mmHG. If blood pressure remains elevated after 1 -2 weeks alongside monitoring SCr and potassium, an additional agent such as chlorthalidone may be added on if on the max tolerated dose of lisinopril. Lifestyle modifications such as at least 150 minutes of moderate aerobic exercise and adhering to a healthy diet will further improve the benefits of stroke prevention therapies.
Competencies Statements covered:
2.1 – Pharmacology, mechanism of action, or therapeutic class
3.3 – Medication reconciliation; indication or therapeutic uses; lack of indication; inappropriate indication; duplication of therapy; omissions
3.6 – Drug contraindications, allergies, or precautions
3.11 – Evidence-based practice
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