Area Drug and Therapeutics Committee

Author: Stroke MCN Version No.: 2 Date: March 2012 Review Date: March 2014 Approved on behalf of NHS Fife by the Fife ADTC Date: April 2012

Appendix 2C - Stroke Services in Fife

Stroke and TIA Management Guidance for GPs The aim of this document is to;

• Inform GPs of acute stroke services in Fife

• Summarise who to admit and describe acute management in hospital

• Provide guidance on diagnosing a Transient Ischaemic Attack (TIA) and referral to TIA clinics

• Describe stratification of risk for patients, and initiation of secondary prevention based on Scottish Intercollegiate Guidelines Network (SIGN) and Royal College of Physicians (RCP) guidelines on stroke care.

Stroke Services

• Acute Strokes should be admitted to hospital for immediate assessment, investigation and treatment. NHS Quality Improvement Scotland (QIS) standards require that on the day a patient is admitted to hospital with a suspected stroke they are CT scanned, have a water swallow screening test and are admitted to a stroke unit (HEAT target of 90% on day of or day following admission).

• Suspected TIAs should be referred to the TIA clinic; there are 4 a week in NHS Fife. There is a telephone clinic Hotline for information and advice Contact Hospital switchboard and ask for the Stroke consultant on Call Monday to Friday 9 – 5pm for advice.

• Electronic referrals to the TIA clinics will be screened daily by a stroke consultant. TIA AND STROKE IN PATIENTS ON WARFARIN

ALL PATIENTS ON WARFARIN , WITH ANY FOCAL NEUROLOGY EVEN WHEN RESOLVED, MUST BE ADMITTED FOR URGENT CT HEAD SCAN

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Area Drug and Therapeutics Committee

Author: Stroke MCN Version No.: 2 Date: March 2012 Review Date: March 2014 Approved on behalf of NHS Fife by the Fife ADTC Date: April 2012

Stroke Thromobolysis

Stroke thrombolysis is available 24/7. This is delivered locally within hours and is available out of hours via tele-health link with Lothian stroke consultants

Suitability of patients for thrombolysis: Time is Brain FAST TEST Has the patient got sudden onset of new focal neurological deficits? Face Can they smile? Does one side droop Arm Can they lift both arms? Is one weak

Speech Is their speech slurred or muddled? Test Check for all three symptoms if one or more abnormal suspect stroke

According to ‘FAST’ do you think that your patient may be suffering an acute ‘stroke’ or Brain Attack? Now answer the following questions:

1. Has there been any seizure activity? Y/N 2. Has there been any loss of consciousness? Y/N 3. Is the time between onset of symptoms and likely time of

arrival in the Emergency Dept greater than 4 hours? Y/N 4. Have the symptoms now fully resolved Y/N 5. Does the patient have a known severe cognitive or physical illness

which results in severe dependence on aids or carers? Y/N If the answer is yes to any of these questions this patient may not benefit from thrombolysis but should be transferred to hospital for admission.

TIA Referral Guidelines using the ABCD2 scoring system Recent evidence shows patients who have had TIAs are at high risk of developing stroke. They need to be seen for assessment, investigation and secondary prevention as early as possible. NHS Fife offers a first available appointment service and runs clinics 4 days a week. Those at highest risk should be referred for admission. ABCD2 Scoring

Risk Score Totals A Age > 60yrs 1 B BP Systolic>140

or Diastolic >90 1

C Clinical Factors Unilateral Weakness

Speech disturbance alone Other

2 1 0

D1 Duration of Symptoms > 60 minutes

10 – 59 minutes < 10 minutes

2 1 0

D2 Diabetes No diabetes

1 0

Total

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Area Drug and Therapeutics Committee

Author: Stroke MCN Version No.: 2 Date: March 2012 Review Date: March 2014 Approved on behalf of NHS Fife by the Fife ADTC Date: April 2012

ABCD2 Score for 7 day risk of stroke

Score Risk group Risk of recurrence ¹1 0 - 3 low 1.0% at 2 day - 1.2% at 7

days 4 to 5 medium 4.1% at 2days - 5.9% at 7

days

6 to 7 High 8.1% at 2 days - 11.7% at 7 days

• Patients with an ABCD2 score of 6-7 should be admitted.

• ABCD2 score 4 to 5 should be URGENTLY referred to TIA clinic and discussed with the on call stroke physician

• ABCD2 score under 4 should be referred urgently to TIA clinic.

• All patients on anticoagulants with neurological symptoms must be admitted for urgent CT scan

• Patients with neck pain suggestive of dissection should be admitted

• Patients with atrial fibrillation are at high risk of recurrence and should be considered for admission

• Patients with persisting neurology should be referred for admission and CT scan of brain that day.

• Patients with 2 or more TIAs within the past week should be considered for admission

Patients admitted Patients not admitted Admit and arrange tests and treatment

Arrange tests and treatment

Bloods, ECG, CXR Bloods, CT same day Start appropriate secondary

prevention (Aspirin 300mg for two weeks) If aspirin is contraindicated then consider clopidogrel stat dose 300mg initially then 75mg.

Echo, if abnormal ECG or hypertensive

If Hypertensive, treatment for this should also be initiated with an ACE inhibitor as first line, unless contraindicated (e.g. aortic stenosis, raised creatinine). Refer to Appendix 2A – Guidance on Management of Hypertension.

Stroke Unit same day Complete referral form and fax to TIA service. Ensure patients telephone number on form. FAX: 01592 648041

Water swallow screening test same day

Advise call 999 if further symptoms pending review

Aspirin 300mg if ischaemic stroke Give driving advice The DVLA recommends that any patient who has had a TIA or minor stroke should be told they must not drive for at least a month.

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Area Drug and Therapeutics Committee

Author: Stroke MCN Version No.: 2 Date: March 2012 Review Date: March 2014 Approved on behalf of NHS Fife by the Fife ADTC Date: April 2012

DIAGNOSIS OF A TRANSIENT ISCHAEMIC ATTACK

• A TIA is a clinical syndrome characterised by sudden loss of focal or monocular function with symptoms lasting less than 24 hours which is thought to be due to inadequate cerebral or ocular blood supply as a result of arterial thrombosis or embolism associated with arterial, cardiac or haematological disease.

• Abnormal but functionally unimportant focal neurological signs such as reflex asymmetry or an extensor plantar response may persist for longer (about 5% of patients). CT or MRI evidence of infarction may be present in an area of the brain relevant to the transient symptoms in at least 25% of patients. In patients with transient monocular symptoms, emboli may or may not be seen in the retina.

The diagnosis of TIA is clinical; symptoms should have been caused by cerebral or ocular ischaemia. FOCAL Neurological and Ocular Symptoms

• MOTOR Weakness or clumsiness of one side of the body, in whole or in part (hemiparesis) Simultaneous bilateral weakness* Difficulty swallowing (dysphagia)* Imbalance (ataxia)*

• SPEECH/LANGUAGE Difficulty understanding or expressing spoken language (dysphasia) Difficulty reading (dyslexia) or writing (dysgraphia) Difficulty calculating (dyscalculia) Slurred speech (dysarthria)*

• SENSORY SYMPTOMS Somatosensory - altered feeling on one side of the body, in whole or in part (hemisensory disturbance)

• VISUAL Loss of vision in one eye, in whole or part (transient monocular blindness or amaurosis fugax) Loss of vision in the left or the right half or quarter of the visual field (Hemianopia, quadrantanopia) Bilateral blindness Double vision (diplopia)*

• VESTIBULAR SYMPTOMS A spinning sensation (vertigo)*

• BEHAVIOURAL/COGNITIVE SYMPTOMS Difficulty dressing, combing hair, cleaning teeth etc, geographical disorientation (visual-spatial-perceptual dysfunction) Forgetfulness (amnesia)*

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Area Drug and Therapeutics Committee

Author: Stroke MCN Version No.: 2 Date: March 2012 Review Date: March 2014 Approved on behalf of NHS Fife by the Fife ADTC Date: April 2012

* as an isolated symptom, this does not necessarily indicate transient focal cerebral ischaemia

Subdivision of area of insult:

CAROTID TERRITORY therefore suitable for carotid imaging Hemiparesis Hemisensory loss Dysphasia Apraxia/visuospatial problems Homonymous hemianopia Amaurosis Fugax

POSTERIOR CIRCULATION TERRITORY ; not suitable for carotid imaging Unilateral visual field defects Midbrain events with gaze palsy/facial palsy +/- hemiparesis or tetraparesis Cerebellar signs Ipsilateral cranial nerve palsies with contralateral hemiparesis or hemisensory loss NON FOCAL Neurological Symptoms, therefore not a stroke or TIA Generalised weakness and/or sensory disturbance Light headedness / Faintness ‘Blackouts’ with altered or loss of consciousness or fainting, with or without impaired vision in both eyes Incontinence of urine or faeces Confusion Intermittent diplopia Any of the following symptoms if isolated:

• vertigo / tinnitus / dysphagia / dysarthria / diplopia / ataxia Consider alternatives such as hypoglycaemia, migraine, focal epilepsy, syncope, cerebral hypoperfusion, If diagnosis is unclear please refer to clinic for assessment.

SECONDARY PREVENTION

Advice should be sought on suitable preparations for medicines from a pharmacist if there are swallowing difficulties

ANTIPLATELET THERAPY

• Presumed ischaemic event give stat dose of 300mg aspirin, as soon as possible, continue 300mg for 14 days. Change to Clopidogrel 75mg as lone antiplatelet therapy for long term secondary prevention.

• Clopidogrel is the1st line treatment in patients with a stroke or TIA (off-label use).

• A combination of aspirin + dipyridamole should only be considered in patients where clopidogrel, is contraindicated or not tolerated.

• If gastro-protection is required for patients on Clopidogrel, co-prescribe Lansoprazole. Omeprazole and esomeprazole should be avoided due to the potential antagonism of the anti-platelet effect.

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Area Drug and Therapeutics Committee

Author: Stroke MCN Version No.: 2 Date: March 2012 Review Date: March 2014 Approved on behalf of NHS Fife by the Fife ADTC Date: April 2012

ATRIAL FIBRILLATION

• In patients with Atrial Fibrillation, anticoagulation should be used in preference to antiplatelet therapy to reduce the risk of recurrent ischaemic stroke, unless anticoagulation is not appropriate for other clinical reasons, e.g. falls, poor compliance, alcohol excess and cognitive impairment.

• Wait two weeks after the ischaemic stroke (treat in the acute phase with aspirin). For warfarin therapy, start warfarin and continue with aspirin until INR is over 2. Aim for a therapeutic level of 2.5 (Range 2-3).

• Consideration may be given to newer oral anticoagulants if warfarin is unsuitable. See Appendix 2H.

HYPERTENSION

• Reduction of blood pressure should be considered using a combination of long acting ACE-inhibitor (e.g. perindopril erbumine or ramipril and a diuretic (e.g. indapamide standard tablets). Anti-hypertensives should be gradually titrated to achieve target BP. Monitor U&Es at base line and after each titration.

• Consider combination therapy in the longer term.

• Additional agents may be required. See Appendix 2A – Guidance on Management of Hypertension.

• Optimal treatment targets are <140/<90mmHg

• Diabetics <130/<80mmHg

LIPIDS

• For ischaemic stroke or TIA, treatment with a statin should be given to patients irrespective of cholesterol level.

• There are no target levels for cholesterol and LDL levels in stroke guidelines.

• Statin choice may depend on individuals overall vascular risk profile.

• Simvastatin 40mg daily should be considered for patients with TIA or ischaemic stroke and coronary events.

• Atorvastatin 40 – 80mg can also be considered as an alternative.

• Give dietary advice. See Appendix 2B - Prevention of Cardiovascular Disease See Appendix 2F – Management of Cholesterol

LIFESTYLE MEASURES

• Smoking cessation – refer to local smoking cessation service. Consider use of Nicotine Replacement Therapy, varenicline or bupropion. For further information see Appendix 4D- Stop Smoking Guidance.

• Increase physical activity to accumulate 30 minutes a day on most days of the week if possible.

• Patients whose BMI is over 25 or waist >35ins (88cms) for women, >40 ins (102cms)

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Area Drug and Therapeutics Committee

Author: Stroke MCN Version No.: 2 Date: March 2012 Review Date: March 2014 Approved on behalf of NHS Fife by the Fife ADTC Date: April 2012

for men are overweight and should be offered weight reduction advice.

• Alcohol – high intake increases haemorrhage risk. Safe limits are for women : <14 units a week, < 2-3 a day, Men: < 21 units a week, <3-4 a day. With 2 drink-free days per week.

• Healthy diet - low fat, low salt, low sugar intake, increase fruit and vegetables. Increase fibre through wholegrain choices, increase folate through green leafy vegetables and eat fatty fish 2 x week.

• Good diabetes control aim for HbA1c < 7% (<53mmol/mol).

• Give advice on driving if appropriate. The DVLA recommends that any patient who has had a TIA or minor stroke should be told they must not drive for at least a month.

http://www.chss.org.uk/publications/documents/factsheets/F9_Driving_after_a_stroke.pdf

PREVENTING RECURRENT STROKE IN PATIENTS WITH PREVIOUS INTRACRANIAL HAEMORRHAGE (ICH)

There is little evidence on prevention of recurrent vascular events following primary cerebral haemorrhage. Overall vascular risk should be considered. ANTIPLATELET THERAPY

• The use of antiplatelet agents following ICH may be considered where there is a high risk of cardiac ischaemic events. Where there is low risk of further vascular events, the use of antiplatelet agents following ICH is not recommended.

BLOOD PRESSURE REDUCTION

• Lowering blood pressure (non acutely) following ICH using a combination therapy of ACE inhibitor and thiazide diuretic should be considered to prevent further vascular events. Anti-hypertensives should be gradually titrated to achieve target BP. Monitor U&Es at base line and after each titration.

Consider combination therapy in the longer term.

• Additional agents may be required. See Appendix 2A – Guidance on Management of Hypertension.

• Target BP same as for ischaemic stroke. ANTICOAGULATION

• Anticoagulation therapy following ICH is NOT recommended unless there is a very high risk of cardiac ischaemic events. Discuss with specialist.

STATINS

• Statin therapy for prevention of further vascular events post-haemorrhagic stroke is not recommended routinely, unless the risk of further vascular events outweighs the risk of further haemorrhage.

LIFESTYLE MEASURES

As above for ischaemic stroke/TIA.

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