Cardiac disease and stroke pearls

from Continuum based on vascular boards review

1. One percent of acute strokes are complicated by coexisting acute MI
2. Treatment issues: STEMI (ST Elevation MI) and Unstable Angina/non STEMI(UA/NSTEMI) are treated differently. The former group contains Q wave MI patients or candidates for; the latter group contains non MI patients and non Q wave MI patients. Differentiate with troponins. Only the first group gets alteplase or acute cath, latter group may get later? cath. ASA 81-162 is always indicated, clopidogrel in suggested in UA/NSTEMI for 12 months based on CURE study (Clopidogrel in Unstable angina to prevent Recurrent iscemic Events). In STEMI clopidogrel is suggested only for those unable to tolerate aspirin or those who receive a stent.
3. Warfarin indications include alternative to aspirin for secondary prevention in aspirin intolerant; addition to asa in post MI or ACS, mural thrombus, or af; as short tern addition to ASA and clopidogrel in a post MI patient with a stent who also has an indication for anticoagulation. In this case, clopidogrel therapy is limited to 1 month for bare metal stents, 3-6 months after coated stents.
4. The use of dipyridamole in patients with stable angina, is problematic due to vasodilatation. ACC/AHA cautions against, although the ESPS II trial did not indicate such.
Summary-- patients may need dual/triple therapy; patients with combined treatment may have been left on dual therapy too long and may need reduction to monotherapy; warfarin after an ACS is added to, does not replace ASA.


Other pearls
1. Andersen et al. suggested that fewer strokes occur with atrial rather than ventricular based pacing; a question exists abotu identifying AF in paced patients due to pacer artefact. In not completely accepted. Temporary pacer reprogramming to low ventricular response rate can sort out underlying rhythm.
2. MOST trial (MOde Selection Trial in sinus node dysfunction) showed atrial high rate events esp. bpm>220 for >10 consecutive beat signal risk of stroke and death. Atrial high rate events showed twice the risk of death and six times risk of AF.
3. Pacer insertion is associated with a one year risk of AF of 10 % and 2 year risk of 11 % in patients not with history. No difference based on reason for pacer insertion (AV node dysfunction v. SSS). Stroke risk is higher though in patients paced for SSS or AV Neurologist role is " insure underlying rhythm evaluation is performed"
4. 25-40 % of stroke patients have known IHD, another 25 % have silent disease
5. Early cardiac death (first 30days) occurs in 1 percent of ischemic stroke patients; in next two years, risk of another stroke is 3-4 times risk of MI; risk of MI reaches parity at abot 5 years.