Curricullum vitae

Nama : Marcelia Suryatenggara, dr, SpS

TemTa Lahir : Jakarta, 20 Maret 1979
Pendidikan : Fakultas Kedokteran Universitas Gadjah Mada 1997-2003
Progam Pendidikan Dokter Spesialis Neurologi Universitas
Padjadjaran 2005-2010
Sertifikasi : Electroencephalographer Certification from Asian
Epilepsy Academy (ASEPA) dan Asean Neurological
Association (ASNA) 2013
Jabatan : Kepala Bagian SMF Neurologi Eka Hospital Pekanbaru
Suami : dr Stephanus Gunawan, SpBS
Anak : Albertus Marvel Gunawan
Maria Sava Gunawan
Alamat e-mail : stelia28@yahoo.co.id
Update Post Stroke Management
in Primary Health Care

Marcelia ,dr, SpS

Eka Hospital
November 2018
Pekanbaru
 Post stroke management
● Secondary stroke prevention
● Prevent complication of disability
● Improve disability: Physiotherapy
 Antiplatelet
Stopping antiplatelet therapy in high-risk patients may itself increase the risk of ischemic stroke:

ASPIRIN

The most commonly used antiplatelet agent, inhibits the enzyme cyclooxygenase, reducing production of
thromboxane A2, a stimulator of platelet aggregation. This interferes with the formation of thrombi, thereby
reducing the risk of stroke. we recommend a dose of 75 to 100 mg/day when using aspirin for the
secondary prevention of ischemic stroke.

CLOPIDOGREL

Benefit equal to aspirin. The side effect profile of clopidogrel 75 mg is favorable compared with aspirin,
with a slightly higher frequency of rash and diarrhea, but a slightly lower frequency of gastric upset or
gastrointestinal bleeding .

ASPIRIN + CLOPIDOGREL

For most patients with ischemic stroke, the combined long-term use of aspirin and clopidogrel does not
offer greater benefit for stroke prevention than either agent alone but does substantially increase the risk of
bleeding complications

CILOSTAZOL

The antiplatelet agent cilostazol is a phosphodiesterase 3 inhibitor that is used mainly for intermittent
claudication in patients with peripheral artery disease. Several controlled trials have found that cilostazol is
effective for preventing cerebral infarction. Dosage 100 mg twice daily.
 MAJOR STROKE RISK FACTORS :
●Hypertension

●Diabetes mellitus
●Smoking

●Dyslipidemia

●Physical inactivity

Two important mechanisms of ischemic stroke are amenable to effective secondary prevention :

●Atrial fibrillation

●Carotid artery stenosis

Important but unmodifiablerisk factors for stroke :

●Older age, particularly age >80 years

●Race and ethnicity, with risk higher for blacks than for whites

●Sex, with risk higher at most ages for men compared with women, except for ages 35 to 44 years
and >85 years, where women have a similar or higher risk than men

●Family history and genetic disorders,

 Blood pressure
Blood pressure management in the acute phase of stroke is different from chronic therapy

●What is the goal blood pressure?

●How to achieve the goal blood pressure?

●Which antihypertensive drugs should be used?

Home blood pressure, typically using an automated oscillometric device (which has been checked
for accuracy in the clinician's office), is self-measured by the patient while out of the office.

On average, systolic pressure readings are 5 to 10 mmHg lower with non-routine than with routine
(eg, auscultatory) measurement because the "white coat" effect is absent
 What is the goal blood pressure?

In patients with underlying hypertension, we recommend a goal blood pressure of

less than 140/90 mmHg

In patients with recent small vessel (ie, lacunar) ischemic stroke, diabetes,older
adults ,chronic kidney disease , we suggest a goal blood pressure of 125 to
130/<80 mmHg
In older adults with severe frailty, dementia, and/or a limited life expectancy or in
patients who are nonambulatory or institutionalized (eg, reside in a skilled nursing
facility), we individualize goals and share decision making with the patient,
relatives, and caretakers, rather than targeting one of the blood pressure goals
mentioned above
 What is the goal blood pressure
In patients with hemodynamically significant large artery disease ?

Frequently defined as ≥80 percent stenosis in a large cervicocephalic artery (ie, internal
carotid, middle cerebral, vertebral, or basilar artery), we suggest cautious blood pressure
lowering as tolerated, but without a specific blood pressure goal other than a minimum
reduction of 10/5 mmHg.
Identifying clinically significant stenosis in a large cervicocephalic artery is important
since these patients have an increased long-term risk of recurrent stroke and may
develop ischemic symptoms after blood pressure lowering.
The patient should be carefully monitored for hypotensive or neurologic symptoms caused
by either failure of autoregulation of cerebral blood flow or by hemodynamic compromise
due to large vessel stenosis.
If the patient develops recurrent neurologic symptoms referable to a stenotic artery when
the blood pressure is lowered below a particular threshold, we recommend management
to maintain blood pressure above that threshold.
Gradual blood pressure reduction (ie, no more than a 5 mmHg reduction in systolic
pressure at a time) is recommended in patients with known cerebrovascular disease or
long-standing uncontrolled hypertension unless there is a hypertensive emergency.
Gradual blood pressure reduction can be aided by home blood pressure monitoring
 Which antihypertensive drugs should be used?

Based upon observations, angiotensin inhibitors, calcium channel blockers and

diuretics are reasonable options for initial antihypertensive monotherapy in
patients who have had a stroke.
There is some evidence from clinical trials that beta blockers may not reduce
stroke risk compared with angiotensin inhibitors, calcium channel blockers, and, in
some trials, placebo. Thus, unless there is a compelling indication for their use,
beta blockers should not be used as monotherapy for prevention of recurrent
stroke
Combination therapy may be required to achieve blood pressure goals and is
initially preferred in patients at high risk or stage 2 hypertension.
Supine and standing pressures should be measured prior to the initiation of
combination therapy in patients at increased risk for orthostatic (postural)
hypotension, such as older adult patients and those with diabetes. Orthostatic
hypotension is diagnosed when, within two minutes of quiet standing, one or more
of the following is present:
●At least a 20 mmHg fall in systolic pressure
●At least a 10 mmHg fall in diastolic pressure
●Symptoms of cerebral hypoperfusion, such as dizziness
 Which antihypertensive drugs should be used?

ACE ( angiotensin converting enzyme ) inhibitor

For patients with heart failure with reduced ejection fraction (HfrEF). We avoid ACE inhibitor therapy in
nondialysis patients with serum creatinine >3.5 mg/dL (310 micromol/L) or estimated GFR (eGFR) <20
mL/min/1.73 m2 ; for such patients, combination hydralazine-isosorbide dinitrate (rather than an ARB) is
suggested.

Side effects of ACE inhibitors include hypotension, worsening renal function, hyperkalemia, cough, and
angioedema

Captopril, Ramipril

Angiotensin II receptor blocker(ARB)

When using an ARB, we prefer either candesartan (starting at 4 to 8 mg daily, titrated to a target dose of 32
mg daily) or valsartan (starting at 20 to 40 mg twice daily, titrated to a target dose of 160 mg twice daily),

For patients with heart failure with reduced ejection fraction (HFrEF) who are intolerant of angiotensin
converting enzyme (ACE) inhibitor due to cough, we recommend an ARB (candesartan or valsartan) (
Grade 1B). The above recommendation does not apply when the ACE inhibitor intolerance involves
hyperkalemia or renal insufficiency, in which case the same risks would apply to an ARB. For patients who
have developed angioedema on an ACE inhibitor, we suggest cautiously substituting an ARB since
angioedema has been infrequently reported with ARB therapy.
 Which antihypertensive drugs should be used?

Calcium channel blockers

There are no absolute indications for calcium channel blockers in patients with hypertension. Long-acting
dihydropyridines (amlodipin, nifedipine) are most commonly used.the nondihydropyridine calcium channel
blockers (verapamil, diltiazem) can be given for rate control in patients with atrial fibrillation or for control of
angina in patients with coronary disease and normal left ventricular systolic function . Calcium channel
blockers also may be preferred in patients with obstructive airways disease.calcium channel blockers
should generally be avoided in patients with HfrEF (heart failure with reduced ejection fraction)

Thiazide diuretics
If monotherapy is appropriate in a patient with hypertension and osteoporosis, thiazide-like diuretics may
have advantages over ACE inhibitors, ARBs, and calcium channel blockers. These drugs stimulate distal
tubular reabsorption of calcium, leading to a decrease in urinary calcium excretion. As a result, thiazide
diuretics may have a beneficial effect on bone mineral density.Diuretics should also be given for volume
control in patients with heart failure or chronic kidney disease, with or without nephrotic syndrome; these
settings usually require loop diuretics. In addition, a mineralocorticoid receptor antagonist (spironolactone
or eplerenone) is indicated in patients with HF who have relatively preserved renal function and for the
prevention or treatment of hypokalemia. Electrolyte disturbances: Hypokalemia, hypochloremic alkalosis,
hypomagnesemia, and hyponatremia may occur. Development of electrolyte disturbances can be
minimized when used in combination with other electrolyte sparing antihypertensives (eg, ACE inhibitors or
angiotensin receptor blockers) . Be carefull in using in disability patient for the risk of falling down
everytime going to the toilet. Diabetes: Use with caution in patients with prediabetes or diabetes mellitus;
may see a change in glucose control
 Smoking
An important goal of therapy is to help smokers identify their triggers to smoke. The
smoker anticipating quitting should be encouraged to identify situations, internal states, or
activities that may increase the risk of continuing to smoke or of relapsing . Examples of
common triggers include stressful situations, being around other smokers, consuming
alcohol, or drinking coffee
Once smokers have identified situations that trigger them to smoke, they should engage
in problem solving and practice coping skills to deal with such problems. Examples of
coping strategies include :
●Exercise – Use exercise as an outlet and a way to address post-smoking cessation
weight gain.
●No-smoking zones – Enact no-smoking policies for home and car to minimize time spent
with smokers.
●Behavioral distraction – Engage in repetitive or simple activities (eg, doodling, knitting).
●Cognitive distraction – Think about what needs to be done (eg, for work, errands). Make
a to-do list of priorities.
●Oral strategies – Chew gum, drink a glass of water or have a small, healthy snack.
●Positive self-talk and visualization – Think "this will get easier," or visualize yourself not
smoking.
●Benefits of quitting – Remember the health benefits of quitting.
 Smoking
Stress management strategies that may be helpful include deep breathing, guided
imagery, progressive muscle relaxation, brief meditation, or stretching.
Mindfulness interventions focused on decoupling associations between cravings
and smoking have also been used increasingly in smoking cessation treatment
If the patient is experiencing nicotine symptoms that are contributing to the
feelings of stress, nicotine replacement therapy (NRT) may be added or adjusted
For smokers who are willing to quit, we recommend a combination of behavioral
support and pharmacologic therapy. The combination produces higher tobacco
quit rates than either type of treatment alone
In a systematic review of 10 randomized trials, there was no difference in
abstinence rates between those who reduced smoking before the quit date and
those who quit abruptly, regardless of whether behavioral and/or pharmacologic
treatments were used . However, subsequent studies suggested that abruptly
stopping was associated with higher quit rates
 Diabetes mellitus
Treatment of patients with type 2 diabetes mellitus includes education, evaluation for
microvascular and macrovascular complications, attempts to achieve near-normal
glycemia, minimization of cardiovascular and other long-term risk factors, and avoidance
of drugs that can aggravate abnormalities of insulin or lipid metabolism.
All of these treatments need to be tempered based on individual factors, such as age, life
expectancy, and comorbidities.
Although several studies have noted remissions of type 2 diabetes mellitus that may last
several years, most patients require continuous treatment in order to maintain normal or
near-normal glycemia.
.
 Impaired glucose tolerance (IGT):

The ADA recommends lifestyle modification in subjects with impaired fasting glucose (IFG):
● •Modest weight loss (5 to 10 percent of body weight)
● •Moderate-intensity exercise (30 minutes daily)
● •Smoking cessation

Because of its effectiveness, low cost, and long-term safety, the ADA recommends consideration of
metformin for prevention of diabetes in individuals at highest risk for developing diabetes, such as those
with IGT, IFG, or an A1C of 5.7 to 6.4 percent, particularly for those who benefited most from metformin
during the Diabetes Prevention Program (DPP) (<60 years of age, body mass index [BMI] ≥35 kg/m 2,
women with a history of gestational diabetes).

Assessment for and treatment of modifiable cardiovascular risk factors, such as hypertension and
dyslipidemia, is important to reduce cardiometabolic risk.

Patients treated with metformin require at least annual monitoring (A1C or fasting glucose) for the
development of diabetes.
 The American Diabetes Association (ADA) recommendation :

● A reasonable goal of therapy is an A1C value of ≤7 percent for most patients.In order to achieve the A1C
goal, a fasting glucose of 80 to 130 mg/dL (4.4 to 7.2 mmol/L) and a postprandial glucose (90 to 120
minutes after a meal) less than 180 mg/dL (10 mmol/L) are usually necessary . More stringent goals (ie, a
normal A1C, <6.5 percent) can be considered in individual patients. Less stringent treatment goals (eg, <8
percent) may be appropriate for patients with a history of severe hypoglycemia, patients with limited life
expectancies, older adults, and individuals with comorbid conditions.

●Obtain an A1C at least twice yearly in patients who are meeting treatment goals and who have stable
glycemic control and quarterly in patients whose therapy has changed or who are not meeting glycemic
goals.

There are three major components to nonpharmacologic therapy of blood glucose in type 2 diabetes :
● ●Dietary modification: typically high in fruits, vegetables, whole grains, beans, nuts, and seeds; include olive oil as an
important source of monounsaturated fat; . There are typically low to moderate amounts of fish, poultry, and dairy products, with
little red meat

● ●Exercise:adults at high risk for diabetes are encouraged to perform 30 to 60 minutes of moderate-intensity, aerobic activity
on most days of the week (at least 150 minutes of moderate-intensity, aerobic exercise per week). It leads to improved glycemic
control due to increased responsiveness to insulin

● ●Weight reduction

In addition to glycemic control, vigorous cardiovascular risk reduction (smoking cessation, aspirin, blood
pressure control, reduction in serum lipids, diet, and exercise) should be a top priority for all patients with
type 2 diabetes.
 INITIAL PHARMACOLOGIC
THERAPY

When to start — The metabolic abnormalities that characterize type 2 diabetes worsen
with age. Early institution of treatment for diabetes, at a time when the A1C is not
substantially elevated, is associated with improved glycemic control over time and
decreased long-term complications. Pharmacologic therapy is often not initiated soon
enough, resulting in poor glycemic control.
●For most patients presenting with A1C at or above target level (ie, >7.5 to 8 percent),
pharmacologic therapy should be initiated at the time of diabetes diagnosis.
●For highly motivated patients with A1C near target (ie, <7.5 percent), a three- to six-
month trial of lifestyle modification before initiating pharmacologic therapy is reasonable.
 Advice for prophylactic foot care should be given to all patients

•Avoid going barefoot, even in the home.

•Test water temperature before stepping into a bath.
•Trim toenails to shape of the toe; remove sharp edges with a nail file. Do not cut
cuticles.
•Wash and check feet daily.
•Shoes should be snug but not tight and customized if feet are misshapen or have
ulcers.
•Socks should fit and be changed daily.
Patients who may have neuropathy (based on abnormal results from a microfilament
and one other test) or who have calluses or other foot deformities should be referred
to clinicians with expertise in diabetic foot care (podiatrist, nurse, diabetes foot clinic,
or other, depending on available local resources).
Thank you