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Stroke. Mark Sudlow Consultant and Senior Lecturer Stroke Northumbria/NHCT/University of Newcastle. Money talks. NAO estimates of cost of stroke £7 billion annually Of which £2.2 billion are direct costs to NHS Cf £1.9 billion for coronary heart disease

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Stroke

Stroke

Mark Sudlow

Consultant and Senior Lecturer

Stroke Northumbria/NHCT/University of Newcastle


Money talks

Money talks

  • NAO estimates of cost of stroke £7 billion annually

    • Of which £2.2 billion are direct costs to NHS

    • Cf £1.9 billion for coronary heart disease

  • Incidence the same as coronary heart disease – but greater associated disability

  • Recommend ways to save money

  • DOH obliged to make formal response via Public Accounts Committee

  • NAO to review progress


Nao recommend

NAO Recommend

  • Faster access to specialist care for patients with TIA

    • High risk on same day

    • Lower risk within a week maximum

  • Faster access to specialist stroke care

    • Acute stroke units

    • Early scanning – 24 hours maximum

    • Thrombolysis - ?10% target and timed benchmarks for onset to needle

  • Better long term care provision


Response from doh

Response from DOH

  • Stroke is no longer under Elderly or Long Term Conditions but under Vascular Disease

  • Working parties set up to look at recommendations on changing provision of care

  • NICE asked to fast track guidelines

  • Intercollegiate Acute Stroke and TIA Guidelines


Transient ischaemic attack

Transient Ischaemic Attack

High early risk and effective early treatment


Risk in transient ischaemic attack

Risk in Transient Ischaemic Attack

  • Risk of completed stroke within a week = 10%

  • Risk > 20% if

    • More than one TIA in 7 days

    • 3 or more of

      • BP > 140/90

      • Unilateral weakness of speech disturbance

      • Duration > 60 mins

      • Diabetes

  • The unstable angina of the brain


Effective treatment

Effective treatment

  • Aspirin 75 mg od – reduces risk by 25%

  • Dipyridamole MR 200mg bd – reduces risk by further 20% when added to aspirin

  • Cholesterol reduction

  • Blood pressure reduction

  • Smoking

  • Exercise

  • Alcohol


What to do

What to do ..

  • Identify high risk patients and refer for urgent admission

    • More than one TIA in 7 days

    • 3 or more of

      • BP > 140/90

      • Unilateral weakness of speech disturbance

      • Duration > 60 mins

      • Diabetes

  • Refer lower risk patient urgently to TIA clinic

  • Start aspirin and consider dipyridamole


What we will do

What we will do ..

  • Admit high risk patients

    • Start treatment

    • Arrange urgent imaging

    • Refer to vascular surgery – where they will be seen within a couple of days

  • See lower risk patients within a week of referral

    • Start treatment

    • Information

    • Lifestyle advice

    • Arrange imaging

    • Refer to vascular surgery – where they will be seen within two weeks


Acute stroke

Acute Stroke

FAST response allows life saving treatment


Evidence for specialist care

Evidence for specialist care

  • Clear evidence that hospitalisation and treatment by a coordinated specialist team improves mortality and outcome

    • Absolute improvement of 10%

  • Increasing evidence that early specialist care is the key


Evidence for early aspirin

Evidence for early aspirin

  • 1% absolute reduction in recurrence and mortality if given within 24 hours

  • Requires CT scan to exclude haemorrhage


Evidence for thrombolysis

Evidence for thrombolysis

  • Within 3 hours of onset of symptoms

  • With CT scan showing no haemorrhage

  • 10% absolute improvement in number of patients with minimal disability


What to do1

What to do ..

  • If a patient presents or calls with symptoms suggesting acute stroke

  • Call an ambulance


What we will do1

What we will do..

  • If a patient presents with stroke within thrombolysis window

    • Immediate referral to stroke specialist

    • Immediate scanning

    • Thrombolysis

  • If a patient present outside that window

    • Admit to specialist stroke ward

    • CT scan within 24 hours

    • Preventative treatment started early

    • Coordinated specialist assessment and rehabilitation

    • Information

    • Lifestyle advice


Secondary prevention

Secondary Prevention

Need for risk reduction as for any high risk vascular disease

With a few minor additions


Stroke

  • Risk of MI, cardiac death and further stroke is similar to after MI

  • Strategies are broadly similar


Stroke

  • Aspirin

  • Statin

  • Blood pressure – best evidence is for ACE and thiazide


Stroke specific

Stroke specific

  • Dipyridamole MR 200 mg bd for at least 2 years

  • Risk of further stroke is particularly high with atrial fibrillation

    • 15% absolute per annum

    • Benefits of warfarin highest in this group

  • Risk of further stroke is particularly high with carotid stenosis

    • Carotid ultrasound and intervention if good recovery

    • Particularly important in partial anterior circulation strokes


What to do2

What to do ..

  • Annual check

    • Antiplatelets

    • Blood pressure

    • Cholesterol

    • Lifestyle


What we will do2

What we will do ..

  • Arrange ongoing rehabilitation

  • Outpatient check at 6 weeks (as an inpatients if not discharged)

  • Outpatient check at six months


Life after stroke

Life After Stroke

Isolation and Dependency


Stroke

  • Information

  • Inclusion of function and mood in annual screening

  • Access to social services and rehabilitation review


How it should be

How it should be


Presentation

Presentation

  • 64 year old man

  • Sudden onset at 11 am of

    • Complete loss of speech

    • Total paralysis of right arm and leg

  • Called GP surgery

    • Advised to call 999 ambulance

  • Arrives hospital 11.28

    • No speech

    • Right hemianopia

    • Right face, arm and leg paralysis


Expected outcome

Expected outcome


Stroke

  • CT scan 12.00

  • Thrombolysis 13.00

  • Statin that night

  • Aspirin and dipyridamole start the next day


Stroke

  • Carotid doppler on day 7

  • 95% stenosis of left carotid artery

  • Urgent referral to vascular surgery

  • Seen in vascular outpatients 2 days later and arranged for urgent admission

  • Carotid stenting 2 weeks after stroke


Stroke

  • Out of stroke unit by 10 days

  • Out after carotid intervention by 2 weeks after stroke

  • On treatment with

    • Aspirin

    • Dipyridamole

    • Simvastatin

    • Perindopril

    • Bendroflumethiazide


Stroke

  • Cholesterol 3.2

  • Blood pressure 128/76

  • Stopped smoking

  • Complete recovery

  • Minimal ongoing risk


Stroke

  • With a coordinated approach from

    • Ambulance service

    • Primary care

    • Emergency care

    • Stroke service

    • Vascular surgeons

  • We can do this


Stroke

  • And save money


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