Stroke prevention

1. Stroke prevention An interactive workshop for nurses and Aboriginal health workers October 2009

2. Learning Objectives Identify the risk factors for stroke Use a cardiovascular risk (CV) assessment tool to determine a patients overall CV risk Recognise the role of medicines in stroke prevention Recommend non-pharmacological therapies to reduce patients risk Reinforce to patients on warfarin the importance of INR monitoring and medication management

3. Topics for discussion today Incidence of stroke in Australia Risk factors for stroke Overall cardiovascular risk reduction Importance of stroke prevention as part of ongoing therapy The safe use of warfarin Clinical scenario

4. Stroke in Australia Stroke is the second leading cause of death in Australia, and often results in significant long-term disability Stroke remains one of the leading causes of death, disability and health care expenditure, but in many cases its incidence can be reduced or prevented. Indigenous Australians living in remote areas were 50% more likely to report heart, stroke and vascular conditions than those living in non remote areas (24% compared with 18%), and this happens at a younger age.

5. What is cardiovascular disease? Cardiovascular disease (CVD) covers all diseases and conditions of the heart and blood vessels including: Coronary heart disease Stroke Heart failure High blood pressure Peripheral vascular disease Rheumatic fever and rheumatic heart disease

6. What is a stroke? • A stroke (also known as cerebrovascular disease) occurs when the supply of blood to the brain is suddenly disrupted • Blood may stop moving through an artery because the artery is blocked by a blood clot or plaque, or because the artery breaks or bursts • A stroke can occur in two main ways: Ischaemic stroke (blocked artery) Haemorrhagic stroke (bleed in the brain)

7. Meet Joe • Joe is a 38 year-old Aboriginal man who has come into the clinic. • You notice that Joe is a little puffed after his walk to the clinic, and he appears a bit overweight. • You have a chat with Joe whilst he is waiting to see the doctor and find that he: • smokes about 10 cigarettes and drinks a bit… • doesn’t eat very well (lots of fried take-away) • You take his blood pressure and find it to be high 150/100mmHg, his pulse feels a little strange to you also.

8. Does Joe have any risk factors for stroke? What are the risk factors for stroke? Can you help Joe do anything to change these?

9. Some risk factors for stroke Modifiable: atrial fibrillation (irregular heart beat) Hypertension (high blood pressure) smoking diabetes cardiovascular disease hypercholesterolaemia (high cholesterol) Non-modifiable: age ethnicity (some cultures have a higher risk) previous stroke

10. Is Joe at high risk of having a stroke or other CV event? Use the new Australian overall CV risk assessment tool to work out his overall CV risk? • Does he have diabetes? • Male • Smoker • Age • Blood pressure • Cholesterol

11. What did you find? His risk is moderate (10-15% chance of an event over the next 5 years) or high (>15% chance of an event over the next 5 years) (depending on his cholesterol levels) Refer him to see the doctor for further assessment AND Consider counseling him to reduce his risks: (use life scripts tools to help you) quit smoking improve diet increase exercise less alcohol lose weight These will all help him to reduce his blood pressure also!

12. The doctor meets with Joe, and discovers alongside your findings of high blood pressure that he has an irregular heart beat (called atrial fibrillation). The doctor decides to start him on two new medicines: a blood pressure medicine (an ACE-inhibitor) warfarin

13. What is AF? Atrial Fibrillation (AF) is an important risk factor for stroke It is the leading cause of cardiogenic stroke (stroke which starts in the heart), the subtype of stroke with the highest morbidity and mortality Many patients may not know that they have AF, until they have a stroke or transient ischemic attack (TIA), sometimes called a mini-stroke. AF can be caused by: binge drinking rheumatic heart disease

14. Joe starts warfarin What are the potential benefits and harms of his therapy? How can you help Joe to take his warfarin (and other medicines) safely? What written patient materials could you provide to him?

15. Benefits Warfarin is approximately 40% more effective than other medicines used to prevent stroke (antiplatelet therapy with aspirin) if you have AF Harms Warfarin increases the risk of bleeding. Warfarin

16. Common concerns • Bleeding risk: • extra care is needed with medicines interactions • Diet (limit alcohol intake) • Discomfort and inconvenience of regular blood tests • regular blood tests are essential to use this medicine safely • Fear • Can’t use if planning a pregnancy or pregnant

17. Encourage Joe to take ownership of his health! Attend clinic visits and have regular blood tests Know his numbers INR Current dose of warfarin Tell his health care team members (dentist etc) that he takes warfarin Check before starting or stopping other drugs, vitamin supplements, complementary or over-the-counter products. Tell the clinic immediately if he has any unexplained bruising, bleeding, pink, red or dark brown urine, or black or red faeces.

18. INR monitoring maintain 2-3 Warfarin effects everyone differently so everyone will need their own individual dose and have blood tests to check that this dose is right for them. For most patients INR should be between 2 and 3

19. Blood tests are needed: On starting warfarin, and then daily until INR is stable in the therapeutic range. Then at regular intervals of no more than 4 weeks More frequently if there are changes to the patient’s condition including concurrent illness, concurrent drugs, amount of alcohol consumed, or diet.

20. Make sure that Joe has had education on warfarin use His daily dose, date of blood test and INR result What to do when starting or stopping medicines (prescription, OTC or complementary) Signs and symptoms of bleeding and thrombotic events and to seek help if this occurs The effect of diet (vitamin-K rich foods) and alcohol intake Importance of using the same brand of warfarin

21. Patient materials Ensure that Joe has written warfarin information or a warfarin booklet. (These are available from your pharmacist) The stroke foundation also produces patient leaflets see their website: www.strokefoundation.com.au

22. Other medicines used to prevent stroke • Aspirin • Recommended for most patients who have a high overall CV risk (calculated as >15% over 5 years) • Reduces the risk of stroke compared to no treatment • Inexpensive and easy to use • Can be used for patients with AF who are unable to take warfarin

23. Medicines used to prevent a second stroke • If Joe had already had a stroke than his risk of having a second stroke will be much higher. • At present, the selection of antiplatelet therapy after stroke and TIA should be individualised • Aspirin, aspirin plus dypridamole SR, or clopidogrel are options for long term antiplatelet therapy in patients with previous ischaemic stroke or TIA due to arterial disease. • Considerations: cost, co-morbid illness, side effects

24. Key Messages: stroke prevention Identify the risk factors for stroke Use a cardiovascular risk (CV) assessment tool to determine a patients overall CV risk Recommend non-pharmacological therapies to reduce your patients risk Recognise the role of medicines in stroke prevention Reinforce to patients on warfarin the importance of INR monitoring and medication management

25. Your name • Add your own contact details here for further information This activity has been endorsed by APEC number 061110344 on behalf of Royal College of Nursing, Australia according to approved criteria, and attracts 2 CNE points