Lipid Drugs (Stroke Prevention)

• Statins

  Drugs that lower lipoprotein production
• HMG-CoA Reductase Inhibitors (Atorvastatin-Lipitor)

  Lowers LDL (25%-60%) and total cholesterol + HDL (5-22%)
• Statins lower risk of heart failure, MI, and sudden death

  With a significant reduction in 2 weeks but effect goes away if drug is stopped
• HMG-CoA Reductase Inhibitors (Atorvastatin-Lipitor) MOA

  Inhibit synthesis of cholesterol by blocking HMG CoA enzyme, increases LDL receptors in hepatocytes allowing for á removal of LDL
• Atorvastatin (Lipitor) Indication

  Hypercholesterolemia and 1° and 2° prevention of cardiovascular (CV) events (even those with normal LDL) + Diabetes and Stroke Prevention (Aiming to reduce progression of atherosclerosis that leads to ischemic stroke!)
• Atorvastatin (Lipitor) Adverse effects

  • GI disturbance (usually transient)
  • Headache, memory loss
  • Myopathy/Rhabdomyolysis (mild 5-10%, rare myositis-> rhabdo)
  • Hepatotoxicity (0.5-2%)
• Atorvastatin (Lipitor) Nursing Considerations

  Dose should be given in evening because of cholesterol synthesis/GI assessment (dyspepsia, cramps, flatulence, constipation, abd pain)/Monitor Liver and Renal Function / observe for muscle pain (legs often)
• Aspirin

  Used for: Prevention of stroke + Treatment following ischemic stroke
• Thromboxane A2

  Stimulates activation of new platelets and increases platelet aggregation
• Often strokes result from platelet aggregation at site of endothelial damage

  Thromboxane A2
• Aspirin

  Prevents platelet adhesion and aggregation = inhibits the formation of thromboxane A2 by platelets
• Treatment after ischemic stroke > initiate within 48 hours of stroke onset
• Acetylsalicylic Acid (Aspirin, ASA) Mechanism of Action

  1. Suppresses platelet aggregation by causing irreversible inhibition of cyclooxygenase (an enzyme)

  2. Relaxes vasoconstriction

  3. Reduces risk of arterial thrombosis
• Acetylsalicylic Acid Indication

  Inflammatory disorders, fever, prophylaxis for myocardial infarction and stroke, chronic stable angina, unstable angina, acute MI, primary and secondary prevention of MI
• Acetylsalicylic Acid Adverse Effects

  • Heartburn, nausea (take with food or full glass of water)
  • GI bleeds (May cause anemia with chronic occult blood loss)
• ASA can cause gastric ulceration, perforation, bleeding, HEMORRHAGE + prophylaxis with a proton pump inhibitor is recommended
• Discontinue ASA 1-2 weeks prior to surgical procedures
• ASA Nursing considerations

  GI assessment (bleeding), give with food to reduce GI upset<|>Monitor for signs and symptoms of bleeding & hypotension, tachycardia, dizziness, weakness, pallor, bruising, bleeding gums, epistaxis, hematuria, melena, labs (CBC)<|>After procedures and injections apply pressure to site to prevent bleeding and monitor the site carefully
• Take aspirin with food or glass of water + Discontinue at least one week prior to surgery + Monitor Renal function - weigh patient, urea and creatinine levels, urine output
• Blood pressure


  A significant part of cerebral perfusion
• If BP is too low, there is not enough blood flow to brain


  Causes ischemia
• If BP is too high, there is risk of brain bleeds


  Also causes ischemia
• Following a stroke, many patients present with: Increase in blood pressure + Increase in blood sugar
• Ischemic Stroke

  If candidate for TPA we must keep Systolic BP ≤ 185 mmHg and Diastolic BP ≤ 110 mmHg + If not candidate for TPA we must keep systolic blood pressure <220 mmHg or diastolic blood pressure <120 mmHg
• Hemorrhagic Stroke Goal

  Systolic between 140 to 160 mmHg to prevent rebleeds
• Labetalol (Trandate) Mechanism of Action

  Blocks stimulation of beta 1 and beta 2 adrenergic receptor sites. Also has blocking effect on alpha 1 receptor sites.
• Labetalol (Trandate) Indications

  Management of hypertension
• Labetalol (Trandate) Therapeutic Effect

  Decreased blood pressure
• Labetalol (Trandate) Adverse Effects

  • Fatigue, weakness
  • Bronchospasm
  • Arrhythmias, bradycardia
  • Congestive heart failure, pulmonary edema
  • Orthostatic hypotension
• Labetalol (Trandate) PRECAUTIONS

  • Allergies/hypersensitivity
  • Heart failure
  • Pulmonary edema and pre-existing obstructive lung diseases
  • Bradycardia and heart blocks
  • Use cautiously in renal and liver dysfunction!
• Labetalol (Trandate) Patient Education

  Inform patient to make slow position changes. Assess for signs of acute fluid overload (lung sounds, wt, edema, etc.) + Diabetic patients should have sugars monitored closely
• Abrupt withdrawal of labetalol can cause life threatening arrhythmias, hypertension, or myocardial infarction
• Tissue Plasminogen Activator (Alteplase) Mechanism of Action

  Binds to fibrin in a clot & activates plasminogen, forming plasmin (fibrinolytic enzyme) which breaks down and dissolves the clot
• Tissue Plasminogen Activator (Alteplase) Indications

  Acute MI + Ischemic stroke + Pulmonary embolus
• Tissue Plasminogen Activator (Alteplase) Therapeutic Effect

  Break down clot and restore blood flow through the vessel
• Tissue Plasminogen Activator (Alteplase) Adverse Effects

  There are two main reasons for bleeding = Plasmin destroys pre existing clots and can promote bleeding at sites that have recently healed + Degradation of clotting factors which disrupts the ability for the body to coagulate when trauma or injury does occur
• Tissue Plasminogen Activator (Alteplase) Nursing Considerations


  Careful screening before administration – ischemic stroke must be confirmed on CT scan + Must be administered within 3-4.5 hours of symptom onset – "door to needle" < 60 minutes<|>Baseline coagulation blood work sent (INR, aPTT, platelets, hgb) with frequent monitoring of vital signs and EKG monitoring + GCS and neuro checks – high risk for intracranial bleeding<|>Monitor for bleeding – major risk<|>Hold all anticoagulants and antiplatelets for 24hr + Avoid pokes (subcut, IMs) when on Tissue Plasminogen Activator (Alteplase)
• ABSOLUTE Contraindications for Tissue Plasminogen Activator (Alteplase)

  • Previous intracranial bleeding
  • Known intracranial lesions/tumors
  • Active internal bleeding (with the exception of menses)
  • Suspected aortic dissection
• RELATIVE Contraindications for Tissue Plasminogen Activator (Alteplase)

  • Severe uncontrolled hypertension >185/110 mmHg
  • Current anticoagulant use
  • Traumatic/prolonged CPR/surgery <3 weeks ago
  • Recent internal bleeding (within 2-4 weeks)
  • Pregnancy
  • Active peptic ulcer
• Unfractionated Heparin Mechanism of Action

  Enhances activity of antithrombin (protein that inactivates clotting factors: thrombin and factor Xa). Without these clotting factors, there's reduced fibrin production and clotting is suppressed.