Clinical Presentation and Assessment of Medical Treatments for Ischemic Stroke: A Case Study from Thailand

Introduction:

Stroke, or cerebrovascular disease, occurs when the brain is deprived of blood due to blocked or ruptured blood vessels, leading to brain tissue damage. Ischemic stroke, which accounts for about 80% of all strokes, is primarily caused by blood clots, often due to atherosclerosis. Other causes include blood vessel inflammation or embolism, where foreign material blocks blood flow to the brain.

Methodology:

Assessment of Current Drugs and Therapy:

The patient presented with symptoms of ischemic stroke, such as left-sided facial droop and a stiff tongue, and was stabilized during the acute phase. To prevent recurrence, secondary prevention was necessary. Diagnosed with cardioembolic stroke and a CHA2DS2-VAS score of 6, indicating a high risk of recurrent stroke, the patient requires an anticoagulant. Options include Warfarin, Dabigatran, Rivaroxaban, Apixaban, and Edoxaban.

Results and Conclusion:

The IESAC table shows that Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) generally present a lower risk of ischemic stroke than Warfarin, though they are more expensive. Rivaroxaban is not recommended for those with a creatinine clearance of <30 mL/min.

Given the patient’s participation in the 30-baht (THB) healthcare program and stable INR levels on Warfarin (3 mg) for a year, it was decided that Warfarin be continued. To address other stroke risk factors, Atorvastatin (40 mg), Nebivolol (5 mg), and Enalapril (5 mg) were prescribed to control cholesterol and blood pressure.

The CHA2DS2-VAS should be reassessed at each visit to evaluate stroke risk. INR levels must be monitored if the patient is on Warfarin. Bleeding, chest tightness, difficulty breathing, and severe headaches need to be monitored. If INR is not within the target range, switching to an NOAC, like Apixaban 5 mg, twice daily is recommended. The patient should consistently manage atrial fibrillation, dyslipidemia, and hypertension, monitor symptoms using BEFAST (Balance, Eyes, Face, Arms, Speech, and Time), and seek immediate medical help if any signs appear.