Stroke: (long-term management)

  • Must be on Aspirin 81mg PO qd + Plavix 75mg PO qd [secondary-prevention of stroke]
    1. If recurrent Strokes: Change Aspirin to Aggrenox. Aggrenox vs. Plavix. New info suggests that Plavix alone is superior****
      1. Aggrenox: May cause syncope! (Dipyridamole vasodilates à increase orthostatic hypotension)
  • Must also be on a statin.
  • Check bilateral carotid Doppler US. EKG: rule out Afib. Echo
  • Recurrent stroke:
    1. Plavix***
      1. Use to use Aggrenox, but Plavix alone has been proven superior to Aggrenox.
        1. Aggrenox can also cause/intensify orthostatic hypotension with resulting syncope (especially in elderly, which would most likely be the same patients with the recurrent strokes).
      2. Prior to Colonoscopy: Need to hold Plavix for 5 days prior to Colonoscopy. The patient is to restart taking Plavix following her Colonoscopy per the recommendation of GI.
  • Hold Plavix/Coumadin/Effient/Xarelto/Eliquis/Pradaxa for 5 days prior to Colonoscopy.
  1. Rule out genetic hypercoagulability: May need other anticoagulation like Warfarin. Panel of labs to order:
    1. Antinuclear Antibody (ANA) w/ reflex
    2. Antiphospholipid Antibody screening panel: Anti-Cardiolipin IgA,G,M.
      1. Only hypercoagulable state that causes thrombosis in both VEIN and ARTERY!
      2. Recurrent pregnancy loss.
  • CPK (CK) – Screening for Connective Tissue Disorder in general:
  1. Factor V Leiden mutation
  2. Protein C&S – outpatient
    1. Patients with a history of Warfarin-induced skin necrosis are at increased risk of Protein C deficiency (rarely Protein S deficiency or Factor V Leiden).
  3. Rheumatoid Factor antibody titer
  • Antithrombin III – outpatient
  • Prothrombin 20210A
  1. Beta 2-glycoprotein Ab
  2. Lupus anticoagulase
  3. Others: Homocysteine, folic acid, Vitamin B12, peripheral smear, ESR, FOBT, chest x-ray
  • OUTpatient: Protein S, Protein C, Antithrombin III, Colonoscopy.

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