Hospital Pharmacy - February 2020 - 12

791504
research-article2018

HPXXXX10.1177/0018578718791504Hospital PharmacyArmahizer et al

Critical Care Series
Hospital Pharmacy
2020, Vol. 55(1) 12-25
© The Author(s) 2018
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https://doi.org/10.1177/0018578718791504
DOI: 10.1177/0018578718791504
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Early Acute Ischemic Stroke
Management for Pharmacists
Michael Armahizer1 , Alison Blackman1,
Michael Plazak1, and Gretchen M. Brophy2
Keywords
critical care, neurology, disease management, clinical services

Introduction
Approximately 795 000 people in the United States experience stroke annually, with 610 000 initial and 185 000
recurrent events.1 The majority of these events (87%) are
ischemic in nature.1 Stroke ranks fifth among all causes of
death in the United States, although rates of mortality due
to stroke have decreased overall by 2.3% between 2005
and 2015.1 Given the aging population of the United
States, it is likely that the incidence of stroke will continue
to rise.
The management of patients with acute ischemic stroke
(AIS) continues to evolve, with the recent publication of
several trials evaluating fibrinolytic, interventional, and
medical management of critically ill patients presenting
with occlusions of the cerebral vasculature. Recently published American Heart Association and American Stroke
Association (AHA/ASA) guidelines on the early management of these patients have provided updated recommendations for a variety of pharmacotherapeutic interventions
for the treatment of AIS.2 The primary focus of this article
will be the early pharmacologic management of patients
presenting with AIS. Pharmacists should be aware of medical and surgical interventions available to patients presenting with AIS to effectively manage and monitor
therapy.

Diagnostic Testing
Following the initial clinical recognition of symptoms potentially caused by AIS, a series of diagnostic tests will be performed to identify the cause of the symptoms. The majority
of patients will be diagnosed with an AIS based on clinical
criteria, such as the National Institute of Health Stroke Scale
(NIHSS), and either a noncontrast CT (NCCT) scan demonstrating a lack of intracranial hemorrhage (ICH) or evidence
of early ischemic changes.2-5 NCCT imaging remains the
gold standard for the detection of acute ICH as a causative
etiology of stroke-like symptoms, effectively ruling out fibrinolytic therapies.

Several laboratory and diagnostic tests will be evaluated,
although only a blood glucose evaluation must precede the
use of intravenous (IV) fibrinolytic therapy to rule out stroke
mimics secondary to hyperglycemia or hypoglycemia.2
Other diagnostic evaluations, such as an international normalized ratio (INR), activated partial thromboplastin time
(aPTT), platelet count, baseline electrocardiogram (ECG), or
troponin evaluation, can be considered depending on the
patient's relevant past medical history or presenting symptoms. In the absence of a specific contraindication related to
the administration of tissue plasminogen activator (tPA or
alteplase) as it relates to these additional diagnostic evaluations, the review of these tests should not delay administration of fibrinolytic agents, if indicated.2

Supportive Care
Basic evaluation of the airway, breathing, and circulation
(ABCs) should occur in all stroke patients. Oxygen saturation
should be maintained above 94% with supplemental oxygen
when clinically indicated.2 Management of blood pressure is
dependent upon the planned treatment strategy and will be
discussed as it relates to individual situations. In general, for
patients who do not receive acute reperfusion therapy with a
presenting blood pressure ⩾220/120 mm Hg, a 15% reduction in blood pressure within the first 24 hours is reasonable.2
Blood pressure goals and antihypertensive options are summarized in Tables 1 and 2. Hyperthermia, defined as a temperature greater than 38°C, should be treated with antipyretic
medications.2 Blood glucose should be maintained between
140 and 180 mg/dL, with a blood glucose <60 mg/dL being
considered detrimental to patients presenting with AIS.2

1

University of Maryland Medical Center, Baltimore, USA
Virginia Commonwealth University, Richmond, USA

2

Corresponding Author:
Michael Armahizer, University of Maryland Medical Center, 22 S. Greene
Street, Baltimore, MD 21201-1595, USA.
Email: michaelarmahizer@umm.edu
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Hospital Pharmacy - February 2020

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