Pharmacotherapy Case 14: Post-Ischemic Stroke Management By: Dr. Nehad Ahmed

 

Chief Complaint:

A 68-year-old male presents for a follow-up appointment to assess the management of his post-ischemic stroke condition. The patient has a history of ischemic stroke that occurred 3 months ago and is currently being managed for secondary prevention. He reports concerns regarding his medication regimen and rehabilitation progress.

Subjective Data:

History of Present Illness (HPI):

The patient is a 68-year-old male who experienced an ischemic stroke 3 months ago. The stroke was initially diagnosed as a right-sided ischemic stroke, resulting in weakness and numbness in the left arm and leg, as well as difficulty with speech. He underwent thrombolysis within the first 3 hours of symptom onset and was then treated in the hospital for a few days, where he was started on a secondary prevention regimen. The patient reports gradual improvement in his motor function and speech but still experiences mild weakness in his left arm and slowness in speech. He denies any new neurological symptoms, such as slurred speech, weakness, or confusion, since discharge. He is concerned about whether his current medications are the best for preventing another stroke.

Past Medical History (PMH):

Ischemic stroke, 3 months ago

Hypertension, diagnosed 10 years ago

Type 2 diabetes mellitus, diagnosed 7 years ago

Hyperlipidemia, diagnosed 8 years ago

Coronary artery disease with stable angina, diagnosed 5 years ago

Obesity

No history of major bleeding.

Medications:

Aspirin 81 mg daily (secondary stroke prevention)

Clopidogrel 75 mg daily (secondary stroke prevention)

Atorvastatin 40 mg daily (for hyperlipidemia)

Lisinopril 10 mg daily (for hypertension)

Metformin 500 mg twice daily (for diabetes)

Amlodipine 5 mg daily (for blood pressure control)

Acetaminophen 500 mg as needed for mild pain or discomfort

No over-the-counter or herbal supplements reported.

Allergies:

No known drug allergies (NKDA).

Family History:

Father had a history of hypertension and stroke at age 72.

Mother had a history of type 2 diabetes and cardiovascular disease.

Social History:

Smoking: Former smoker, quit 5 years ago after a 20-pack year history.

Alcohol: Drinks 1-2 beers on weekends.

Physical activity: Sedentary lifestyle but participates in light walking for 10-15 minutes daily.

Diet: High-fat, low-fiber diet, not strictly controlled, and tends to eat fast food a few times a week.

Review of Systems:

Neurological: Mild residual left-sided weakness and slow speech but no new deficits.

Cardiovascular: Denies chest pain, palpitations, or shortness of breath.

Respiratory: No cough or shortness of breath.

Gastrointestinal: No nausea, vomiting, or abdominal pain.

Musculoskeletal: No joint pain aside from mild left-sided weakness.

Psychiatric: Occasional mild anxiety related to the stroke and recovery process.

Objective Data:

Vital Signs upon Arrival:

Blood Pressure: 140/85 mmHg

Heart Rate: 72 bpm (regular rhythm)

Respiratory Rate: 16 breaths/min

Temperature: 36.9°C (98.5°F)

Oxygen Saturation: 98% on room air

Weight: 98 kg (BMI 33.5 kg/m²)

Height: 175 cm

 

Physical Exam:

General: Alert, oriented, and in no acute distress.

Speech: Mild dysarthria, but understandable.

Motor: Left-sided weakness (left arm and leg 4/5 strength). No facial droop.

Cranial Nerves: Intact, no abnormalities.

Sensory: Decreased sensation on the left side, primarily in the arm and leg.

Cardiovascular: Regular rate and rhythm, no murmurs, no jugular venous distension.

Respiratory: Clear lung fields bilaterally, no wheezes or crackles.

Abdomen: Soft, non-tender, no hepatomegaly or ascites.

Musculoskeletal: Mild weakness in left arm and leg, but no signs of atrophy.

Psychiatric: Mild anxiety observed but no overt signs of depression or acute stress disorder.

Laboratory Results:

Complete Blood Count (CBC): Normal white blood cell count, hemoglobin 13.2 g/dL, hematocrit 39%.

Electrolytes: Sodium 138 mEq/L, Potassium 4.0 mEq/L, Chloride 102 mEq/L

Creatinine: 1.0 mg/dL (normal renal function)

Liver Function Tests (LFTs): Normal

Blood Glucose: 130 mg/dL (target range for diabetes: 80-130 mg/dL)

Lipid Profile:

Total Cholesterol: 210 mg/dL

LDL: 115 mg/dL

HDL: 45 mg/dL

Triglycerides: 170 mg/dL

CT Scan of the Brain (3 months ago):

Findings: Evidence of a right-sided ischemic stroke with no acute hemorrhagic transformation.

Carotid Ultrasound:

Mild stenosis of the left carotid artery (50-60%), no evidence of occlusion.

Assessment:

The patient is a 68-year-old male with a history of a right-sided ischemic stroke that occurred 3 months ago. He is being managed for secondary stroke prevention with aspirin and clopidogrel, along with treatment for his underlying risk factors (hypertension, hyperlipidemia, and diabetes). The patient has residual left-sided weakness and dysarthria, but there are no signs of acute neurological decline. His blood pressure is moderately elevated, which may increase his stroke risk if not well-controlled. His lipid levels are also elevated, despite statin therapy, which could contribute to future cardiovascular events.

Plan:

Secondary Stroke Prevention:

Continue dual antiplatelet therapy with aspirin 81 mg daily and clopidogrel 75 mg daily for at least 12 months to prevent recurrence of ischemic stroke.

Consider transitioning to monotherapy (aspirin or clopidogrel) after 12 months based on stroke subtype and further clinical evaluation.

Blood Pressure Management:

Continue lisinopril 10 mg daily for blood pressure control.

Increase the dose to lisinopril 20 mg daily to achieve better blood pressure control (target BP: < 130/80 mmHg), given the patient’s moderately elevated blood pressure and history of stroke.

Lipid Management:

Continue atorvastatin 40 mg daily for hyperlipidemia.

If LDL remains above target (70 mg/dL), consider increasing statin dose or switching to a more potent statin (e.g., rosuvastatin) to further reduce cardiovascular risk.

Diabetes Management:

Continue metformin 500 mg twice daily.

Encourage lifestyle changes (diet and exercise) to improve blood sugar control and prevent complications of diabetes.

Goal: HbA1c < 7.0%.

Physical Rehabilitation:

Refer to physical therapy for strengthening of the left arm and leg, and speech therapy for dysarthria.

Encourage light walking as tolerated to improve cardiovascular health and mobility.

Explore occupational therapy for assistance with daily activities due to left-sided weakness.

Lifestyle Modifications:

Dietary counseling to help the patient achieve better glycemic and lipid control. Recommend a low-sodium, heart-healthy diet, and a diabetic-friendly meal plan.

Recommend moderate-intensity exercise (e.g., walking, swimming) for at least 30 minutes per day to improve cardiovascular health, weight management, and mobility.

Psychosocial Support:

Address the patient’s anxiety related to stroke recovery by recommending a follow-up with a counselor or psychologist.

Support groups for stroke survivors may help with emotional recovery and adaptation to post-stroke life.

Follow-up:

Follow-up in 1 month for blood pressure and diabetes monitoring.

Regular neurological evaluations every 3 months to assess any further improvement or new deficits in function.

Follow-up with cardiologist in 3-6 months to assess progress with lipid management.

Patient Education:

Educate the patient on the importance of medication adherence, blood pressure control, and lifestyle changes in preventing recurrent strokes and improving overall health.

Provide guidance on recognizing signs of a stroke (e.g., sudden numbness or weakness, especially on one side of the body, trouble speaking or understanding speech, vision changes, or loss of balance).

Discussion:

Managing patients after an ischemic stroke requires a multidisciplinary approach to secondary prevention. This includes the use of antiplatelet therapy, aggressive management of cardiovascular risk factors (e.g., hypertension, hyperlipidemia, and diabetes), and rehabilitation to address any functional impairments. In this case, the patient's treatment plan focuses on optimizing blood pressure control and lipid management, while also addressing the residual deficits from the stroke through rehabilitation and psychosocial support. Monitoring of secondary prevention medications and regular follow-up visits are crucial to ensure ongoing stroke risk reduction and recovery.