Acute Ischemic Stroke Pharmacotherapy Checklist
(Full update March 2024)
Use this checklist to help you keep pharmacotherapy of acute ischemic stroke patients on track from admission to discharge, and prevent readmission.
Goal |
Suggested Approach |
Get the correct dose of IV alteplase to qualifying patients fast (within |
|
Consider alternatives to IV alteplase. |
|
Achieve blood pressure goals. |
|
Manage blood glucose. |
|
Treat body temperature >38oC. |
|
Manage thrombolysis complications. |
Angioedema
|
Intracranial bleed within 24 hours of thrombolysis (based on alteplase recommendations) In addition to appropriate labs, imaging, and supportive care:
Bleeding reversal options:
|
|
Start an antiplatelet. |
|
Prevent deep venous thrombosis. |
|
Identify and treat depression. |
|
Optimize lipid-lowering therapy. |
|
Help patient stop smoking. |
|
Quickly identify and respond to in-hospital stroke. |
|
Abbreviations: ASPECTS = Alberta Stroke Programme Early CT Score; ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; CT = computed tomography; DBP = diastolic blood pressure; DW-MRI = diffusion-weighted magnetic resonance imaging; FLAIR = fluid attenuated inversion recovery; IA = intra-arterial; IV = intravenous; M1 = middle cerebral artery segment 1; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Score; PHQ = Patient Health Questionnaire; SBP = systolic blood pressure; SSRI = selective serotonin reuptake inhibitor; TIA = transient ischemic attack.
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
|
B |
Inconsistent or limited-quality patient-oriented evidence.* |
|
C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/pubs/afp/issues/2004/0201/p548.html.]
References
- Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418. Erratum in: Stroke. 2019 Dec;50(12):e440-e441.
- Barrow T, Khan MS, Halse O, Bentley P, Sharma P. Estimating Weight of Patients With Acute Stroke When Dosing for Thrombolysis. Stroke. 2016 Jan;47(1):228-31.
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):e13-e115. Erratum in: Hypertension. 2018 Jun;71(6):e140-e144.
- Campbell BCV, Mitchell PJ, Churilov L, et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med. 2018 Apr 26;378(17):1573-1582.
- Joint Commission. Specifications manual for Joint Commission National Quality Measures (v2021A1). September 25, 2020. https://manual.jointcommission.org/releases/TJC2021A1/MIF0126.html. (Accessed March 27, 2024).
- Nouh A, Amin-Hanjani S, Furie KL, et al. Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke: A Scientific Statement From the American Heart Association. Stroke. 2022 Apr;53(4):e165-e175.
- Aspirus. Alteplase administration for stroke patients. February 18, 2021. https://www.wha.org/Quality-Patient-Safety/Patient-Safety-Resources/Stroke-Care/Pursuing-Acute-Stroke-Readiness-Hospital-(ASRH)-Ce/Alteplase-Administration-for-Stroke-Patients_2-202.pdf. (Accessed March 27, 2024).
- US Preventive Services Task Force. Final recommendation statement. Depression and suicide risk in adults: screening. June 20, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-adults. (Accessed March 27, 2024).
- American Psychological Association. Patient Health Questionnaire (PHQ-9 & PHQ-2). Last updated June 2020. https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/Patient-health. (Accessed March 27, 2024).
- Mortensen JK, Andersen G. Pharmacological management of post-stroke depression: an update of the evidence and clinical guidance. Expert Opin Pharmacother. 2021 Jun;22(9):1157-1166.
- Katsanos AH, Safouris A, Sarraj A, et al. Intravenous Thrombolysis With Tenecteplase in Patients With Large Vessel Occlusions: Systematic Review and Meta-Analysis. Stroke. 2021 Jan;52(1):308-312.
- Gao L, Moodie M, Mitchell PJ, et al. Cost-Effectiveness of Tenecteplase Before Thrombectomy for Ischemic Stroke. Stroke. 2020 Dec;51(12):3681-3689.
- Kernan WN, Viera AJ, Billinger SA, et al. Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke. 2021 Aug;52(9):e558-e571.
- Renú A, Millán M, San Román L, et al. Effect of Intra-arterial Alteplase vs Placebo Following Successful Thrombectomy on Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke: The CHOICE Randomized Clinical Trial. JAMA. 2022 Mar 1;327(9):826-835.
- Collette SL, Bokkers RPH, Mazuri A, et al. Intra-arterial thrombolytics during endovascular thrombectomy for acute ischaemic stroke in the MR CLEAN Registry. Stroke Vasc Neurol. 2023 Feb;8(1):17-25.
- Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015 Jan 1;372(1):11-20. Erratum in: N Engl J Med. 2015 Jan 22;372(4):394.
Cite this document as follows: Clinical Resource, Acute Ischemic Stroke Pharmacotherapy Checklist. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. March 2024. [400365]