Type and Cause of Steven's CVA
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The evaluation of Steven's symptoms for the CVA can be done using FAST (Face, Arms, Speech, and Time) approach. As mentioned in the case study, Steven has experienced sudden facial droop on the left side, slurring of speech with weakness in the lower and upper side limbs. All these are the symptoms of the ischaemic CVA as mentioned by Aliasghari et al (2019).According to Chen et al (2016), the Ischaemic stroke occurs by virtue of interruption of supply of blood to the brain's artery due to an embolus or thrombus (clot). The blockage diminishes the blood and oxygen supply to the brain that damages the brain cells. In the worst case, the brain might get permanently damaged (Alnsasra et al., 2019). Nearly 85% strokes are ischemic strokes and rest 15% are haemorrhagic strokes. Steven's case lies in the 85% cases.
Merkler et al (2020) outlined five key causes that could lead to the Ischemic stroke. These are atherosclerosis, lacunar stroke, cardioembolism, cryptogenic stroke, and haematological disorders. Steven's CVA can be associated with his two existing conditions. Steven has been taking medication for hypertension and prediabetes. These could be two reasons that have contributed to the current situation of Steven. There is no information provided about the high cholesterol level or atrial fibrillation, or prior heart attack. Also, he was not having any clotting disorders or congenital heart defect that could have resulted in the CVA. Hence, high blood pressure and diabetes are the prime reason for Steven's current situation.
Aliasghari et al (2019) outlined that hypertension leads to high blood pressure. This puts an additional strain on the blood vessels in the human body. This could cause ischaemic stroke as it leads to a blood clot. This can damage the blood vessels and could make them narrow and stiffer. This can lead to clots formation and this could travel to the brain and could cause a stroke. When Steven was brought to the emergency department, his blood pressure was 165/90 mmHg and HR was 95. This means that high blood pressure has caused the stroke in the case of Steven.
Coming on to the prediabetes of Steven, Alnsasra et al(2019) mentioned that diabetes is a well-established cause of the CVA. It can lead to pathologic transformation in the arteries at various locations. This can result in stroke in case the cerebral vessels get affected. Additionally, the mortality rate is a bit higher and poststroke outcomes are poorer in people with uncontrolled levels of glucose in the blood. No doubt Steven has left smoking due to prediabetes but he was consuming beer or alcohol (10-15 drinks per week) that could have been a major reason in the increase in the glucose level or strokes (Merkler et al., 2020).Alnsasra et al (2019) mentioned that people with prediabetes have higher chances to suffer from high blood pressure or myocardial infarction (MI). This could increase the cholesterol level and this could be another reason for the stroke.
Merkler et al (2020) mentioned some of the mechanisms through which diabetes could cause vascular endothelial dysfunction, stiffening of the capillary basal membrane, systematic inflammation, and arterial stiffness as well.
Two Risk Factors Steven has for the CVA
Apart from hypertension and prediabetes, there are other risk factors as well that could cause the CVA in the case of Steven. The first and foremost is atherosclerosis and the other is a hectic schedule. Montalvan et al (2020) outlined that the majority of the ischemic strokes occur due to atherosclerosis which is caused due to hardening of the blood arteries. This usually happens when cholesterol levels are up in the blood vessels. This blocks the arteries and causes hindrance in the flow of blood. Cigarette smoking is one of the primary cause of atherosclerosis. No doubt Steven has quit smoking 3 years back but before that, he was a regular smoker for more than 30 years and his daily consumption of secrets was nearly between 10-15 units a day. This might have already caused the damage to the blood vessels and eventually, atherosclerosis was developing. The impact result of which might have appeared after three years as ischemic strokes. The inner lining of the blood vessels (endothelium) can get damaged due to triglyceride in the cigarette. After quitting smoking, the process of internal healing might have started but the chances of strokes are still there (Chen et al., 2016). Once the arteries get damaged, the development of atherosclerosis begins and the chances of strokes would be there until the atherosclerosis is there in Steven's body.
Being the Senior Partner at a law firm, Steven was working for more than 60 hours a week that was reduced to 30 hours after he was diagnosed with the prediabetic condition. However, at the age of 61 years, he is still working and which increases the stress on him and could cause cardiovascular risks and strokes occurrences.Earlier he was working more than 10 hours per day and this increases the chances of strokes.
Coming on to the symptoms that appeared in Steven after the occurrence of CVA, these include slurring of speech and facial droop on his left-hand side or weakness in the left side upper and lower limbs. There are many reasons for slurred speech after the stroke. Nozoe et al (2019)mentioned that slurred speech can occur due to cutting off the oxygen supply caused by a blood clot in the arteries. This might cause slurred speech. In the worst case, one might face permanent language problem which is often called aphasia. Montalvan et al (2020) mentioned that the brain controls each and every function of a human body and the left side of the brain controls the language. Steven's stroke affected his left part of the body and has weakened the left side. This caused communication problems and paralysis on the left side of the body of Steven. Coming on to the facial palsy or droops which is quite noticeable, it is caused due to the damage that occurred to the facial nerves in the brain. Since Steven witnessed an ischaemic stroke, all the damages occurred to his nerves and tissues in the brain are caused by the lack of oxygen caused by the clot in the arteries (Chen et al., 2016).
Out of all the five medications recommended to Steven, the following three medications have been chosen and their pharmacodynamics and pharmacokinetics are illustrated here. These medicines are:-
Apixaban is aXa inhibitor anticoagulant medicine used in the prevention of the deadly blood clots. It works by avoiding the blood to clot quickly by blocking a substance causing clotting called Factor Xa in the blood (Woodruff et al., 2011). People who are taking this medicine needs to have a regular blood test (PT INR Test) to determine the clotting time of the blood. The doses of this tablet need to be adjusted based on the range of the PT INR test. It is also used in the case of pulmonary embolism and thrombosis. There are certain considerations for people. Persons with liver or kidney issues must not take it. Pregnant or breastfeeding women must not take it as there are chances of internal bleeding which is one of the common side-effects of this tablet.
Atorvastatin 40 mg is quite popular for reducing the levels of bad cholesterol or fats while increasing the HDL level in the blood. It reduces the production of cholesterol in the liver and increases the risks of heart disease and preventing strokes and heart attacks (Chen et al., 2016). Some exercise or physical activities are also suggested along with this tablet. Smoking and alcohol consumption need to be stopped. The side effects include mild memory issues leading to confusion. It can also increase the glucose level and rarely does it cause muscle cramps and pain.
Coming on to Ezetimibe, it is also used to reduce the bad cholesterol level in the blood. It can also be used along with other Statin drugs, such as Atorvastatin. Ezetimibe prevents strokes and heart attacks by reducing the amount of fat or bad cholesterol absorbed by the body from the diet. The dosage is as per the medical condition of the patient. There are some precautions associated with this medication. It can allergic reactions in some cases and therefore, it should be taken as per the prescription. It should be avoided in case of liver problems and pregnant women must consume this drug after consulting with the physician. The side effects include muscle damage, yellowing eye, fever, and unusually dark urine or abdominal pain.
The First Pass Effect and Its Implications on the Drug's Bioavailability
As Steven has been given five different medication, each of them would have to undergo the first-pass effect. Therefore, it is important to understand its meaning and implication. As mentioned by Zaidat et al (2018), the first pass effect is the phenomenon wherein the drug gets metabolised at a particular part of the body that reduces the concentration of the active drug on reaching its location of the action. It is directly related to the liver as the majority of the drugs get metabolised there only. However, some of the first pass effects can be noticed in the gastrointestinal tract or lungs, or vasculature of the body. The issues with the first pass effect are related to its variability among different people. The dosing needs to consider the natural variation in the metabolic activity of individuals to make sure that patients stay within the therapeutic thresholds of the drug (Nikoubashman et al., 2019). Due to the biotransformation suffered by the drug, the bioavailability gets drastically reduced and shows sub-therapeutic actions.
Aliasghari, F., Izadi, A., Khalili, M., Farhoudi, M., Ahmadiyan, S., &Deljavan, R. (2019). Impact of premorbid malnutrition and dysphagia on ischemic stroke outcome in elderly patients: a community-based study. Journal of the American College of Nutrition, 38(4), 318-326.
Alnsasra, H., Haim, M., Senderey, A. B., Reges, O., Leventer-Roberts, M., Arnson, Y., ...&Avgil-Tsadok, M. (2019). Net clinical benefit of anticoagulant treatments in elderly patients with nonvalvular atrial fibrillation: experience from the real world. Heart Rhythm, 16(1), 31-37.
Chen, R., Ovbiagele, B., & Feng, W. (2016). Diabetes and stroke: epidemiology, pathophysiology, pharmaceuticals and outcomes. The American journal of the medical sciences, 351(4), 380-386.
Fischer, U. M., Harting, M. T., Jimenez, F., Monzon-Posadas, W. O., Xue, H., Savitz, S. I., ... & Cox Jr, C. S. (2009). Pulmonary passage is a major obstacle for intravenous stem cell delivery: the pulmonary first-pass effect. Stem cells and development, 18(5), 683-692.
Merkler, A. E., Parikh, N. S., Mir, S., Gupta, A., Kamel, H., Lin, E., ...&Navi, B. B. (2020). Risk of ischemic stroke in patients with coronavirus disease 2019 (COVID-19) vs patients with influenza. JAMA neurology, 77(11), 1366-1372.
Montalvan, V., De Toledo, J., & Nugent, K. (2020). Mechanisms of stroke in coronavirus disease 2019. Journal of Stroke, 22(2), 282.
Nikoubashman, O., Dekeyzer, S., Riabikin, A., Keulers, A., Reich, A., Mpotsaris, A., &Wiesmann, M. (2019). True first-pass effect: first-pass complete reperfusion improves clinical outcome in thrombectomy stroke patients. Stroke, 50(8), 2140-2146.
Nozoe, M., Kanai, M., Kubo, H., Yamamoto, M., Shimada, S., &Mase, K. (2019). Prestrokesarcopenia and functional outcomes in elderly patients who have had an acute stroke: a prospective cohort study. Nutrition, 66, 44-47.
Woodruff, T. M., Thundyil, J., Tang, S. C., Sobey, C. G., Taylor, S. M., &Arumugam, T. V. (2011). Pathophysiology, treatment, and animal and cellular models of human ischemic stroke. Molecular neurodegeneration, 6(1), 1-19.
Zaidat, O. O., Castonguay, A. C., Linfante, I., Gupta, R., Martin, C. O., Holloway, W. E., ... &Nogueira, R. G. (2018). First pass effect: a new measure for stroke thrombectomy devices. Stroke, 49(3), 660-666.
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