Minutes of the Exeter Sessional GPs Group Darts Farm – 1 November 2016

The meeting was kindly sponsored by:

Galderma Alison

Chiesi Kristina Duncan

Teva Cathy Griffiths

Attendance: 30+ members

Welcome:

Dr Tim Dyke opened the meeting, thanked the reps for sponsoring and the reps each gave a two minute talk. Notably there is a dermatology evening at Escot on 8 November (details from Galderma) and an asthma study day at Sandy Park on 23 November (details from Teva – ).

Tim welcomed the speaker Dr Martin James Consultant Stroke Physician, RDE and part of the expert group which has produced the RCP Stroke Guidelines published October 2016 and available on https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines. The talk was based on these Guidelines and there is also a primary care concise guideline – printed copy distributed at end of meeting although too few copies for the excellent turnout. Will be available on-line from 29 November: https://www.strokeaudit.org/Guideline/Concise-Guideline.aspx.

Clinical meeting

Stroke and TIA Update Dr Martin James Consultant Stroke Physician RDE

Major new changes:

·  Acute ischaemic stroke – thrombectomy; faster and more thrombolysis

·  Carotid stenosis – endarterectomy more effective than stenting

·  Prevention of cardioembolic stroke – especially in AF

Proximal MCA occlusion without treatment leaves 50% dead, 45% dependent in nursing homes and 5% independent.

Thrombectomy – a “game changer”. Stent retriever is used to pull out the clot. Done by interventional neuroradiologists.

Lancet study – An individual patient meta-analysis. 43% reduction in severe disability for thrombectomy compared with thrombolysis. Benefit is time sensitive – RCP Guideline says need to do within 5 hours but there is evidence of benefit up to 6 hours. Posterior circulation strokes – may benefit 12-24 hours post occlusion. Can use if contraindication to thrombolysis but also can combine with thrombolysis. Number needed to treat with thrombectomy to get one patient free of serious disability is between 3 and 7. This is highly favourable compared with interventions which are accepted as beneficial in other specialities.

Cochrane study May 2012 – 12 trials using rtPA – used within six hours, an increased rate of haemorrhage but an increased chance of independence at six months.

FAST positive – an emergency – this has been very much taken on board by ambulance services and there has been widespread advertising to general public.

NICE appraisal of 2012 still applies.

Use of Ateplase within 4.5 hours – cost is £4,500 per QALY and this is favourable compared with other interventions.

UK thrombolysis rate is 11-12%. RDE is above 15%. Likely that maximum would be in the high teens with the remainder being unsuitable / contraindicated.

Speed of delivery – UK average door to needle is 54 mins (RDE 30-40 mins).

NNT very time sensitive:

·  0-90 mins 4.5

·  91-180 mins 9

Aspirin once haemorrhage excluded

If haemorrhagic then BP control

Evidence for hyper acute stroke units:

Prevent death and severe disability

Prevent lower resp tract infections, other infections, stroke progression and pressure sores.

Evidence for nursing to patient ratio – increased 30 day mortality if nurses per ten beds goes under two to three.

Swallow screen – needs to be done earlier as evidence then for decreased rate aspiration pneumonia.

Evidence that the outcome is improved if in stroke unit within 4 hours – there is a fourfold variation across UK in rates of this being achieved.

95% of patients do get to a stroke unit.

There is no specific evidence pointing to what is the most important feature of the stroke unit – e.g. physio, OT, nursing care.

TIAs:

A lot of the evidence dates back to OXVASC 2005 – showed that after definite TIAs then 7 day risk of completed stroke is 10%.

This is due to unstable atheroma.

Stenting vs endarterectomy – Cochrane study – endarterectomy generally has better outcome.

Advice for primary care – anyone with suspected TIA needs aspirin 300mg immediately and refer to TIA clinic to be seen within 24 hours.

Recommendations:

·  Lifestyle – smoking, alcohol, diet, exercise

·  Clopidogrel 300mg then 75mg od

·  Atorvastatin – 20-80mg

·  BP lowering – thiazide, long acting calcium channel blocker, ACE inhibitor

If refuse or reaction to statin then consider lower dose of more potent statin. Alternate day statin or twice weekly statin can reach target and better than nothing. Target is >40% reduction in non HDL cholesterol.

For symptomatic catotid stenosis then carotid endartectomy is treatment of choice in most cases.

Devon Formulary gives advice on secondary prevention.

Rising tide of cardio embolic stroke in over 80s mainly secondary to AF. In paroxysmal AF then episodes lasting five minutes or more are thrombogenic.

http://www.swscn.org.uk/wp/wp-content/uploads/2016/06/SW-CV-Network-Guidance-on-4-Non-vit-K-Anticoagulants-2016.pdf gives an algorithm to decide on anticoagulation – includes CHA2DS2VASC and HAS-BLED.

Future ESGPG Meetings
6th December 2016 – Gerontology, Dr Ray Sheridan, RD&E

Meeting time

Please note that the meetings are now scheduled to start at 7pm with the guest speaker planned to commence at 7.30pm.

Committee Contacts

Dr Ross Hemingway (chair)

Dr Anna Beazley (treasurer)

Dr Tim Dyke (education co-ordinator)

Dr Anna Griffiths (funding co-ordinator)

Dr Felicity Knott (web site co-ordinator)

Dr Kathryn Shore (minutes’ secretary)