From the Guidelines
The management of a 72-year-old man with hypertension and untreated type 2 diabetes who has suffered a left Sylvian stroke requires immediate comprehensive care, focusing on stabilization, acute treatment, and aggressive risk factor modification to reduce morbidity and improve outcomes, as recommended by the most recent guidelines 1.
Key Components of Management
- Initial management should focus on stabilization in a stroke unit with continuous monitoring of vital signs, neurological status, and blood glucose levels.
- Acute treatment includes aspirin 300mg as an initial dose, followed by 75-100mg daily for secondary prevention, as single antiplatelet therapy is recommended over oral anticoagulation for patients with ischemic stroke or TIA caused by moderate to high-grade intracranial atherosclerotic stenosis 1.
- Blood pressure management is crucial, targeting <140/90 mmHg using appropriate antihypertensives such as ACE inhibitors (e.g., ramipril 2.5-10mg daily) or ARBs, as recommended for patients with ischemic stroke or TIA caused by moderate to high-grade intracranial atherosclerotic stenosis 1.
- For diabetes control, initiate metformin starting at 500mg daily and titrate up to 1000mg twice daily as tolerated, with HbA1c target <7%, as metformin should be first-line therapy in newly diagnosed type 2 diabetes, with consideration of SGLT2i or GLP-1RA in patients at high risk for cardiorenal disease 1.
- Statins are essential regardless of baseline cholesterol levels; atorvastatin 40-80mg daily is recommended, with a target LDL-cholesterol of 1.8 mmol/L (70 mg/dL) to be pursued with high-dose statin therapy, as recommended for patients with ischemic stroke or TIA caused by moderate to high-grade intracranial atherosclerotic stenosis 1.
Additional Recommendations
- Early rehabilitation should begin within 24-48 hours involving physiotherapy, occupational therapy, and speech therapy if aphasia is present.
- Swallowing assessment is necessary before oral intake to prevent aspiration pneumonia.
- Lifestyle modifications, including smoking cessation, regular physical activity, and dietary modification, are essential for reducing morbidity and improving outcomes, as recommended by recent guidelines 1.
- The patient's care should be individualized, taking into account their characteristics, co-morbidities, preferences, and priorities, with a multifactorial approach to managing type 2 diabetes, including glucose-lowering therapy, blood pressure control, statins, and antiplatelet therapy, as recommended by recent guidelines 1.
From the Research
Management of Hypertension and Type 2 Diabetes Mellitus in a Patient with Left Sylvian Stroke
The management of a 72-year-old man with hypertension (HTA) and type 2 diabetes mellitus (DM2) who had a left Sylvian stroke involves a comprehensive approach to reduce the risk of further cardiovascular events and manage his underlying conditions.
- Antiplatelet Therapy: The use of antiplatelet therapy, such as aspirin, is recommended for patients with acute ischemic stroke, as it has been shown to reduce the risk of early recurrent ischemic stroke and improve long-term outcomes 2, 3.
- Antihypertensive Therapy: A combination of antihypertensive drugs, including an ACE inhibitor and a calcium channel blocker, is considered optimal for the treatment of hypertension, especially in patients with diabetes mellitus or cardiovascular disease 4, 5.
- Lipid-Lowering Therapy: The use of statins, such as atorvastatin, is recommended for patients with high cardiovascular risk, including those with hypertension and diabetes mellitus 4, 6.
- Management of Diabetes Mellitus: Tight control of blood glucose levels is essential for patients with diabetes mellitus, especially those with cardiovascular disease or stroke 4, 5.
- Poly-Pharmacologic Approach: A poly-pharmacologic approach, including the use of multiple drugs, such as ACE inhibitors, calcium channel blockers, statins, and antiplatelet agents, may be necessary to achieve optimal control of blood pressure, lipid profiles, and blood glucose levels 4, 6, 5.