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4
Stroke
3
2
TIA and
mild stroke?
Moderate
stroke?
See
Fig. 2
See
Fig. 3
Severe
stroke
See
Fig. 4
Figure 1
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1
TIA & mild
stroke
Exclude common stroke mimickers (Appendix IIA and IIB). Monitor and manage blood pressure, treat if SBP 220 or DBP 120 or MAP >130 (appendix
IIIA).
Precautions:
Avoid precipitous drop in BP >20% of baseline MAP
Do not use rapid-acting sublingual agents; when needed use oral or easily
titratable IV anti-hypertensive medications (Appendix IIIB)
Ensure appropriate hydration. If IV fluid is needed, use 0.9 NaCl.
3
Emergent Diagnostics
Early Specific
Treatment
(Appendix IV)
CT scan
confirmed?
(Appendix
VIA)
N
See
Fig. 2A
Figure 2
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3
Aspirin 160-325 mg/day start as
early as possible and continue for
14 days (for secondary prevention,
see below under delayed management)
Figure 2
2
Ischemic?
Cardioembolic
(Appendix V)?
6
Y
N
TIA
Hemorrhagic
Non-
cardioembolic
(Thrombotic,
N
5
5. Follow recommendations of
surgical intervention (Appendix IVE)
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1
Delayed Management
& Treatment
(Secondary Prevention)
(Appendix VIII)
3
Ischemic?
Thrombotic/
Lacunar?
Hemorrhagic
Cardioembolic
Carotid ultrasound
If this reveals >70% steno
sis, refer to neurologist
for decision-making regarding carotid endarte
rectomy
Antiplatelets (aspirin,
ticlopidine, clopidogrel,
dipyridamole, cilosta
zol)
Figure 2B
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Monitor and manage blood pressure, treat if SBP 220 or DBP 120
or MAP >130 (Appendix IIIA).
Precautions:
Avoid precipitous drop in BP>20% of baseline MAP
Do not use rapid-acting sublingual agents; when needed use oral
or easily titratable IV anti-hypertensive medication (Appendix
IIIB)
Ascertain clinical diagnosis of stroke-history and physical exam
very important
Exclude common stroke mimickers (Appendix II)
Identify co-morbidities (cardiac disease, gastric ulcer, etc.)
Recognize and treat early signs and symptoms of increased ICP
(Appendix IX)
Emergent Diagnostics
Complete blood count (CBC)
Blood sugar (CBG, HGT, or RBS)
PT/PTT
Serum Na+ and K+
Electrocardiogram (ECG)
Plain CT scan of brain as soon as possible
Computation of volume if hemorrhagic
(Appendix VI)
Early Specific
Treatment
See
Fig. 3A
(Appendix IV)
Figure 3
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Figure 3
CT scan
confirmed?
(Appendix
VIA)
See Fig. 3B
Likely
ischemic?
No specific emergent
drug treatment recom
mended
Neuroprotection (Appen
dix IVD)
Refer to specialist
Early supportive rehabili
tation
N
6
Likely
hemorrhagic
Figure 3A
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Figure 3A
2
Ischemic?
Cardio-
embolic
(Appendix
Hemorrhagic
Medical/surgical
treatment
(Appendix IVE)
Non-
cardioembolic
Thrombotic/
Lacunar?
Place of Treatment (Appendix VII): Hospital - Intensive Care Unit or Stroke Unit
Figure 3B
Mild stroke
Ischemic?
Cardio-
embolic
Hemorrhagic
7
Thrombotic/
Lacunar?
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1
Severe
stroke
Neuro-vital signs: BP, PR, CR, RR, Temp, Pupils, Glasgow Coma Scale (Appendix
X)
Recognize and treat early signs and symptoms of increased ICP (Appendix IX)
Monitor and manage blood pressure, treat if SBP 220 or DBP 120 or MAP>130
(Appendix IIIA).
Precautions:
Avoid precipitous drop in BP >20% of baseline MAP
Do not use rapid-acting sublingual agents; when needed use oral or easily titratable
IV anti-hypertensive medication (Appendix IIIB)
Ascertain clinical diagnosis of stroke-history and physical exam very important
Exclude common stroke mimickers (Appendix II)
Identify co-morbidities (cardiac disease, gastric ulcer, etc.)
Emergent Diagnostics
Complete blood count (CBC)
Blood sugar (CBG, HGT, or RBS)
PT/PTT
Serum Na+ and K+
Electrocardiogram (ECG)
Plain CT scan of brain
C omputation of volume if hemorrhagic (Appendix VI)
Early Specific
Treatment
(Appendix IV)
See Fig. 4A
Figure 4
10
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Figure 4
CT Scan
confirmed?
See Figure
4B
Figure 4A
Ischemic?
Thrombotic?
Cardioembolic
Hemorrhagic
N
5
Echocardiography and/or
cardiology consult
If age <75 and PT/INR avai
lable, anticoagulation with
coumadin (target INR 2-3)
If age >75, aspirin 80-325
mg/day or coumadin with
target INR 2-2.5 (if PT/INR
available)
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Figure 4A
CT scan confirmed
(Appendix VIA)
Ischemic?
Non-cardioembolic
(Thrombotic)?
Hemorrhagic
N
5
Cardioembolic
(Appendix V)
day
Supportive treatment:
1. Mannitol 20% 0.5 mg/kg BW q 6h for 2-5 days
2. Neuroprotection (Appendix IVD)
Neurosurgery consult if:
1. Patient not herniated, bleed located in putamen, subcortical area,
or cerebellum, and goal is reduction of mortality
2. Herniated patient but family is willing to accept consequences
of high mortality or irreversible coma and persistent vegetative
state
3. ICP monitoring contemplated and salvage surgery is considered
Figure 4B
12
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Appendix III
Reference:
1. Plum F, Posner J. The Diagnosis of Stupor and Coma. 3rd
Ed. F.A. Davis Company, Philadelphia PA, c1982.
Appendix II
Differential Diagnosis of Stroke
A. The presence of any of the following should alert
the physician to consider conditions other than
stroke:
-
-
-
-
-
-
-
1. Seizures
2. Systemic infection
3. Brain tumor
4. Toxic-metabolic
5. Positional vertigo
6. Cardiac
7. Syncope
8. Trauma
9. Subdural hematoma
10. Herpes encephalitis
11. Transient global amnesia
12. Dementia
13. Demyelinating disease
14. Cervical spine fracture
15. Myasthenia gravis
16. Parkinsonism
Appendix IV
Acute Stroke Treatments
A. Risk of treating patient with mild stroke with
anti-thrombotics:
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APPENDIX I
Abnormal motor posturing responses to painful stimuli
Figures. Response elicited by pressure to supraorbital ridge, sternum, or nailbed. A. Localizes pain. B. Decorticate
posturing. C. Decerebrate posturing
Reference
1. Plum F, Posner J. The Diagnosis of Stupor and Coma. 3rd ed. F.A. Davis Company, Philadelphia PA, c1982.
Onset
of Action
Duration
of Action
Adverse Effects
Nicardipine
5-15 mg/h IV
5-10 min
1-4 h
Tachycardia, head-
HCl
ache, flushing, local
phlebitis
Special Indications
Most hypertensive
emergencies except
acute heart failure;
caution with
coronary ischemia
Hydralazine
10-20 mg IV
10-20 min
3-8 h
HCl
10-50 mg IM
20-30 min
Esmolol
0.5-1 mg/kg
2-10 min
10-30 min
bolus IV over
30 sec. or
0.05/kg/min
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References:
1. The Amaurosis Fugax Study Group. Current manage-ment
of amaurosis fugax. Stroke 1990;21:201-208.
2. Anzalone N, Landi G. Non-ischaemic causes of lacunar
syndromes: prevalence and clinical findings. J Neurol
Neurosurg Psychiatry 1989;52:1188-1190.
3. Bamford J, Sandercock P, Jones L, Warlow C. The natural
history of lacunar infarction: The Oxfordshire Community
Stroke Project. Stroke 1987;18:545-551.
4. Bamford JM, Warlow CP. Evolution and testing of the
lacunar hypothesis. Stroke 1988;19:1074-1082.
5. Bogousslavsky J, Van Melle G, Regli F. The Lausanne
Stroke Registry: Analysis of 1,000 consecutive patients
with first stroke. Stroke 1988;19:1083-1092.
6. Brown RD Jr, Evans BA, Wiebers DO, Petty GW, Meisner
I, Dale AJD. Transient ischemic attack and minor ischemic
stroke: An algorithm for evaluation and treatment. Mayo
Clin Proc 1994;69:1027-1039.
7. Chimowitz MI, Furlan AJ, Sila CA, Paranandi L, Beck
GJ. Etiology of motor or sensory stroke: A prospective
study of the predictive value of clinical and radiological
features. Ann Neurol 1991;30:519-525.
8. Mori E, Tabuchi M, Yamadori A. Lacunar syndrome due
to intracerebral hemorrhage. Stroke 1985;16:454-459.
B. Thrombolytic Therapy
- Thrombolytics is not recommended in mild
strokes.
- Streptokinase and urokinase are not currently
recommended in acute stroke.
Guidelines:
1. Dose of rtPA is 0.9 mg/kg (maximum 90 mg)10% of total volume given as bolus, rest as
infusion over 60 minutes.
2. RtPA is recommended as treatment within 3
hours of onset of ischemic stroke. The benefit
of IV rtPA for acute ischemic stroke beyond 3
hours from onset of symptoms is not established.
Intravenous rtPA is not recommended when the
time of onset of stroke cannot be ascertained
reliably, including strokes recognized upon
awakening.
3. Thrombolytic therapy is not recommended
unless the diagnosis is established by a physi
cian with expertise in diagnosis of stroke, and
CT of the brain is assessed by physicians with
expertise in reading this imaging study. If CT
demonstrates early changes of a recent major infarction such as sulcal effacement, mass effect,
edema or possible hemorrhage, thrombolytic
therapy should be avoided.
4. Thrombolytic therapy cannot be recommended
for persons with any of the following (NINDS
Study):
a. current use of oral anticoagulants or a pro
7. Because the use of thrombolytic drugs carries the real risk of major bleeding, whenever
possible the risks of potential benefits of rtPA
should be discussed with the patient and his or
her family before treatment is initiated.
Reference:
1. NINDS rtPA Stroke Study Group Tissue plasminogen
activator for acute ischemic stroke. N Engl J Med
1995;333:1581-1587.
C. Antithrombotic therapy
1. International Stroke Trial (IST)
- Multicenter randomized clinical trial of 19,435
patients
- Regimen:
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D. Neuroprotection
1. Avoid hypotension, hypoxemia (aspiration pneu
monia), hyperglycemia, hyponatremia, and fever
during acute stroke in an effort to salvage the
ischemic penumbra.
2. Several neuroprotectants for acute ischemic stroke
have been investigated or are currently under in
vestigation. Some results have been encouraging.
References:
1. Clark WM, Warachi SJ, Pettigrew LC, et al for the
Citicoline Stroke Study Group. A randomized doseresponse trial of citicoline in acute ischemic stroke
patients. Neurology 1997;29:671-678.
2. De Deyn PP, Reuck JD, Deberdt W, et al for the Piracetam
in Acute Stroke Study Group. Treatment of acute ischemic
stroke with piracetam. Stroke 1997;28:2347-2352.
3. Davalos A, et al. Oral Citicoline in Acute Ischemic Stroke:
An Individual Patient Data Pooling Analysis of Clinical
Trials. Stroke 2002;33:2850-2857
4. Mohr JP, Orgogozo JM, Harrison MJG, et al. Metaanalysis of oral nimodipine trials in acute ischemic stroke.
Cerebrovasc Dis 1994;4:197-203.
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References:
1. Aver LM, et al. Endoscopic surgery versus medical
treatment for spontaneous intracerebral hematoma: a
randomized study. J Neurosurg 1989;70:530-535.
2. Barnett HJM, Mohr JP, Stein BM, Yatsu FM (eds). Stroke Pathophysiology, Diagnosis, and Management, 2nd edition.
Churchill Livingstone, New York, 1992.
3. Broderick JP, et al. Ultra-early evaluation of intrace-rebral
hemorrhage. J Neurosurg 1990;72:195-199.
4. Brott T, et al. Early hemorrhage growth in patients with
intracerebral hemorrhage. Stroke 1997;28:1-5
5. Caplan L. Intracerebral hemorrhage revisited. Neuro-logy
1988;38:624-7.
6. Fujii Y, et al. Hematoma enlargement in spontaneous
intracerebral hemorrhage. J Neurosurg 1994;80:51-57.
7. Juvela S, et al. The treatment of spontaneous intracerebral hemorrhage: randomized clinical trial. J Neuro-surg
1989;70:755-788.
8. Kazui S, et al. Enlargement of spontaneous intracerebral
hemorrhage: incidence and time course. Stroke 1996;
27:1783-1787.
9. Mayer SA, Sacco RL, Shi T, Mohr JP. Neurologic deterioration in noncomatose patients with supra-tentori-al
intracerebral hemorrhage. Neurology 1994; 44: 1379-84.
10. Mendelon AD. Mechanisms of ischemic brain damage
with intracerebral hemorrhage. Stroke 1993;24 (Suppl
12):1115-1117.
11. Sacco RL, Wolf PA, Bharucha NE, et al. Subarachnoid and
intracerebral hemorrhage: Natural history, progno-sis, and
precursive factors in the Framingham Study. Neurology
1984;34:847-54.
12. Welch KMA, Caplan LR, Reis DJ. Siesjo BK, Weir B (eds).
Primer on Cerebrovascular Diseases. Academic Press. San
Diego, 1997.
Appendix V
1. Atrial fibrillation/flutter
2. Valvular heart disease (including rheumatic heart
disease)
3. Bacterial endocarditis
4. Cardiac thrombus
5. Cardiomyopathy
6. Recent myocardial infarction
7. Atrial myxoma
8. Right-to-left shunts
9. Pulmonary vein thrombosis
References:
1. Foulkes MA, Wolf PA, Price TR, Mohr JP, Hier DB.
The Stroke Data Bank: design, methods, and baseline
characteristics. Stroke 1988;19:547-54.
2. Mohr JP, Caplan LR, Melski JW, et al. The Harvard
Cooperative Stroke Registry: A prospective registry.
Neurology 1978;754-762.
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Vomiting
B.
Level of Consciousness
+4
Unarousable
+4
Drowsy - arousable
+2
Awake
Absent
3. Loss of
Present
Absent
Consciousness
1. Systolic BP
>200 mmHg
160-200 mmHg
<160 mmHg
2. Diastolic BP
>90 mmHg
<90 mmHg
Stuporous-coma
3. Level of
Drowsy
Awake
4. Nuchal rigidity
Present
Absent
+3
consciousness
C.
Fever
D.
Respiratory Pattern
+3
+2
TOTAL SCORE
+1
Normal or regular 0
E.
Upper GI Bleeding
+3
F.
+2
Interpretation:
Score
11-17 = definitely hemorrhagic
8-10 = most probably hemorrhagic
0-7 = unlikely hemorrhagic
G.
Headache
+2
H.
Nuchal rigidity
+2
I.
90
91-99
100
+2
J.
Absent
Siriraj Score
sensitivity 68%
specificity 64%
accuracy 64%
150
2
151-169
1
170-180 0
181-199
+1
200
+2
TOTAL SCORE
Interpretation
Score 7 = >90% probability of bleed
Score <7 = probably infarct
Consciousness (X 2.5)
Alert
Drowsy, stupor
Semicoma, coma
Vomiting (X 2)
No
Yes
Headache within
No
2 hours (X 2)
Yes
Diastolic blood
I. History
1. Vomiting
Present
Absent
2. Headache
Present
DBP X 0.1
Atheroma markers
None
(X 3): diabetes,
angina, intermittent claudication
One or more
Constant
-12
TOTAL SCORE
Interpretation:
Score 1 = infarct
>1 = hemorrhage
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sensitivity 70-88%
specificity 64-78%
accuracy 64-82%
Apoplectic onset
Loss of consciousness
Headache within
2 hours
Vomiting
Neck stiffness
None
0
2 or more 21.9
Level of consciousness
Alert
24 hours after admission Drowsy
Unconscious
0
7.3
Plantar response
Both flexor 14.6
or single
extensor
0
Both extensor 7.1
Diastolic blood
24 hours after
admission
Place of Treatment
DBP X
0.17
Atheroma markers:
None
diabetes, angina,
One or more
intermittent claudication
0
-3.7
Hypertension
-4.1
0
Present
None
Appendix VII
A. Mayo algorithm for management of TIA's and
minor stroke.
Reference:
1. Brown RD Jr, Evans BA, Wiebers DO, Petty GW, Meissner
I, Dale AJD. Transient ischemic attack and minor ischemic
stroke: An algorithm for evaluation and treatment. Mayo
Clin Proc 1994;69:1027-1039.
B. Admission to an organized Stroke Unit or management by a Stroke Team has been shown to:
Heart disease
None
Aortic or
mitral
murmur
Cardiac
failure
Cardiomyo pathy
Atrial
fibrillation
MI within
6 months
Constant
0
-4.3
-4.3
References:
1. Indredavik B, Slordahl SA, Bakke F, Rokseth R, Haheim
LL. Stroke unit treatment. Stroke 1997;28:1861-1866.
2. Langhorne P, Williams BO, Gilchrist W. Do stroke units
save lives? Lancet 1993;342:395-398.
3. Ronning OM, Guldvog B. Stroke unit versus general
medical wards, II: Neurological deficits and activities of
daily living. Stroke 1998;29:586-590.
4. Stroke Unit Trialists' Collaboration. How do stroke units
improve patient outcome? Stroke 1997;28:2139-2144.
-4.3
-4.3
4.3
-12
TOTAL SCORE
Interpretation:
Score <4 = infarct
4-24 = uncertain
>24 = hemorrhage
References:
1. Allen CMC. Clinical diagnosis of the acute stroke
syndrome. Quarterly J Med, New Series LII 1983;
208:515-523.
2. WHAT (Components)
a. Facilities:
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b. Guidelines:
- Guidelines on Acute Brain Attack as published
by the Stroke Society of the Philippines and
Department of Health Non-communicable Di
sease Service
c. Communication system:
- Early warning system by direct communication
link
3. WHO (Personnel)
a. Neurologists/neurosurgeon or stroke physi
cians
b. Stroke nurses
c. Radiologist or physician experienced in reading
CT scans in acute stroke
References:
1. Grotta J. How to organize a stroke team. American
Academy of Neurology Syllabus on Disk 1998.
2. Rudd A, Wolfe CDA. Developing a district stroke service.
Cerebrovasc Dis 1996;6:89-96.
Appendix VIII
Secondary Prevention for Stroke
I. Ischemic
A. Antithrombotics
1. Aspirin
Antiplatelet Trialists Collaboration:
- 145 trials with almost 100,000 patients
- 23% risk reduction for stroke, myocardial
infarction (MI), and vascular death
2. Ticlopidine
Canadian American Ticlopidine Study
(CATS)
- 23% risk reduction vs. placebo for stroke, MI,
or vascular death
Ticlopidine Aspirin Stroke Study (TASS)
- 12% risk reduction vs. aspirin for stroke or
death at 3 years
3. Clopidogrel
Clopidogrel vs. Aspirin in Patients at Risk of
Ischemic Events (CAPRIE)
- 19,185 patients with prior stroke, MI, or PVD
- Clopidogrel 75 mg/day vs. aspirin 325 mg/
day
- 8.7% relative risk reduction in stroke, MI, and
vascular death over aspirin
4. Cilostazol
5. Dipyridamole-Aspirin Combination
- Aspirin 25 mg bid
- Extended release Dipyridamole 200 mg bid
- Aspirin 25 mg bid + extended release dipyri
damole 200 mg bid
- Placebo
Results:
- Aspirin better than placebo
- Dipyridamole better than placebo
- Combination aspirin and dipyridamole better
than either one alone
References:
1. Antiplatelet Trialists' Collaboration. Collaborative
overview of randomized trials of antiplatelet therapy, I:
prevention of death, myocardial infarction, and stroke
by prolonged antiplatelet therapy in various categories of
patients. BMJ 1994;308:81-106.
2. Diener HC, Cunha L, Forbes C, Sivenius J, Smets P,
Lowenthal A. European Stroke Prevention Study 2.
Dipyridamole and acetylsalicylic acid in the secondary
prevention of stroke. J Neurol Sci 1996;143:1-13.
3. Gent M, Blakely JA, Easton JD, et al. The Canadian
American Ticlopidine Study (CATS) in thromboembolic
stroke. Lancet 1989;1:1215-1220.
4. Hass WK, Easton JD, Adams HP, et al. A randomized trial
comparing ticlopidine hydrochloride with aspirin for the
prevention of stroke in high-risk patients. N Engl J Med
1989;321:501-507.
5. CAPRIE Steering Committee. A randomized, blinded trial
of clopidogrel versus aspirin in patients at risk of ischemic
events (CAPRIE). Lancet 1996; 348:1329-1339.
6. Gotoh F, Tohgi H, Hirai S, et al. Secondary prevention of
cerebral infarction with cilostazol - a multicenter, doubleblinded, placebo controlled, long term, randomized study
(Cilostazol Stroke Prevention Study, CSPS) (abstract).
Presented at the International Stroke Society Regional
Meeting, Yokohama, Japan, April 22-24, 1999.
B. Carotid endarterectomy
The North American Symptomatic Carotid Endarte
rectomy Trial (NASCET), European Carotid Surgery
Trial (ECST), and the Veterans Administration Symptomatic Carotid Surgery Trial all showed benefit in
reducing risk of recurrent stroke in patient with severe
internal carotid artery stenosis (70%) who had a TIA
or minor stroke.
References:
1. European Carotid Surgery Trialists' Collaborative Group.
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needed
computed = 2 (Na+) + glucose + BUN
osmolality
18
2.8
C. Anticoagulant
The benefit of oral anticoagulation with coumadin
(target INR=2.0-3.0) has been shown in patients with
non-valvular atrial fibrillation who are at high risk
(hypertension, poor left ventricular function, previous
TIA, stroke, or thromboembolic events).
References:
1. Ezekowitz MD, Levine JA. Preventing stroke in patients
with atrial fibrillation. JAMA 1999;281:1830-1835.
2. Quality Standards Subcommittee of the American
Academy of Neurology. Practice Parameter: Stroke pre
vention in patients with non-valvular atrial fibril-lation.
Neurology 1998;51:671-673.
D. Statins
Appendix IX
Increased Intracranial Pressure (ICP)
- avoid straining
- laxative
- gentle suctioning
- appropriate intubation by exprienced person
References:
1. Wijdick EFM. Neurology of Critical Illness. F.A. Davies,
Philadelphia PA: 1995.
2. Davis SM (ed). Interventional Therapy in Acute Stroke.
Blackwell Science, Inc. Carlton, Victoria: 1998.
Appendix X
Glasgow Coma Scale
Category
Score
Eye opening
Spontaneous
To speech
Deteriorating sensorium
To pain
Cushing's triad
None
1.Hypertension
2.Bradycardia
3.Bradypnea (late)
Localizes
Anisocoria
Withdraws
Abnormal flexion
B.
1.
2.
Abnormal extension
3.
4.
5.
None
Confused conversation
Inappropriate words
Incomprehensible sounds
None
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Cilazapril/Hydrochlorothiazide
Vascace plus
Delapril
Cupressin
Enalapril maleate
Hypace
Naprilate
Renitec
Vasopress
Enalapril/Hydrochlorothiazide
Co-Renitec
Fosinopril sodium
BPNorm
Imidapril
Norten
Vascor
Imidapril HCl/
Hydrochlorothiazide
Norplus
Vascoride
Lisinopril dihydrate
Sinolip
Zestril
Lisinopril/Hydrochlorothiazides
Zestoretic
Moexipril HCl
Univasc
Perindopril
Coversyl
Perindopril/Indapamide
Bipreterax
Preterax
Quinapril
Accupril
Quinapril/Hydrochlorothiazide
Accuzide
Ramipril
Tritace
Verapamil HCl/Trandolapril
Tarka
Alpha Blockers
Terazosin HCl
Conmy
Hytrin
Angiotensin II antagonists
Candesartan
Blopress
Candesartan cilexetil/
Hydrochlorothiazide
Blopress plus
Eprosartan
Teveten
Eprosartan/Hydrochlorothiazide
Teveten plus
Irbesartan
Aprovel
Irbesartan/Hydrochlorothiazide
CoAprovel
Losartan
Bepsar
Cozaar
Lifezar
Losartan/Hydrochlorothiazide
Combizar
Hyzaar/Hyazaar DS
Olmesartan
Olmetec
Telmisartan
Micardis
Pritor
Telmisartan/Hydrochlorothiazide
Micardis plus
Pritor plus
Valsartan
Diovan
Valsartan/Hydrochlorothiazide
Co-Diovan
-blockers
Atenolol
Atestad
Cardioten
Drugmaker's Biotech Atenolol
Durabeta
Ritemed Atenolol
Tenormin
Tenostat
Therabloc
Atenolol/Chlorthalidone
Tenoretic
Betaxolol HCl
Kerlone
Bisoprolol
Concore
Bisoprolol hemifumarate/
Hydrochlorthiazide
Ziac
Carteolol HCl
Mikelan
Carvedilol
Dilatrend
Esmolol
Brevibloc
Metoprolol
Betaloc
Betazok
Cardiosel
Cardiostat
Cardiotab
Drugmaker's Biotech
Metoprolol
Metostad
Neobloc
23
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Pharex Metoprolol
Prolohex
Ritemed Metoprolol
Metoprolol/ Hydrochlorothiazide
Betazide
Pindolol
Visken
Pindolol/Clopamide
Viskaldix
Propranolol
Bedranol
Drugmaker's Biotech
Propranolol
Duranol
Inderal
Phanerol
Ritemed Propranolol
Calcium Antagonists
Amlodipine besylate
Norvasc
Amlodipine/Atorvastatin
Envacar
Barnidipine
Hypoca
Benidipine
Coniel
Diltiazem
Angiozem
Cordazem
Dilatam
Diltac
Diltelan
Dilzem/Dilzem SA/Dilzem SR
Drugmaker's Biotech Diltiazem
Mono-Tildiem
Ritemed Diltiazem
Tildiem
Zandil
Felodipine
Dilahex
Felop ER Tab
Plendil ER
Versant XR
Felodipine/Metoprolol
Logimax
Lacidipine
Lacipil
Lercanidipine
Zanidip
Manidipine
Caldine
Minadil
Nicardipine
Cardepine
Nifedipine
Adalat
Calcheck
Calcibloc/Calcibloc OD
Calcigard-5
Denkifed
Drugmaker's Biotech
Nifedipine
Heblopin
Nelapine
Nifestad
Normadil
Nimodipine
Nimotop
Verapamil
Isoptin/Isoptin SR
Verelan
Verapamil/Trandolapril
Tarka
Centrally-Acting drugs
Clonidine
Catapres
Drugmaker's Biotech Clonidine
Melzin
Methyldopa
Aldomet
Moxonidine
Physiotens
Rilmenidine
Hyperdix
CNS Stimulants/Neurotonics
Citicoline
Nicholin
Somazine
Piracetam
Irahex
Nootropil
Pyritinol HCl
Encephabol/Encephabol forte
Sulbutiamine
Arcalion
Diuretics
Carbonic Anhydrase Inhibitors
Acetazolamide
Diamox
Brinzolamide
Azopt
Dorzolamide
Trusopt
Loop Diuretics
Furosemide
Am-Europharma Furosemide
Drugmaker's Biotech
Furosemide
Edemann
Flexamide
Frusema
Furoscan injection
Lasix
Pharmix
Piplen
Bumetanide
Burinex
Osmotic Diuretics
Isosorbide-5-mononitrate
Angistad/Angistad SR
Elantan/Elantan Long
Imdur Durules
Ismo 20
Isomonit
Schwarz Isosorbide mononitrate
Isosorbide dinitrate
Isoket/Isoket IV/Isoket spray
Isordil
Mannitol
Osmofundin 20%
Potassium-Sparing Diuretics
Spirinolactone
Aldactone
Spirinolactone/Butizide
Aldazide
Thiazides (Benzothiadiazines)
Candesartan/Hydrochlorothiazide
Blopress plus
Cilazapril/Hydrochlorothiazide
Vascace plus
Enalapril/Hydrochlorothiazide
Co-Renitec
Eprosartan/Hydrochlorothiazide
Teveten plus
Imidapril/Hydrochlorothiazide
Norplus
Vascoride
Indapamide hemihydrate
Natrilix
Irbesartan/Hydrochlorothiazide
CoAprovel
Lisinopril/Hydrochlorothiazide
Zestoretic
Losartan/Hydrochlorothiazide
Combizar
Hyzaar/Hyzaar DS
Metoprolol/Hydrochlorothiazide
Betazide
Perindopril/Indapamide
Bipreterax
Preterax
Quinapril/Hydrochlorothiazide
Accuzide
Telmisartan/Hydrochlorothiazide
Micardis plus
Pritor plus
Valsartan/Hydrochlorothiazide
Co-Diovan
Nitroglycerin
Deponit NT 5/Deponit NT 10
Minitran TDP
Nitrostat
Perlinganit
Transderm-Nitro
Parenteral Electrolytes
0.9 NaCl
B. Braun NaCl 0.9% Soln for Inj
B. Braun NaCl 0.9% Soln
Hizon 0.9% Sodium Chloride
LVP S9
Vasodilators
Hydralazine HCl
Apresoline
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