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Stroke: The Overlooked Killer

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Contrary to popular wisdom, what you don't know can sometimes hurt you, and badly. For older adults in particular, this is true when it comes to stroke.

The nickname for stroke is "brain attack." By interrupting the flow of blood to the brain, either by a blockage (usually a blood clot) or, more rarely, by a hemorrhage (usually a burst blood vessel), stroke destroys brains, paralyzes bodies, and silences voices. Stroke affects 700,000 people per year, and kills 160,000, making it America's third most deadly disease and a leading cause of serious disability.

Stroke too often gets away with murder, in part because of ignorance. Stroke can attack anyone at any age, but if you are an older adult, your risk is highest and gets higher as you age, while recovery gets harder and slower. So let's fight back with a few important facts about identifying stroke, treating it, and, most important, preventing it.

Who Is at Risk?

Age is a huge risk factor for stroke, and that doesn't just mean advanced age. After your 55th birthday (not so old, right?), your risk of stroke more than doubles each decade. Overall, 80 percent of people who have a stroke are over age 65. Older people are also more likely to die from a stroke, and to fear the disabling consequences more than death itself. One stroke also makes subsequent ones more likely.

But while age increases everyone's risk, one urgent exception concerns younger African Americans and Hispanics. Between the ages of 45 and 55, African Americans and Hispanics are twice as likely as white Americans to have a stroke, and four to five times more likely to die if they do. (After age 55, the risk evens out among ethnic groups.) Another key risk factor is family history. So if this describes you or someone you love, please pay extra attention to the information about prevention and response, which are the same for all ages.

Prevention May Be the Best Medicine

With limited treatment options and long recovery times, it is much more effective to prevent a stroke than to try to cope with the aftereffects of one.

First and foremost, this means good blood pressure control. High blood pressure is extremely common in older people and represents the single greatest modifiable risk factor for stroke. In an older adult, a healthy blood pressure reading is 140/90 or below. Recent research has proven that systolic blood pressure readings (the "over" number) and diastolic pressure (the "under" number) are both important factors, and that even a small elevation in systolic pressure increases stroke risk.

Unfortunately, about one in three people with high blood pressure (hypertension) don't know they have it, are not being treated, or are being inadequately treated.

Treatment Options and Missed Opportunities

The culprit is a serious lingering misconception about blood pressure and older adults. This misconception even persists among physicians and other health care providers, some of whom still fear that treating hypertension in old adults (age 80 and above) increases the risk of death.

Importantly, this fear was discredited by a study called Hypertension in the Very Elderly Trial (HYVET), which showed that lowering blood pressure in the very old was well worth it, offering a 39 percent reduction in death rate from stroke and 34 percent reduction in risk of death from any type of cardiovascular event. The only caveat: This treatment is not suitable for very frail older patients -- those with severe functional impairment or very short life expectancy.

Another dangerous, yet under-treated, stroke risk: atrial fibrillation (a common form of irregular heartbeat, or arrhythmia). In fact, among people over 80, "a-fib" causes one out of four strokes (often the most damaging and deadly ones).

The most effective treatment is anticoagulation -- medication to prevent the formation of clots inside the heart chamber, which can break loose, go to the brain, and cause stroke. Anticoagulant drugs include warfarin (Coumadin) and aspirin (not nearly as good as warfarin in preventing stroke in fibrillators over age 75), as well as a range of newer anticoagulants that have recently come to market. The downsides of warfarin treatment are that patients must be monitored closely and that there is an increased risk of bleeding, including in the brain (intracranial hemorrhage).

While these considerations are important, most experts, myself included, are convinced by the data showing far greater benefit in stroke prevention than harm due to bleeding. Too often, physicians still err on the side of excess caution and deny their elderly patients with atrial fibrillation the best medication to reduce their serious risk of death and disability from stroke.

"When it comes to patients at high risk of stroke, the choice is stark: The benefits of anti-clotting agents generally far outweigh the risk," says J. Donald Easton, MD, professor of neurology at the University of California San Francisco and past chairman of the American Heart Association Stroke Council. "When physicians shy away from anticoagulants, under-using them in patients for whom they could offer powerful protection, they are actually risking their patients' long-term well-being," Dr. Easton adds.

The bottom line is that only about a third of older patients who could and should receive anti-clotting medication to prevent stroke actually get it. This omission requires attention.

It may be reduced by the new anticoagulants (dabigatran, rivaroxaban and apixaban), as they are easier for patients and doctors to manage and cause less complications of bleeding into the brain.

Lowering Your Risk

Finally, what is good for your heart is good for your brain, which informs the list of other ways to prevent a stroke:
  • Stop smoking
  • Avoid excessive alcohol use
  • Get regular exercise (daily), eat right, and, if necessary, lose some weight. This gives you some vascular protection (stronger heart, lower blood pressure) and can help bring down your blood lipid levels (which include both "good" and "bad" cholesterol, and triglycerides.)

If you have diabetes or congestive heart failure, these are yet other compelling reasons to stick to your medication regimen.

tPA: the only medication for stroke
For many years, there was no treatment for stroke, casting a pall of inevitability over the disease. Now there is just one proven treatment, the drug tPA, authorized by the FDA in 1996.

tPA (tissue plasminogen activator) is a clot-busting enzyme that occurs naturally in the body. It is useful only for the type of stroke that is caused by a blockage, known as ischemic stroke. (It is not used in the case of a hemorrhagic stroke, caused by a burst vessel or aneurysm. Blood is toxic to brain tissue; in these cases, blood pressure control is essential, and sometimes surgery to repair the burst vessel may be needed.)

The downside to tPA: It must be given within three to 4.5 hours of the beginning of the stroke. Speed is crucial -- to get treatment within that window, patients should ideally get to the hospital as fast as possible and receive tPA in the first 60 minutes they are there. Unfortunately, in real life, fewer than one-third of patients receiving tPA get it that quickly.

In addition, tPA is not right for everyone. It is not recommended for children under 18, people already on blood thinners, people who have had surgery, bleeding, or a spinal tap in the last two weeks, or people with very high glucose levels, uncontrolled high blood pressure, or any sign of bleeding inside the head after being scanned at the hospital. And it can only be given to patients whose symptoms definitely began in the previous 4.5 hours.

Am I Having a Stroke?

All of this makes it extra important that everyone, especially people at high risk, know the signs of stroke, immediately call 9-1-1 if they suspect one, and get directly to a certified primary stroke center (PSC) for treatment. (There are about 1,000 primary stroke centers nationally; you can find a local center here.)

Please learn the warning signs of stroke:
  • Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body;
  • Sudden confusion, trouble speaking or understanding;
  • Sudden trouble walking, dizziness, loss of balance or coordination.
  • Sudden severe headache with no known cause.

The National Stroke Association also recommends the following tests, known collectively as FAST, which are well worth printing out and posting on the refrigerator:

  • F = Face. Ask the person to smile. Does one side of the face droop?
  • A = Arms. Ask the person to raise both arms. Does one arm drift downward?
  • S = Speech. Ask the person to repeat a simple sentence. Does the speech sound slurred or strange?
  • T = Time.

If you observe any of these signs (independently or together), call 9-1-1 immediately.

While anyone can have a stroke, at any age, you can reduce some risks, and can chart your own risk, based on age and health, here. The death rate from stroke has been falling recently because of lifestyle improvements, and we can take heart from the fact that scientists at the National Institute of Neurological Disorders and Stroke believe that with continued effort and research, we could eventually prevent up to 80 percent of all strokes. A worthy goal, indeed.

For more by Richard W. Besdine, M.D., click here.

For more on strokes, click here.

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