One Stroke Could Prevent Another

Few things are scarier than the sudden loss of "life as we know it." At least with most devastating diseases there is time to come to grips with fate, but with a stroke, life may be completely normal one minute, and the next, one is thrust into an unknown world, from which there is potentially no return.

We know that patients can go from being independent and energetic to being partially paralyzed, confused, incontinent, and even completely dependent on others for even the most basic activities of daily living. Fortunately, in 2012, there are many success stories as well. While we are saddened about the former, we should focus most of our attention on preventing bad outcomes and optimizing the chances our patients will not have future cerebrovascular events.

Today, in part because of better public awareness of signs and symptoms, stroke and TIA are common reasons for admission to the hospital. I have had numerous patients express their embarrassment for going to the ER for their symptoms, and I always try to reassure them it is better to be safe than sorry. We can always discharge them home – healthy and happy – if we don’t find anything wrong.

Even if a patient has not suffered a stroke, but has a history strongly suspicious for a TIA, studies show that rapid intervention can significantly decrease their risk of having a stroke in the future, such as initiating antiplatelet therapy (unless contraindicated or anticoagulation is more appropriate) and statin therapy, counseling on lifestyle changes, controlling blood pressure, and in some cases referring for a carotid endarterectomy or stenting. An article in the New England Journal of Medicine titled "Secondary Prevention After Ischemic Stroke or Transient Ischemic Attack," reviews some important information to have in mins (N. Engl. J. Med. 2012;366:1914-22). For instance, a randomized, controlled pilot trial demonstrated that the rate of stroke recurrence was 10.8% vs. 7.1% among those randomly assigned to aspirin within 24 hours of a stroke, compared to those assigned to aspirin and clopidogrel.

While prolonged exposure to both antiplatelet agents was shown to be linked to excess hemorrhages and deaths in the Secondary Prevention of Small Subcortical Strokes trial, it is proposed that short-term use of this combination may be beneficial since the risk of stroke is highest soon after a minor stroke or TIA.

Sometimes, we just have to weigh the risks and benefits. Many patients are hesitant to take blood thinners because they bruise easily or have other non-life-threatening side effects. But for most, when they understand the significant benefit of preventing a potentially disabling stroke versus the relatively minimal risk, they agree to comply, even if only temporarily.

Of course, aggressive risk-factor modification and lifestyle changes are in order for many patients who present with TIA and stroke as well, and what better audience can we ever hope to have than those patients who were just spared a catastrophic stroke. In the INTERSTROKE case-control study involving first-time acute strokes (Lancet 2010;376:112-23), researchers found that 10 risk factors accounted for 90% of stroke risk:

1. Hypertension

2. Current smoking

3. High waist-to-hip ratio

4. High dietary risk score

5. Lack of regular physical activity

6. Diabetes mellitus

7. Excess alcohol consumption

8. Psychosocial stress or depression

9. Cardiac causes

10. High ratio of apolioprotein B to apolipoprotein A1.

While we may not be able to affect change in all 10 risk factors, we can certainly make in a dent, if not affect a 180-degree turn around in most of them. Stroke and TIA patients are the ideal patient population to educate. They are uniquely motivated to make the changes needed to prevent a life-altering stroke.

Dr. Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Few things are scarier than the sudden loss of "life as we know it." At least with most devastating diseases there is time to come to grips with fate, but with a stroke, life may be completely normal one minute, and the next, one is thrust into an unknown world, from which there is potentially no return.

We know that patients can go from being independent and energetic to being partially paralyzed, confused, incontinent, and even completely dependent on others for even the most basic activities of daily living. Fortunately, in 2012, there are many success stories as well. While we are saddened about the former, we should focus most of our attention on preventing bad outcomes and optimizing the chances our patients will not have future cerebrovascular events.

Today, in part because of better public awareness of signs and symptoms, stroke and TIA are common reasons for admission to the hospital. I have had numerous patients express their embarrassment for going to the ER for their symptoms, and I always try to reassure them it is better to be safe than sorry. We can always discharge them home – healthy and happy – if we don’t find anything wrong.

Even if a patient has not suffered a stroke, but has a history strongly suspicious for a TIA, studies show that rapid intervention can significantly decrease their risk of having a stroke in the future, such as initiating antiplatelet therapy (unless contraindicated or anticoagulation is more appropriate) and statin therapy, counseling on lifestyle changes, controlling blood pressure, and in some cases referring for a carotid endarterectomy or stenting. An article in the New England Journal of Medicine titled "Secondary Prevention After Ischemic Stroke or Transient Ischemic Attack," reviews some important information to have in mins (N. Engl. J. Med. 2012;366:1914-22). For instance, a randomized, controlled pilot trial demonstrated that the rate of stroke recurrence was 10.8% vs. 7.1% among those randomly assigned to aspirin within 24 hours of a stroke, compared to those assigned to aspirin and clopidogrel.

While prolonged exposure to both antiplatelet agents was shown to be linked to excess hemorrhages and deaths in the Secondary Prevention of Small Subcortical Strokes trial, it is proposed that short-term use of this combination may be beneficial since the risk of stroke is highest soon after a minor stroke or TIA.

Sometimes, we just have to weigh the risks and benefits. Many patients are hesitant to take blood thinners because they bruise easily or have other non-life-threatening side effects. But for most, when they understand the significant benefit of preventing a potentially disabling stroke versus the relatively minimal risk, they agree to comply, even if only temporarily.

Of course, aggressive risk-factor modification and lifestyle changes are in order for many patients who present with TIA and stroke as well, and what better audience can we ever hope to have than those patients who were just spared a catastrophic stroke. In the INTERSTROKE case-control study involving first-time acute strokes (Lancet 2010;376:112-23), researchers found that 10 risk factors accounted for 90% of stroke risk:

1. Hypertension

2. Current smoking

3. High waist-to-hip ratio

4. High dietary risk score

5. Lack of regular physical activity

6. Diabetes mellitus

7. Excess alcohol consumption

8. Psychosocial stress or depression

9. Cardiac causes

10. High ratio of apolioprotein B to apolipoprotein A1.

While we may not be able to affect change in all 10 risk factors, we can certainly make in a dent, if not affect a 180-degree turn around in most of them. Stroke and TIA patients are the ideal patient population to educate. They are uniquely motivated to make the changes needed to prevent a life-altering stroke.

Dr. Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.

Few things are scarier than the sudden loss of "life as we know it." At least with most devastating diseases there is time to come to grips with fate, but with a stroke, life may be completely normal one minute, and the next, one is thrust into an unknown world, from which there is potentially no return.

We know that patients can go from being independent and energetic to being partially paralyzed, confused, incontinent, and even completely dependent on others for even the most basic activities of daily living. Fortunately, in 2012, there are many success stories as well. While we are saddened about the former, we should focus most of our attention on preventing bad outcomes and optimizing the chances our patients will not have future cerebrovascular events.

Today, in part because of better public awareness of signs and symptoms, stroke and TIA are common reasons for admission to the hospital. I have had numerous patients express their embarrassment for going to the ER for their symptoms, and I always try to reassure them it is better to be safe than sorry. We can always discharge them home – healthy and happy – if we don’t find anything wrong.

Even if a patient has not suffered a stroke, but has a history strongly suspicious for a TIA, studies show that rapid intervention can significantly decrease their risk of having a stroke in the future, such as initiating antiplatelet therapy (unless contraindicated or anticoagulation is more appropriate) and statin therapy, counseling on lifestyle changes, controlling blood pressure, and in some cases referring for a carotid endarterectomy or stenting. An article in the New England Journal of Medicine titled "Secondary Prevention After Ischemic Stroke or Transient Ischemic Attack," reviews some important information to have in mins (N. Engl. J. Med. 2012;366:1914-22). For instance, a randomized, controlled pilot trial demonstrated that the rate of stroke recurrence was 10.8% vs. 7.1% among those randomly assigned to aspirin within 24 hours of a stroke, compared to those assigned to aspirin and clopidogrel.

While prolonged exposure to both antiplatelet agents was shown to be linked to excess hemorrhages and deaths in the Secondary Prevention of Small Subcortical Strokes trial, it is proposed that short-term use of this combination may be beneficial since the risk of stroke is highest soon after a minor stroke or TIA.

Sometimes, we just have to weigh the risks and benefits. Many patients are hesitant to take blood thinners because they bruise easily or have other non-life-threatening side effects. But for most, when they understand the significant benefit of preventing a potentially disabling stroke versus the relatively minimal risk, they agree to comply, even if only temporarily.

Of course, aggressive risk-factor modification and lifestyle changes are in order for many patients who present with TIA and stroke as well, and what better audience can we ever hope to have than those patients who were just spared a catastrophic stroke. In the INTERSTROKE case-control study involving first-time acute strokes (Lancet 2010;376:112-23), researchers found that 10 risk factors accounted for 90% of stroke risk:

1. Hypertension

2. Current smoking

3. High waist-to-hip ratio

4. High dietary risk score

5. Lack of regular physical activity

6. Diabetes mellitus

7. Excess alcohol consumption

8. Psychosocial stress or depression

9. Cardiac causes

10. High ratio of apolioprotein B to apolipoprotein A1.

While we may not be able to affect change in all 10 risk factors, we can certainly make in a dent, if not affect a 180-degree turn around in most of them. Stroke and TIA patients are the ideal patient population to educate. They are uniquely motivated to make the changes needed to prevent a life-altering stroke.

Dr. Hester is a hospitalist with Baltimore Washington Medical Center, Glen Burnie, Md., who has a passion for empowering patients to partner in their health care.