The cost of stroke complications is two years of healthy life

A stroke is something you really want to try and avoid. According to a study published Thursday, among people who survive a stroke, complications from the event typically deprive people of about two years of healthy life.

The study examined the outcomes of more than 1,200 stroke patients (their average age was 66) treated in university hospitals in South Korea. All of the patients had serious ischemic strokes, in which a blood vessel supplying blood to the brain is blocked. Researchers calculated the impact of the stroke in terms of a measure called "disability-adjusted life years." This measure combines years of life lost with years of healthy life lost due to disability. The average disability-adjusted life years lost to stroke was 3.82. But among patients suffering any of a range of complications, the average was 5.21 -- a difference of two years.

About 34% of stroke patients have some complication within four weeks of the event, such as stroke progression, pneumonia, urinary tract infection, seizure or other problems. However, aggressive care can minimize the risk of complications. Information on recovering from a stroke can be found on this web page.

The study is published in Stroke: Journal of the American Heart Assn.

-- Shari Roan

Photo credit: Laszlo Balogh  /  Reuters

Unpublished FDA study says diabetes drug Avandia should be withdrawn

An unpublished study by a Food and Drug Administration researcher and colleagues at Medicare indicates that as many as 48,000 heart attacks, strokes and other cardiovascular problems in the elderly between 1999 and 2009 could have been averted if the patients had taken other medications instead of the controversial diabetes drug Avandia, the Wall Street Journal reported Friday.

The paper by Avandia critic Dr. David Graham has been submitted to the Journal of the American Medical Assn., but the journal has not acknowledged whether it is considering publication.

The Graham study, which reviewed Medicare records, was reported by the respected pharmaceutical industry blog Pharmalot, which also published an e-mail from Graham to his superiors arguing that senior FDA officials were trying to suppress the work.

The FDA is scheduled to conduct a review of Avandia's safety next month.

Previous criticisms of the drug can be found here and here. The group Public Citizen has argued that ongoing clinical trials of Avandia should be halted immediately because of the risks of the drug, as has biomedical ethicist Ruth Macklin.

Stay tuned. The argument is sure to get hotter next month.

-- Thomas H. Maugh II

Hormone patch not as likely as the pill to cause stroke, study finds

Hormone replacement therapy is known to increase the risk of stroke. However, a new study indicates that a low-dose skin patch may be less risky than the HRT pill.

The risks of HRT have been debated for years, but the medications are still popular choices for the treatment of menopause-related symptoms, such as hot flashes. Data from the long-running Women's Health Initiative linked HRT pills to a slightly increased risk of stroke, especially in the second year of use or thereafter. However, that study did not examine the risks of hormones from a different delivery system, such as a patch.

In the new study, researchers looked at the records of 870,000 women ages 50 to 79 from 1987 to 2006. They identified 15,710 women who had strokes and compared them with 59,958 women who did not have strokes. They found there was no higher risk of stroke with a low-dose estrogen patch compared with not using HRT. However the risk of stroke increased up to 88% with high-dose patches compared with no use of hormones. The risk of stroke was increased about 25% from the HRT pill compared with no use of hormones.

The research suggests that more effort should be put into understanding how the route of administration of hormones may change the risk profile.

The study was released this week online by the British Medical Journal.

-- Shari Roan

Photo: A packet of hormone replacement therapy pills. Credit: Eric Boyd / Los Angeles Times

Too many stroke patients don't get cholesterol-lowering statins to prevent further episodes, researchers say

Nearly one in every five patients hospitalized for stroke do not receive prescriptions for cholesterol-lowering statins on their discharge, despite strong evidence that the drugs can prevent further strokes, as well as heart attacks and other problems, UCLA researchers said this week. About one in 10 stroke victims suffers another stroke within a week, said Dr. Bruce Ovbiagele of the UCLA Stroke Center, and while physicians have been improving in prescribing statins to prevent these secondary strokes, more education needs to be done.

Every year, about 795,000 Americans suffer a stroke, and nearly 144,000 die from it. About 600,000 of the strokes are first strokes, and the rest are repeat events.

A 2006 study called SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) showed that giving statins to stroke victims provided major benefits. The drugs produced a 16% reduction in the risk of a subsequent stroke, a 42% reduction in the risk of major coronary events, such as heart attacks, and a 45% reduction in the need for angioplasty or bypass surgery. Current guidelines from the American Heart Assn. and the American Stroke Assn. thus recommend that stroke victims be started on a cholesterol-lowering program as soon as possible.

Ovbiagele and his colleagues studied data on 173,284 stroke patients hospitalized between January 2005 and December 2007. They reported in the journal Stroke: Journal of the American Heart Assn. that, over the entire period, 83.5 of the patients received statin prescriptions at discharge. The proportion rose from 75.7% at the beginning of the study period to 84.8% at the end, indicating that more physicians were coming into compliance with the guidelines.

Women were 13% less likely than men to receive statin prescriptions, while hospitals in the South were 34% less likely to prescribe the drugs than hospitals in the West.

The next step is to investigate why these disparities exist and determine how best to bridge them, Ovbiagele said.

-- Thomas H. Maugh II

Angioplasty plus stents is as good as surgery for clearing neck arteries, study finds

A combination of angioplasty and stenting are as good as the gold standard of surgery for clearing fat deposits from neck arteries and keeping them open, researchers reported Wednesday. The findings in the NIH-funded trial, which included more than 2,500 patients, contradict the findings from smaller European trials which concluded that stenting is riskier.

The results, reported at a meeting in February and published in the New England Journal of Medicine on Wednesday, show that the two procedures are virtually equivalent, but that patients who undergo stenting tend to have more strokes in the months after the procedure, while those who undergo surgery tend to have more heart attacks. "Which complication would you prefer?" asked Dr. Christopher White of the Ochsner Heart & Vascular Institute in New Orleans, a spokesman for the Society for Cardiovascular Angiography and Interventions. "The answer is, I don't want either one." As a cardiologist, he wants to match one procedure or the other to the patient to minimize complications. "That's why I, as a clinician, need freedom to pick and choose, and I currently don't have that freedom" because Medicare and many insurance companies do not reimburse for stenting of the neck artery.

Experts hope the new results from the study known as CREST will convince Medicare to change its reimbursement policies. That change might also be helped along by new guidelines on choosing between the two surgeries to be issued this summer by SCAI and the Society for Surgery.

"We now have two safe and effective methods to treat carotid artery disease that can be targeted to individual patients," Dr. James Meschia, a neurologist at the Mayo Clinic in Jacksonville and one of the study's principal co-authors, said in a statement

An estimated 700,000 Americans suffer strokes each year, and the bulk of those incidents are caused by the buildup of plaque in the carotid arteries, the primary vessels in the neck that carry blood to the brain. The plaque can build up to the point where it completely blocks blood flow, or pieces can break off and lodge in smaller vessels in the brain.

The gold standard for treatment of the condition is surgery to scrape the plaque out of the artery, a process called carotid endarterectomy. About 150,000 of the procedures are performed in the United States each year. A newer procedure is to insert a catheter through the groin and thread it to the neck, where a balloon is inflated to compress the plaque and a wire mesh spring called a stent is inserted to prevent the plaque from re-expanding. They are less invasive, require a shorter hospital stay and are cheaper, but some have questioned their safety.

The CREST (Carotid Revascularization Endarterectomy vs. Stenting Trial) study, led by Dr. Thomas G. Brott of the Mayo Clinic, enrolled 2,502 patients at 117 centers in the United States and Canada between 2000 and 2008. They were randomly assigned to undergo either surgery or stenting.  The study was conducted in large and small, public and private hospitals. "The idea was to design a study that reflects the U.S. experience," he said in a statement.

The chief difference between the U.S. and European studies, White said, is that those who performed the stenting procedure in this country were required to demonstrate proficiency with the technique before the trial began, while those who performed it in Europe were "novices" who had just been taught the technique. "Which is ridiculous," he said. "How can you compare procedures when you are teaching how to do one and have an expert on the other side?" White, it should be noted, is a stenter.

Overall, 4.1% of patients in the stenting group had strokes in the weeks after the procedure, compared with 2.3% of those who had surgery. But 2.3% of those in the surgical group had heart attacks, compared with 1.1% of those with stents. The results were similar whether or not the patients had displayed symptoms before the operation.

The higher incidence of strokes for stenting is misleading, White said. "Not all strokes are the same. For big, damaging strokes, there was no difference between surgery and stenting. The difference was in minor strokes," from which patients generally recover with no significant problems.

The results do provide some general guidelines for how to choose between the two approaches. Patients in CREST who were over 70 tended to do better with surgery, perhaps because their arteries are less flexible. Those under 70 did better with stenting. People with cardiovascular disease are likely to do better with stenting, but those with hardened or "twisty" arteries are more likely to do better with surgery.

"Local experience is also important," White said. "If you don't have someone who is an expert at stenting, I would favor surgery. Procedures tend to be things that are learned, developed and in which people develop expertise.... I would prefer not to be treated by a beginner."

Abbott Laboratories, whose stents were used in the study, said it would use the data to apply to the Food and Drug Administration to market the stents to most patients with problematic carotid arteries. The stents are now approved only for use in patients who are at high risk from surgery due to anatomical factors, age or other considerations.

-- Thomas H. Maugh II

Causes of mild strokes, such as the one suffered by Beau Biden, are varied

The news that Delaware Atty. Gen. Beau Biden suffered a mild stroke today probably came as a surprise to many people, considering the son of vice president Joe Biden is relatively young (41), trim and in seemingly good health.

But strokes are not unheard-of in people that age, says Dr. David S. Liebeskind, associate director of the UCLA Stroke Center. "It doesn't surprise me at all," he said. "Overall the perception is that only older people have strokes, but we see a lot of people who have strokes at that age, even younger sometimes."

The cause of Biden's stroke isn't known yet, but Liebeskind said that a mild stroke could be caused by a number of things, including a tear in the wall of one of the major arteries leading to the brain, causing a blockage. That could be due to arterial structural abnormalities, or from stress put on the arteries caused by a sudden twisting movement. "Sometimes it can occur with trauma as severe as whiplash," he said, "or something like a tennis serve or a particular swimming movement or other sporting activities."

General stroke symptoms can include numbness or weakness on one side of the body, loss of speech, imbalance, trouble with speaking or speech loss, or a sudden severe headache.

A mild stroke can also be caused by a blood clot, which, Liebeskind said, can occur anywhere in the circulatory system, cutting off blood flow to the brain. A transient ischemic stroke, also called a mini-stroke, is the temporary blockage of an artery caused by a blood clot. A tendency to form blood clots, he added, can be something we're born with. "In many cases we're unaware of it." Infections or minor illnesses can cause inflammation, which can also lead to blood clots.

Another cause of stroke is a cerebral hemorrhage, when an artery in the brain bursts and fills the area with blood. Singer and reality show star Bret Michaels reportedly recently suffered a subarachnoid hemorrhage, a specific type of bleeding stroke that happens between the tissues around the brain and the brain itself.

Some types of migraines may also lead to a stroke, said Dr. Patrick Lyden, chairman of the department of neurology at Cedars-Sinai Medical Center. Those who have classical migraines, he said, which include an aura and sometimes loss of vision or function on one side, may be at more risk for stroke than those who have common migraines, which typically cause pain only one side of the head and almost never include an aura.

A statement from the vice president's office said Biden is in stable condition, alert with complete motor and speech skills. But prognosis following a stroke depends on its cause, Lyden said. "First you think about the cause, then you think about the severity of the symptoms, then you think about how to treat it."

-- Jeannine Stein

Photo: Beau Biden at the Democratic National Convention in 2008. Credit: Mark Wilson / Getty Images

Answers on Bret Michaels' brain hemorrhage (a.k.a. stroke)

With former Poison frontman (now reality-show celeb) Bret Michaels having reportedly suffered a subarachnoid hemorrhage, three questions naturally arise: What is it? What causes it? What's the prognosis?

First answer: A subarachnoid hemorrhage is a type of bleeding stroke that occurs between the tissues around the brain and the brain itself.

Second answer: Sometimes such strokes are the result of a ruptured aneurysm, or weak spot in a blood vessel; sometimes they arise from an existing weakness in the connection between the brain's arteries and veins; sometimes they're caused by an injury (a fall in the elderly, car accident in the young). Sometimes, there's simply no way to know.

Third answer: That depends -- upon complications, amount of bleeding, age, symptom severity. (More on this in a bit.)

All of this info is from the ever-reliable Medline Plus. Here's what else it has to say about subarachnoid hemorrhages.

Now back to that prognosis question. Here's a just-the-facts summary from Merck.com.

About 35% of people die when they have a subarachnoid hemorrhage due to an aneurysm because it results in extensive brain damage. Another 15% die within a few weeks because of bleeding from a second rupture. People who survive for 6 months but who do not have surgery for the aneurysm have a 3% chance of another rupture each year. The outlook is better when the cause is an arteriovenous malformation. Occasionally, the hemorrhage is caused by a small defect that is not detected by cerebral angiography because the defect has already sealed itself off. In such cases, the outlook is very good.

Some people recover most or all mental and physical function after a subarachnoid hemorrhage. However, many people continue to have symptoms such as weakness, paralysis, or loss of sensation on one side of the body or aphasia.

More from Merck here.

And here's the latest story, posted on latimes.com, about Michaels: Bret Michaels undergoing new tests

-- Tami Dennis

Photo: Bret Michaels. Credit: File photo

 

Rodent of the Week: Antidepressants could lessen stroke severity

Existing drugs used to treat depression and other mood disorders might be useful to limit brain damage following a stroke because they promote the growth of new nerve cells in the brain, according to a study in mice. The research is tantalizing because drugs that are known to spur nerve growth are already available and because there are few other options to mitigate the effects of stroke once brain damage has occurred.

Researchers at the Buck Institute for Age Research in Novato, Calif., compared stroke size and recovery in mice who were genetically altered and treated to either grow or not grow new neurons prior to stroke. The strokes in the animals that did not grow new neurons were 30% larger. The mice that did grow new neurons -- called neurogenesis -- showed improvement in motor function following the stroke.

It's not known exactly how new neurons improve stroke outcome. But the lead author of the study, Dr. David Greenberg, said in a news release: "Assuming that neurogenesis is also beneficial in humans, drugs approved by the FDA for other purposes and already shown to promote new neuron growth in rodents might be worth studying as a potential treatment for stroke in humans."

Studies still need to be conducted in humans. And, Greenberg cautions, people who have suffered strokes should not treat themselves with antidepressants or lithium without medical advice.

Further research will examine the effects of drugs that produce new nerve growth in other brain diseases, such as Parkinson's, Alzheimer's and Huntington's diseases.

The study is published online this week in the Proceedings of the National Academy of Sciences.

-- Shari Roan

Photo credit: Advanced Cell Technology Inc.

Mexican Americans less likely to call for help after a stroke, study says

Mexican Americans are less likely than Caucasians to call for medical assistance after a stroke, but an alarmingly low proportion of both groups actually called for help and less than a third arrived at a hospital within three hours of the stroke, the so-called golden window of time in which clot-busting therapy is most effective, researchers reported Thursday. "Stroke is a bad disease, but it is the most treatable of the bad diseases," said Dr. Lewis B. Morgenstern of the University of Michigan, lead author of the study appearing in Stroke: Journal of the American Heart Assn. "Something can be done for ischemic stroke if you call 911 and get to the hospital in time," he said in a statement. Ischemic strokes result from a blood clot impairing blood flow to parts of the brain.

Moregenstern and his colleagues used data from the Brain Attack Surveillance in Corpus Christi project to compare use of emergency medical services and hospital arrival time in 1,134 Mexican Americans and whites who suffered ischemic strokes between 2000 and 2006. Subjects were 45 or older and 53% were Mexican American; 52% were women.

The team found that only 40% of Mexican Americans called for emergency medical services (EMS), compared with 56% of whites. Only 27% of the former group arrived at a hospital within three hours, and 29% of the latter. Language did not play a role in how soon patients arrived at the hospital. "In this study, less than half of people use EMS for stroke," Morgenstern said. "That's sobering. Everyone should know that we have effective treatments for stroke, so they must learn the symptoms and be motivated to call 911." Driving to the hospital or having someone take you is not an effective alternative, he added. When EMS takes patients to the hospital, they arrive faster, the responders call in advance to have the emergency room's stroke response team ready to go, and doctors and nurses respond faster to patients arriving by ambulance.

Everyone should be familiar with stroke symptoms:

-- Sudden numbness or weakness of the face, arm or leg, especially on one side of the body

-- Sudden confusion and trouble speaking or understanding

-- Sudden trouble seeing in one or both eyes

-- Sudden trouble walking, dizziness and loss of balance or coordination

-- Sudden severe headache with no known cause

The results are particularly concerning, Morgenstern concluded, because Mexican Americans, like blacks, are at a higher risk of strokes and tend to have them at younger ages.

-- Thomas H. Maugh II

How many heart attacks and strokes would we need to prevent to convince Americans to eat less salt?

What will it take to get Americans – and the food industrial complex – to get serious about taking some of the salt out of our diets?

In September, a study in the American Journal of Health Promotion calculated that Americans could eliminate 11 million cases of hypertension, save $18 billion in medical costs and add 312,000 years to our collective lives by reducing our daily sodium intake from about 3,300 milligrams per day to the recommended daily maximum of 2,300 mg.

In January, another study published in the New England Journal of Medicine concluded that excising 1,200 mg of sodium from our daily diets would prevent up to 120,000 cases of cardiovascular disease, 66,000 strokes, 99,000 heart attacks and reduce annual deaths from any cause by as much as 92,000. That study found that the cost savings would add up to as much as $24 billion and save as many as 392,000 years of life.

Still not convinced? This week, researchers from the Stanford University School of Medicine and the Veterans Affairs Palo Alto Health Care System entered the fray with their own analysis.

They used a computer model to estimate would what happen if consumers and food-makers here copied a British salt-reduction campaign. Their conclusions: Americans between the ages of 40 and 85 would cut their salt intake by 9.5%, preventing strokes in 513,885 people and heart attacks in 480,358 others. Total savings to the healthcare system would top $32 billion, according to their study published Monday in Annals of Internal Medicine.

They also ran a computer model using another popular idea – a sin tax aimed at salt. The hypothetical salt tax was less effective, cutting salt intake by only 6% and preventing 327,892 strokes and 306,173 heart attacks. The researchers said they thought the salt tax was less feasible than voluntary efforts by the food industry to cut sodium out of their products.

The researchers also noted that cutting back on salt could have the unintended consequence of motivating consumers to eat more foods made with fat and sugar, which present their own health risks.

You can read the study here, or check out the summary for patients here.

For those who are finally motivated to cut some of the salt out of their diets – or at least give it a try – check out this list of helpful hints from the National Heart, Lung and Blood Institute. And if you still need a little push, check out this story from the Health section about the perils of ingesting too much sodium.

-- Karen Kaplan

Photo: Would you rather have a little salt or a heart attack? Credit: Kirk McKoy/Los Angeles Times