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Newsletters November 2010 - Jefferson Cardiology Happenings

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Stroke Prevention and Treatment

Stroke is the third leading cause of death in the United States and the number one cause of long term disability. There are 750,000 strokes in the United States annually. Between 1908-1996 there was a 60% decline in stroke mortality with subsequent slowing of this rate of decline.

Atherosclerosis affects blood vessels throughout the body. Measures to reduce atherosclerosis, hardening of the arteries, may reduce heart attacks and strokes. Research has shown that with statin therapy each 10% reduction in LDL cholesterol results in a 15% reduc-tion in stroke.

Diabetes is another major risk factor for stroke. There is conflicting evidence that tight diabetic control re-duces strokes.

Carotid surgery has been shown to reduce stroke. Currently, there is a recommendation that persons with symptomatic mini-strokes, or transient neurologic deficits related to carotid dis-ease, be considered for carotid surgery if there is a greater than 5 year life expectancy and carotid blockage of 50-99%. Similarly, asymptomatic persons with greater than 5 year life expectancy and 60-99% carotid stenosis may benefit from carotid surgery.
What is the role of carotid stenting compared to carotid surgery? A recent study, the CREST study, involving 2,500 patients and followed over 2.5 years, demonstrated no significant difference in incidence of stroke, heart attack or death between the two procedures. Carotid stenting was associated with a higher risk of stroke and carotid surgery was associated with a higher risk of heart attack.

In patients with persistent or intermittent atrial fibrillation, blood thinning therapy definitely reduces the risk of stroke. Risk factors have been identified for stroke secondary to atrial fibrillation. Risk factors have been identified as age over 75, history of high blood pressure, diabetes, and congestive heart failure. Persons with atrial fibrillation and no risk factors may be treated with 81-325mg aspirin daily. For patients with atrial fibrillation and one risk factor, excluding stroke history, either aspirin or Coumadin would be rec-ommended. If there is a history of stroke or two other risk factors, then Coumadin would be recommended.

Because of limitations of the use of Coumadin, other new drugs are being investigated. One promising alternative is dabigatran. This drug may be more effective than Coumadin, has similar safety and does not require frequent monitoring blood tests. A recent study showed similar effectiveness between the two drugs when Coumadin dosage results in effective levels of anticoagula-tion. When Coumadin dosage results in more sub-therapeutic values then dabigatran is more effective preventing strokes. In persons who are not Cou-madin candidates, the combination of aspirin and Plavix is more effective than aspirin alone.

Hypertension has long been noted to result in increased risk of stroke. All classes of blood pressure medications have been shown to reduce stroke risk. Smoking cessation may also reduce the risk for cerebral hemorrhage.
Stroke therapy may include clot busting drugs. These drugs may be able to reverse a stroke if given within 3 hours of onset. In Europe, these drugs may be given within 4.5 hours after a stroke. In one study, these drugs in-creased the risk of cerebral hemorrhage up to 6% as compared to 0.6% of those not receiving this type therapy and 2% compared to 0.2% in another study. There have been clinical trials utilizing intra-arterial clot busters up to 6 hours after a stroke. The results were not overwhelmingly favorable and did not receive FDA approval.

Intra-cranial hemorrhage ac-counts for 9-15% of all strokes and has a mortality rate approaching 50%. Pro-gress in treating cerebral hemorrhage is limited. Dramatic acute blood pressure reduction may have merit but definitive studies have not yet been published. Surgical treatment has not proven supe-rior to non-surgical treatment up to now.

In short, new drugs may have future benefit. Mechanical clot removal is experimental and may have future potential. Aging of the United States population and increasing obesity may continue to increase stroke risk in the future.

In Honor of All of Our Veterans!!
Happy Veterans Day!
American Dream Cake

1 Box yellow cake mix
1 Can crushed pineapples
1 Box instant vanilla pudding
1 pkg low fat cream cheese
1 tub low fat cool whip
Strawberries and Blueberries

Bake cake in 9x13 cake pan. Poke holes in the top of the cake before it cools. Pour can of pineapples over top of cake after approximately 10 minutes. Allow to cool completely. Make pudding with ONLY 1 ½ cups of milk (not the 2 cups as directed on box). Mix pudding with softened cream cheese with electric mixer. Spread over pineapples. Spread cool whip over top. Arrange strawberries and blueberries in flag pat-tern ( red and white stipes, blue stars). Refrigerate for at least one hour then serve.

A publication of Jefferson Cardiology Association
Alan D. Bramowitz, M.D. | Michael S. Nathanson, M.D. | Gennady Geskin, M.D.

Jefferson Hospital Medical Building
Suite 403, Coal Valley Road
P.O. Box 18285

Belle Vernon Office
1533 Broad Ave
Belle Vernon, Pa 15012