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Secondary Prevention: Stopping the Next Stroke

Posted Aug 24 2008 1:49pm
PAUL J. MONIZ: I'm Paul Moniz. Thank you for joining us on this webcast. Do you know someone in the United States has a stroke every minute? If you or someone you're close to is in that category, you need to know two things. Your likelihood of having another stroke within five years is within 35%. But if you modify your lifestyle, you can reduce your chances of suffering another stroke.

Here to answer questions about secondary prevention are two specialists in the field. Dr. Ralph Sacco is an Associate Chairman of Neurology at Columbia University. Thanks for joining us. Dr. Dara Jamieson is a neurology at Pennsylvania Hospital. Thank you.

Dr. Sacco, let's begin with you. When people talk about secondary prevention, what are we really talking about here?

RALPH L. SACCO, MD: The key is somebody who has now had a stroke, or a TIA, preventing an event — preventing a recurrence. Most of the time we talk about secondary or tertiary prevention. We're really talking about how to prevent a recurrent stroke. It's clear that if you've survived your stroke, you're at risk for a recurrence. If you have a recurrence, it's going to make a major impact. It will increase the chance of dying. It will clearly add more disability to your life. It's important for us to be thinking about ways to reduce the chance — in the survivors of stroke — the chance of a recurrent stroke.

PAUL J. MONIZ: You mentioned TIA. For those viewers who are just joining us, again could you explain what that is.

RALPH L. SACCO, MD: TIA is a warning sign, a transient ischemic attack — it's a brain attack. It may be a warning sign of a stroke. In TIA patients who are at high risk for stroke, we want to prevent a stroke and this fits into prevention as well.

PAUL J. MONIZ: Dr. Jamieson, as time goes on someone's chances of having another stroke actually increases. Can you give us the numbers? The breakdown?

DARA JAMIESON, MD: Certainly the risk accumulates over time. After you've had a TIA or after you've had one stroke, your risk of actually having another episode is highest right near that — in the next hours to days to weeks. But the risk continues to accumulate so that by one year, you may have a 5-10% chance of having another stroke. Or by five years, you may have a 30-35% chance of having another stroke. The process of prevention continues for many years, both in terms of lifestyle and in terms of medication.

PAUL J. MONIZ: So this is something that people have to be really serious about for the rest of their lives once it happens.

DARA JAMIESON, MD: Often a stroke is a wake-up call. I remember a woman I saw in the office today who at 65 really didn't think she needed to go see doctors. But when she had her stroke, it was discovered that her blood pressure was too high, her glucose was too high, her cholesterol was too high and all of a sudden she needed specialists to help her with these risk factors and intervention to help prevent another stroke from occurring.

PAUL J. MONIZ: Dr. Sacco, are second strokes always more serious?

RALPH L. SACCO, MD: Sometimes. The key is that when you have one stroke, and you survived it, if you have another one, the next one may leave you with a lot more disability. For example, if you have right-sided weakness and then go on to have a stroke on the other side of the brain, you may have your right and left side impaired. Clearly if you're going to have another brain injury, another stroke, it's going to disable you further. There are ways that we can think of to try to reduce that risk.

PAUL J. MONIZ: What are some of the ways to reduce the risk?

DARA JAMIESON, MD: The first way which we may think of as being the simplest, but for some patients is truly the hardest, is lifestyle adjustment. Basically decreasing those risk factors, making sure that your physician is keeping your blood pressure under control, making sure your sugar — your glucoses are under control if you have diabetes, making sure your cholesterol is normal. Eating a good diet. If you smoke, stop. Exercise. Get your weight down.

Once you've dealt with risk factors, then there are antiplatelet medications. In some cases, there are anticoagulant medications and, in some cases, surgery that can help decrease your risk as well.

PAUL J. MONIZ: This wave of new medications is certainly increasing the likelihood that people can survive and maintain somewhat of their lifestyle. How effective are they generally?

RALPH L. SACCO, MD: What's great now is we have a lot of medicines to choose from. We think of stroke as many different types of stroke. The first thing we do is try to figure out what caused it. Then try to intervene to reduce the chance of another one occurring. If the stroke was caused by large artery blockage, then surgery is the most effective thing we can do. If the stroke was caused by the heart, then blood thinners are needed to prevent clots from forming to prevent another clot from breaking off and blocking an artery.

If it's one of the other types of stroke, some small arteries or other types, then we have a choice of antiplatelet agents. These are certain kinds of drugs that help prevent certain particles of the blood from sticking together. Something as simple as aspirin, Plavix, clopidogrel, ticlopidine or Aggrenox, the latest one to be approved to really help reduce the risk of a recurrent stroke.

PAUL J. MONIZ: Can these drugs be given before someone actually has a stroke, if there are significant risk factors within a family?

DARA JAMIESON, MD: The major thing to do before somebody has had a TIA or stroke is to deal with risk factors. In general, we don't think of the antiplatelet drugs as being appropriate for patients who have never had a TIA or never had a stroke. But if you've had a TIA, you need to be put on an antiplatelet medication unless there is a very, very significant reason not to. If you've had a stroke, you need to be put on an antiplatelet medication, unless there is another medication, such as Warfarin or anticoagulation that would be considered more appropriate. But we don't in general use them for patients who have never ever ever had any kind of indication of stroke to their brain.

RALPH L. SACCO, MD: However, I would add that in the future, there are going to be some studies that we're going to be looking at this. We are now thinking about preventing stroke with some of these drugs. We just need to do the studies to prove it's effective and not doing harm. We can maybe help prevent stroke using some of these medicines — it's possible.

PAUL J. MONIZ: It's very important research that needs to be done and the implications are really huge if you think about the number of people that are having strokes.

Heredity is always a concern with these kinds of things. Is having a stroke generally a hereditary condition?

DARA JAMIESON, MD: The risk factors can be hereditary. The tendency to have diabetes can be inherited. The tendency to have high blood pressure can be inherited. There are certain lipid or cholesterol disorders that can be inherited.

In general, having a stroke per se is not inherited although there are some very rare conditions where it can be.

RALPH L. SACCO, MD: But like everything else, genetics is some of the wave of the future in terms of our research. We are starting to look at certain genetic factors that may be linked to some of the risk factors, like hardening of the arteries or maybe linked to increasing the risk of stroke in other ways. I think in the future we will be able to expand our ability to predict who is at risk — not just environmental risk factors, but using genetic risk factors as well.

PAUL J. MONIZ: In terms of misconceptions about stroke, what do you think some of the myths are that are out there — common myths?

DARA JAMIESON, MD: I think one of the most common myths is that stroke cannot be prevented. There are a lot of things that can be done to lower your risk very significantly. There can be relatively easy things such as a management of blood pressure. They can be things that patients would consider more difficult such as smoking cessation. They can be things that require a commitment such as taking medication. That would be a myth.

I think the myth that stroke is not treatable also needs to be debunked because there certainly are things you can do to treat stroke once it has occurred.

PAUL J. MONIZ: Dr. Sacco, your final comments?

RALPH L. SACCO, MD: The old term for stroke used to "cerebral vascular accident." There is nothing accidental about stroke. It is something that can be prevented. It is something that can be treated and we have a lot of choices and a lot of medicines out there now to try to prevent a stroke, try to treat a stroke and prevent a recurrence.

PAUL J. MONIZ: Some very good information. Thank you both for joining us. Dr. Ralph Sacco of Columbia University and Dr. Dara Jamieson of Pennsylvania Hospital. Thanks for your time as well.

Again if you have questions about what your risk factors are, you need to contact your doctor. And as our two guests, just mentioned, there is help out there either to try to prevent you from having a stroke or help you live through the consequences if you do have one.

I'm Paul Moniz. Thanks for being with us.

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