New preventive medications, treatment address strokes

Lee Goren suffers from cardiac arrhythmia — an irregular heartbeat also referred to as atrial fibrillation or AFib — and has been taking a blood thinner since 2014.

“I was having a problem with tinnitus — ringing in the ears — and had two operations for it,” the second in November 2016, which meant he had to temporarily stop taking the blood thinner, he says.

“A week after the operation, I was in my house sitting in a chair and the next thing I know I was in the hospital,” the Worcester man says. Goren had a stroke. One emerging risk factor for stroke — “a bit of an epidemic in our society” — is atrial fibrillation, said his cardiologist, Dr. Eric Rosenwinkel of Cardiology Consultants in Lansdale. “Sometimes the first result is a stroke.”

Stroke accounts for one of every 20 deaths in the United States, where, according to the American Heart and American Stroke associations, someone suffers a stroke about once every 40 seconds. It’s the fifth highest cause of death in the U.S., killing nearly 133,000 people annually.

May being National Stroke Prevention Month, the two associations, which claim 80 percent of all strokes can be prevented, suggest three main actions to avoid the cardiovascular disease: stop smoking, exercise and get enough sleep.

The AHA, whose goal is to reduce deaths from cardiovascular diseases and stroke by 20 percent by 2020, tracks seven factors that increase the risk for heart disease and stroke: smoking, exercise, diet, body weight, cholesterol, blood pressure and blood sugar.

There are three main types of stroke: ischemic — the most common — hemorrhagic and transient ischemic attack (TIA), according to online resources. Ischemic strokes may be caused by a blood clot in an artery supplying blood to the brain, or a clot forms elsewhere in the body and travels through blood vessels to the brain, where it gets stuck and stops blood flow. Hemorrhagic strokes are caused by the rupture of a blood vessel in the brain.

Symptoms include weakness on one side, difficulty speaking, trouble finding words and facial droop on one side. Those who get to the hospital within three hours from the onset of symptoms may be eligible for tPA, a drug intended to lessen the effects of ischemic stroke.

Ischemic strokes account for 87 percent of all strokes, according to the stroke association. Treatment is aimed at breaking up or removing the clot. For hemorrhagic strokes, the goal is to stop the bleeding.

Most of the patients in his practice, Rosenwinkel said, “primarily have AFib or advanced diabetes,” which are “associated with ischemic stroke.”

They usually have advanced vascular disease, tapering of the blood vessels or arteries in the brain and may have had a prior heart attack, he said.

With ischemic stroke, there is a problem of plaque building up in the wall of an artery, narrowing the blood flow, he said. The main difference with embolic stroke is that a blood clot, usually from the heart, goes to the brain and blocks an artery, he said.

“Smoking, for sure, is probably the most important risk factor,” Rosenwinkel said. Poor sleep — seven to eight hours a night recommended — and lack of exercise — 30 minutes most days of the week recommended — are also risk factors.

Transfats have also been linked with bad outcomes — heart attack, high cholesterol, obesity, metabolic syndrome and stroke, he said.

“Less interventions are first line of treatment,” he said, “but it’s hard to achieve in a lot of patients. We always recommend working on losing weight, exercise and attention to diet. In my experience, not a lot are successful with using that approach to lower blood pressure and cholesterol to safe levels.”

The latest recommendation for blood pressure is “more lenient for patients with no other associated heart disease,” Rosenwinkel said. “We used to target 120/80; now we allow 150/90,” which reduces the number of those recommended for medication.

Some “novel” anticoagulant medications have been developed to replace the blood thinner Cumadin, which is “kind of a boon for cardiologists,” because they are as safe, easier to take and the patient doesn’t have to have blood tests as often.

“They’re more convenient to take, more palatable,” he said. “The real change in how we manage AFib.”

There are also new PCSK9 inhibitors — cholesterol-lowering drugs, which are injectable, for those with high levels of cholesterol that weren’t reduced with statin medications, he said. “They’re pretty amazing; they achieve an incredible reduction in lipid profiles.

“Medications work if the patients take them,” Rosenwinkel said. “They’re very effective at preventing embolic stroke from AFib. The main barrier is cost,” as they are not generics, he said.

Goren’s stroke was attributed to the fact that he stopped taking one of the news anticoagulant medications because of the surgery, Rosenwinkel said.

“It was interrupted too long and he had a stroke. He had a good outcome; a catheter was able to suck out the clot from his brain.”

“I lost my speech for two months, but finally got it back,” Goren said. “I have a lot of weakness on my left side and will need physical therapy. I’m very lucky I only suffered what I did.”

Patients used to be helicoptered to Center City hospitals for the catheter treatment Goren received, but several hospitals in Montgomery County have that expertise now, Rosenwinkel said.

People should pay attention to diet and exercise, and if they don’t have a primary care doctor, they “should seek one out and get blood pressure and cholesterol checked,” he said.

Staff writer Linda Finarelli writes a monthly health column. She can be reached at lfinarelli@21stcenturymedia.com. Follow her on Twitter: @ lkfinarelli.