Guess what the 5th leading cause of death is?

Staff writer Jerry Carino:

Over the last two decades, the medical community has made considerable advances in treating strokes. A big stumbling block remains, though.

Human nature.

Treatment is time sensitive — three to four hours after a stroke’s onset, it’s ineffective or less effective — so the key is discerning when you, or someone around you, has had a stroke.

“People have to be aware of the risk factors and recognize when it’s happening,” said Ellen Ciacciarelli, clinical leader of neurology at CentraState Medical Center.

A new study found that people who have extended work weeks are at a higher risk of stroke. Emily Eden (@edenandtheapple) has the details. Buzz60

It’s not necessarily obvious.

“The one thing about the majority of strokes is they’re not painful,” said Gerald Ferencz, medical director of the Primary Stroke Center at Community Medical Center in Toms River. “It’s rare that people get headaches.”

What do they get? Here is what to look for.

Signs of a stroke

The classic acronym for stroke awareness is FAST. It stands for Face, Arms, Speech and Time, and it functions as sort of a stroke checklist. Here is Ciacciarelli’s breakdown of each.

Face: “Does it look irregular? When you look at someone’s face, does one side droop down? Ask them to smile. Is there a lopsided smile?”

Arms: “Is one of the arms weaker? If they hold it out in front, does it drift off? Hold their arm in front of them and close their eyes. See if one arm drops toward the ground.”

Speech: “Does their speech sound garbled? Are they having challenges verbalizing at all? Have them repeat a phrase after you and see if they can do it.”

Time: “Call 9-1-1 and get help immediately. We only have a golden three hours to give them this medication (tPA). If someone is sitting at a dinner table at 6 and drops their glass, and their face looks funny, don’t wait until 9 to get them to an emergency room. The longer you wait, the more damage there is.”

Ciacciarelli added two more letters to the acronym to form BE FAST. The B is for balance (“see if they are off-balance or dizzy”) and E is for eyes (“double vision or difficulty seeing through one or both eyes”).

Risk factors

Strokes might seem to strike at random, but there are risk factors, some of which can be managed. Ferencz explains:

Age: “Generally the older you get the more risk there is of a stroke. That’s something we can’t change of course. Ocean County tends to be a high stroke-risk group location mainly because of age. We have a lot of retirees.”

Eating habits: “Hypertension, diabetes, high cholesterol, excess weight — these are things we have some control over and are potentially treatable. There is a stroke belt in this country in the southern states. It’s related to high-cholesterol foods — butter, grease, fatty foods, carbs. We (in New Jersey) are just at the outside portion of that. The closer you get to the Mason-Dixon line, where diets change, the higher the risk.”

Gender: “Younger women who have normal hormones may be in a protected phase, but when they get to the age when they are post-menopausal they are at the same risk as men.”

Bad habits: “Smoking, alcohol, drugs increase the risk”

Genetics: “There are cases where people inherit a stroke risk, but those are very uncommon.”

Evolving treatments

Advances is stroke treatment have been “huge,” Ferencz said, since the breakthrough drug known as tPA came out in 1995.

“Given within three to four-and-a-half hours of a stroke’s onset,” he said, “it can help reverse a stroke or make the outcome significantly better by a three-month window, which is what we look at for stroke recovery.”

More recently, “in situations where drugs are not getting an effect or when large arteries are blocked,” Ferencz said, doctors have made progress in inserting tiny catheters into the brain similar to those used to treat cardiac disease. The goal is to capture the blood clot and withdraw it.

“We can do that up to a six-hour period,” he said.

Progress also is being made in treating a different class of stroke — bleeding in the brain. If a blood vessel bursts and causes a stroke because an artery develops a hole, there are intravascular procedures available as opposed to underdoing major open surgery.

For those suffering this class of stoke, Ferencz issued a warning.

“Unlike people having a heart attack, when you have a stroke it’s not the best thing to take Aspirin right away,” he said. “The best thing is to get to an emergency room. If you take Aspirin and are bleeding in the brain, it will not help and it could make it worse.”

“A long way to go’

The bottom line is education. Ciacciarelli speaks to as many groups as she can.

“We have a lot of patients wake up and feel as though their face is numb and their arm is numb, and they go back to sleep,” she said. “When they wake up (later) their arm is totally flaccid. If you wake up and something doesn’t feel right, don’t go back to sleep. Have it evaluated. Once you go back to sleep, it could be too far out (time-wise) for us to do anything.”

She points out that stroke has dropped from the third-most common killer to “four or five,” but remains one of the leading causes of disability.

“The word is out there but we still have a long way to go,” she said. “We need to have everybody understand that the face of stroke is everybody — young and old, male and female, black and white. Our youngest here (at CentraState) was 29 years old. Our oldest was late 90s.”

Doctors may miss this!


Most people often fail to recognize symptoms of vascular disease. Unfortunately, so do their doctors.

“The knowledge gap between heart disease and vascular disease among the public and health care providers is quite dramatic,” said American Heart Association President Mark Creager, a cardiovascular disease specialist.

Hoping to bridge that gap, a group of leading experts on vascular disease met Thursday in a Boston summit to discuss the broad series of common illnesses that alter the function of arteries and veins. They discussed ways to boost awareness and knowledge of these common vascular diseases among patients and doctors, as well as within the broader health care community.

“There have been such tremendous advances in biology and technology. There are a lot of novel therapies in place to prevent and treat vascular diseases. You’re all aware of this, but the public in general and many health care providers are not,” Creager told the group as he opened up the conference. “We need to find a way to improve this public awareness and make sure we’re educating the public, patients and health care providers, and also making sure the actions they’re taking are ending up improving quality of life and reducing the mortality of our patients.”

William Hiatt, a University of Colorado School of Medicine professor, described vascular diseases and disorders as “a bit of a stepchild to coronary disease and stroke” but expressed optimism that “now we’re sort of coming into our own.”

“Primary care physicians have a lot on their plate today,” said Creager, “They’re dealing with so many medical issues that sometimes it’s hard for them to recognize when a patient is at risk for vascular disease or already has it, and they should. If they’re not sensitive to it or focusing on it, they’re going to miss the signs.”

Most doctors get little training about vascular disease, especially compared to other topics they are taught in school, said Creager, director of the Heart and Vascular Center at the Dartmouth-Hitchcock Medical Center.

“As a result, they have a less sophisticated understanding of vascular diseases, how to diagnose them, what the implications are and how to treat them,” he said.

That delay in diagnosis, and treatment, can have devastating consequences. Among those speaking at the summit will be patients and their family members who will recount personal tragedies about what can happen when physicians fail to recognize symptoms, Creager said.

Those with limited understanding about vascular disease sometimes see it as a condition that only affects certain limbs – like a blood clot in the leg – but vascular disease is rarely restricted to one area of the body.

“Plaque build-up in their legs, the problem that causes peripheral artery disease, typically affects arteries all over, including those in the heart and those that go to the brain,” Creager said. “So if someone has peripheral artery disease, they’re at significant risk for a heart attack or stroke if they don’t start addressing the problem.”

He added: “A clot in the vein of the leg may travel through the heart to the lungs, causing a pulmonary embolism, which might be fatal.”

The summit, which will convene leading cardiologists, vascular specialists, cardiologists, clinical scientists, patients and health organizations, will be the first for the AHA, although other organizations, such as the Vascular Disease Foundation,  have worked on similar awareness campaigns in the past.

The AHA’s summit will limit its scope to peripheral artery disease, aortic and peripheral aneurysms, and venous disease, primarily venous thromboembolism.

Peripheral artery disease is now recognized as one of the most common and dangerous of all cardiovascular diseases. It affects 8 million people in the country, with risk factors that include smoking, high blood pressure, and high cholesterol. Venous thromboembolism affects about 900,000 people, and it kills 60,000-100,000 people in the United States each year.

“All of us as health professionals, supported by the American Heart Association, have to do a much better job in informing every adult about the very high prevalence and truly dangerous short-term adverse outcomes of the common vascular diseases,” said Alan T. Hirsch, a vascular medicine specialist and cardiologist at the University of Minnesota, who will address public awareness gaps and opportunities at the AHA summit.

People are unfamiliar with the immense human risk and negative community impact associated with vascular diseases, he explained.

“There are lots of risks that are actively promoted to the public, and that consume most of our limited attention, such as Ebola, West Nile virus, or even Lyme disease,” he said. “These diseases seem to be core to major news stories, but they are, in reality not the true risk that affects nearly every American family. Vascular diseases are pandemic and kill daily in every city and town.  This risk, and the opportunity to lower this risk, is the story that must be told.”

A good campaign starts by “creating simple, easy-to-understand, and compelling messages for the public” and ensuring that they are understood among all cultural groups, he said.

“An effective national vascular disease public awareness platform also requires continuous outreach to all health professionals, including physicians, nurse practitioners and physician assistants, nurses, pharmacists, and a range of other clinicians to assure that the vascular science that underpins effective vascular disease prevention, diagnosis and treatment are used to achieve measurable public health goals,” he said. “An informed public and an informed health professional work force obviously can make substantial improvements over short time frames. But, this action plan starts with providing accurate and actionable information.”

That’s where the AHA can provide a heavy lift.

“Look at what we’ve done for awareness of heart disease in women. We really raised the flag there,” Creager said, pointing to improvements in how women understand how heart disease presents differently among genders. “And the American Stroke Association is raising awareness for the risk factors of stroke, and what to do if symptoms stroke occur. That’s why we’re doing this for vascular disease, because the American Heart Association is so well positioned to make a difference.

“It will have impact, on the public, on the health care providers, on entire systems of care. That’s why we’re having the summit.”


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